Final Review Quiz
1. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? a. Apply gentle pressure. b. Reinforce the dressing. c. Document the findings. d. Contact the health care provider (HCP).
c. Document the findings.
1. The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? a. Warming the crib pad b. Closing the doors to the room c. Drying the infant with a warm blanket d. Turning on the overhead radiant warmer
c. Drying the infant with a warm blanket
1. The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? a. Paleness of the calf area b. Coolness of the calf area c. Enlarged, hardened veins d. Palpable dorsalis pedis pulses
c. Enlarged, hardened veins
1. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? a. Infection b. Hemorrhage c. Chronic hypertension d. Disseminated intravascular coagulation
b. Hemorrhage
1. Which assessment following an amniotomy should be conducted first? a. Cervical dilation b. Bladder distention c. Fetal heart rate pattern d. Maternal blood pressure
c. Fetal heart rate pattern
1. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. a. Lethargy b. Sleepiness c. Irritability d. Constant crying e. Difficult to comfort f. Cuddles when being held
c. Irritability d. Constant crying e. Difficult to comfort
1. The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. a. "I should wear a bra that provides support." b. "Drinking alcohol can affect my milk supply." c. "The use of caffeine can decrease my milk supply." d. "I will start my estrogen birth control pills again as soon as I get home." e. "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." f. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
a. "I should wear a bra that provides support." b. "Drinking alcohol can affect my milk supply." c. "The use of caffeine can decrease my milk supply." f. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
1. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? a. "I will begin abdominal exercises immediately." b. "I will notify the health care provider if I develop a fever." c. "I will turn on my side and push up with my arms to get out of bed." d. "I will lift nothing heavier than my newborn baby for at least 2 weeks."
a. "I will begin abdominal exercises immediately."
1. The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication? a. "I will flush the eyes after instilling the ointment." b. "I will clean the newborn's eyes before instilling ointment." c. "I need to administer the eye ointment within 1 hour after delivery." d. "I will instill the eye ointment into each of the newborn's conjunctival sacs."
a. "I will flush the eyes after instilling the ointment."
1. The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? a. "I will need to increase my insulin dosage during the first 3 months of pregnancy." b. "My insulin dose will likely need to be increased during the second and third trimesters." c. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." d. "My insulin needs should return to pre-pregnant levels within 7 to 10 days after birth if I am bottle-feeding."
a. "I will need to increase my insulin dosage during the first 3 months of pregnancy."
1. The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. a. "The ductus arteriosus allows blood to bypass the fetal lungs." b. "One vein carries oxygenated blood from the placenta to the fetus." c. "The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." d. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." e. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."
a. "The ductus arteriosus allows blood to bypass the fetal lungs."
1. The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? a. "We want to attend a support group." b. "We never want to try to have a baby again." c. "We are going to try to adopt a child immediately." d. "We are okay, and we are going to try to have another baby immediately."
a. "We want to attend a support group."
1. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? a. "What can I do for you?" b. "Now you have an angel in heaven." c. "Don't worry, there is nothing you could have done to prevent this from happening." d. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."
a. "What can I do for you?"
1. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? a. "You will need to bottle-feed your newborn." b. "You will need to feed your newborn by nasogastric tube feeding." c. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." d. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."
a. "You will need to bottle-feed your newborn."
1. The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? a. 3 days postpartum b. 7 days postpartum c. On the day of birth d. Within 2 weeks postpartum
a. 3 days postpartum
1. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? a. A normal test result b. An abnormal test result c. A high risk for fetal demise d. The need for a cesarean section
a. A normal test result
1. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? a. Administer oxygen via face mask. b. Place the mother in a supine position. c. Increase the rate of the oxytocin intravenous infusion. d. Document the findings and continue to monitor the fetal patterns.
a. Administer oxygen via face mask.
1. The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. a. Age 54 b. Body mass index of 28 c. Previous difficulty with fertility d. Administration of oxytocin for induction e. Potassium level of 3.6 mEq/L (3.6 mmol/L)
a. Age 54 d. Administration of oxytocin for induction
1. The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. a. Allows for fetal movement b. Surrounds, cushions, and protects the fetus c. Maintains the body temperature of the fetus d. Can be used to measure fetal kidney function e. Prevents large particles such as bacteria from passing to the fetus f. Provides an exchange of nutrients and waste products between the mother and the fetus
a. Allows for fetal movement b. Surrounds, cushions, and protects the fetus c. Maintains the body temperature of the fetus d. Can be used to measure fetal kidney function
1. The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. a. Ballottement b. Chadwick's sign c. Hagar Sign d. Uterine enlargement e. Positive pregnancy test f. Fetal heart rate detected by a non-electronic device g. Outline of fetus via radiography or ultrasonography
a. Ballottement b. Chadwick's sign c. Hagar Sign d. Uterine enlargement e. Positive pregnancy test
1. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? a. Bring the infant to the clinic. b. This is a normal occurrence and no further action is needed. c. Increase the number of times that the cord is cleaned per day. d. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues
a. Bring the infant to the clinic.
1. he nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? a. Changes in vital signs b. Signs of heavy bruising c. Complaints of intense pain d. Complaints of a tearing sensation
a. Changes in vital signs
1. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? a. Client pain level b. Inadequate urinary output c. Client perception of body changes d. Potential for imbalanced body fluid volume
a. Client pain level
1. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. a. Cyanosis b. Tachypnea c. Hypotension d. Retractions e. Audible grunts f. Presence of a barrel chest
a. Cyanosis b. Tachypnea d. Retractions e. Audible grunts
1. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? a. Delivery of the fetus b. Strict monitoring of intake and output c. Complete bed rest for the remainder of the pregnancy d. The need for weekly monitoring of coagulation studies until the time of delivery
a. Delivery of the fetus
1. An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur? a. Naloxone b. Morphine sulfate c. Betamethasone d. Hydromorphone hydrochloride
a. Naloxone
1. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? a. Notify the health care provider (HCP). b. Continue monitoring the fetal heart rate. c. Encourage the client to continue pushing with each contraction. d. Instruct the client's coach to continue to encourage breathing techniques.
a. Notify the health care provider (HCP).
1. The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. a. Proteinuria b. Hypertension c. Low-grade fever d. Generalized edema e. Increased pulse rate f. Increased respiratory rate
a. Proteinuria b. Hypertension d. Generalized edema
1. A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? a. Supine position with a wedge under the right hip b. Trendelenburg's position with the legs in stirrups c. Prone position with the legs separated and elevated d. Semi-Fowler's position with a pillow under the knees
a. Supine position with a wedge under the right hip
1. A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? a. The appearance of the fetal external genitalia b. The beginning of differentiation in the fetal groin c. The fetal testes are descended into the scrotal sac d. The internal differences in males and females become apparent
a. The appearance of the fetal external genitalia
1. The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. a. The client has a history of intravenous drug use. b. The client has a significant other who is heterosexual. c. The client has a history of sexually transmitted infections. d. The client has had one sexual partner for the past 10 years. e. The client has a previous history of gestational diabetes mellitus.
a. The client has a history of intravenous drug use. c. The client has a history of sexually transmitted infections.
1. The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. a. The contractions are regular. b. The membranes have ruptured. c. The cervix is dilated completely. d. The client begins to expel clear vaginal fluid. e. The spontaneous urge to push is initiated from perineal pressure
a. The contractions are regular. c. The cervix is dilated completely. e. The spontaneous urge to push is initiated from perineal pressure
1. The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? a. The diet should include additional fluids. b. Prenatal vitamins should be discontinued. c. Soap should be used to cleanse the breasts. d. Birth control measures are unnecessary while breast-feeding.
a. The diet should include additional fluids.
1. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. a. Wear a supportive bra. b. Rest during the acute phase. c. Maintain a fluid intake of at least 3000 mL/day. d. Continue to breast-feed if the breasts are not too sore. e. Take the prescribed antibiotics until the soreness subsides. f. Avoid decompression of the breasts by breast-feeding or breast pump
a. Wear a supportive bra. b. Rest during the acute phase. c. Maintain a fluid intake of at least 3000 mL/day. d. Continue to breast-feed if the breasts are not too sore.
1. A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate? a. "Did you ever had surgery?" b. "Do you plan to have any other children?" c. "Do either of you have diabetes mellitus?" d. "Do either of you have problems with high blood pressure?"
b. "Do you plan to have any other children?"
1. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts. Which statement by the client indicates a need for further instruction? a. "I will record the number of movements or kicks." b. "I need to lie flat on my back to perform the procedure." c. "If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." d. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."
b. "I need to lie flat on my back to perform the procedure."
1. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? a. "I will watch for the evidence of the passage of tissue." b. "I will maintain strict bed rest throughout the remainder of the pregnancy." c. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." d. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."
b. "I will maintain strict bed rest throughout the remainder of the pregnancy."
1. A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? a. "How often do you have sexual relations?" b. "Please share with me more about your concerns." c. "You are still young and have nothing to be concerned about." d. "You should not have a decline in testosterone until you are in your 80s."
b. "Please share with me more about your concerns."
1. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? a. "Come to the clinic immediately." b. "The vaginal discharge may be bothersome, but is a normal occurrence." c. "Report to the emergency department at the maternity center immediately." d. "Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."
b. "The vaginal discharge may be bothersome, but is a normal occurrence."
1. The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? a. "Your type of pelvis has a narrow pubic arch." b. "Your type of pelvis is the most favorable for labor and birth." c. "Your type of pelvis is a wide pelvis, but it has a short diameter." d. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."
b. "Your type of pelvis is the most favorable for labor and birth."
1. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? a. Length of 19 inches b. Abnormal palmar creases c. Birth weight of 6 lb, 14 oz (3120 g) d. Head circumference appropriate for gestational age
b. Abnormal palmar creases
1. The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? a. A temperature of 100.4 °F (38 °C) b. An increase in the pulse rate from 88 to 102 beats/minute c. A blood pressure change from 130/88 to 124/80 mm Hg d. An increase in the respiratory rate from 18 to 22 breaths/minute
b. An increase in the pulse rate from 88 to 102 beats/minute
1. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? a. Identify the types of accelerations. b. Assess the baseline fetal heart rate. c. Determine the intensity of the contractions. d. Determine the frequency of the contractions.
b. Assess the baseline fetal heart rate.
1. A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? a. Nalbuphine b. Betamethasone c. Rho(D) immune globulin d. Dinoprostone vaginal insert
b. Betamethasone
1. Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment? a. Uterine tone b. Blood pressure c. Amount of lochia d. Deep tendon reflexes
b. Blood pressure
1. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? a. Turn on the apnea and cardio-respiratory monitors. b. Connect the resuscitation bag to the oxygen outlet. c. Set up the intravenous line with 5% dextrose in water. d. Set the radiant warmer control temperature at 36.5 °C (97.6 °F).
b. Connect the resuscitation bag to the oxygen outlet.
1. The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? a. Feed the newborn less frequently. b. Continue to breast-feed every 2 to 4 hours. c. Switch to bottle-feeding the infant for 2 weeks. d. Stop breast-feeding and switch to bottle-feeding permanently.
b. Continue to breast-feed every 2 to 4 hours.
1. The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? a. Notify the health care provider. b. Discontinue the infusion of oxytocin. c. Place oxygen on at 8 to 10 L/minute via face mask. d. Contact the client's primary support person(s) if not currently present.
b. Discontinue the infusion of oxytocin.
1. A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? a. Providing sitz baths b. Encouraging fluid intake c. Placing ice on the perineum d. Monitoring hemoglobin and hematocrit levels
b. Encouraging fluid intake
1. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? a. Hemoglobin of 11 g/dL (110 mmol/L) b. Fetal heart rate of 180 beats/minute c. Maternal pulse rate of 85 beats/minute d. White blood cell count of 12,000 mm3 (12.0Â109/L)
b. Fetal heart rate of 180 beats/minute
1. The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document n the client's chart? a. G.3, T.2, P.0, A.0, L.1 b. G.2, T.1, P.0, A.0, L.1 c. G.1, T.1, P.1, A.0, L.1 d. G.2, T.0, P.0, A.0, L.1
b. G.2, T.1, P.0, A.0, L.1
1. The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route? a. Intradermal b. Intratracheal c. Subcutaneous d. Intramuscular
b. Intratracheal
1. A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? a. Therapeutic abortion is required. b. Isoniazid plus rifampin will be required for 9 months. c. She will have to stay at home until treatment is completed. d. Medication will not be started until after delivery of the fetus.
b. Isoniazid plus rifampin will be required for 9 months.
1. A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2019. Using Nagele's rule, which expected date of delivery should the nurse document in the client's chart? a. July 12, 2020 b. July 26, 2020 c. August 12, 2020 d. August 26, 2020
b. July 26, 2020
1. The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? a. Developmental delays because of excessive size b. Maintaining safety because of low blood glucose levels c. Choking because of impaired suck and swallow reflexes d. Elevated body temperature because of excess fat and glycogen
b. Maintaining safety because of low blood glucose levels
1. The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? a. Monitoring the newborn's vital signs routinely b. Maintaining standard precautions at all times while caring for the newborn c. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems d. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment
b. Maintaining standard precautions at all times while caring for the newborn
1. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? a. Elevate the client's legs. b. Massage the fundus until it is firm. c. Ask the client to turn on her left side. d. Push on the uterus to assist in expressing clots
b. Massage the fundus until it is firm.
1. The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? a. Providing comfort measures b. Monitoring the fetal heart rate c. Changing the client's position frequently d. Keeping the significant other informed of the progress of the labor
b. Monitoring the fetal heart rate
1. The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? a. Prepare the client for an ultrasound. b. Obtain equipment for a manual pelvic examination. c. Prepare to draw a hemoglobin and hematocrit blood sample.
b. Obtain equipment for a manual pelvic examination.
1. The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? a. Gently push the cord into the vagina. b. Place the client in Trendelenburg position. c. Find the closest telephone and page the health care provider stat. d. Call the delivery room to notify the staff that the client will be transported immediately.
b. Place the client in Trendelenburg position.
1. 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? Select all that apply. a. Breast-feeding needs to be stopped for 3 months. b. Pregnancy needs to be avoided for 1 to 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. Pregnancy needs to be avoided for 1 to 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.
1. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? Select all that apply. a. Proteinuria of 3+ b. Respirations of 10 breaths/minute c. Presence of deep tendon reflexes d. Urine output of 20 mL in an hour e. Serum magnesium level of 4 mEq/L (2 mmol/L)
b. Respirations of 10 breaths/minute d. Urine output of 20 mL in an hour
1. The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? a. Ambulation b. Rest between contractions c. Change positions frequently d. Consume oral food and fluids
b. Rest between contractions
1. The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply a. Bed rest as a necessary preventive measure may be prescribed. b. Routine administration of subcutaneous heparin may be prescribed. c. An over-bed lift may be necessary if the client requires a cesarean section. d. Less frequent cleansing of a cesarean incision, if present, may be prescribed. e. Thromboembolism stockings or sequential compression devices may be prescribed.
b. Routine administration of subcutaneous heparin may be prescribed.
1. After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? a. Encourage the mother to breast-feed soon after birth. b. Support the mother in her reaction to the newborn infant. c. Tell the mother that it is important to hold the newborn infant. d. Document a complete account of the mother's reaction on the birth record.
b. Support the mother in her reaction to the newborn infant.
1. The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? a. The client is a 35-year-old primigravida. b. The client has a history of cardiac disease. c. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). d. The client is a 20-year-old primigravida of average weight and height.
b. The client has a history of cardiac disease.
1. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? a. Soft abdomen b. Uterine tenderness c. Absence of abdominal pain d. Painless, bright red vaginal bleeding
b. Uterine tenderness
1. The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? a. "I should stay on the diabetic diet." b. "I should perform glucose monitoring at home." c. "I should avoid exercise because of the negative effects on insulin production." d. "I should be aware of any infections and report signs of infection immediately to my health care provider (HCP)."
c. "I should avoid exercise because of the negative effects on insulin production."
1. Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? a. "I will place my baby's crib close to the door." b. "Some health care personnel won't have name badges." c. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." d. "It's okay to allow the nurse assistant to carry my newborn to the nursery."
c. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."
1. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? a. "It connects the pulmonary artery to the aorta." b. "It is an opening between the right and left atria." c. "It connects the umbilical vein to the inferior vena cava." d. "It connects the umbilical artery to the inferior vena cava."
c. "It connects the umbilical vein to the inferior vena cava."
1. The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? a. "It promotes the fertilized ovum's chances of survival." b. "It promotes the fertilized ovum's exposure to estrogen and progesterone." c. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." d. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."
c. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus."
1. The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. a. A primigravida with mild preeclampsia b. A primigravida who delivered a 10-lb infant 3 hours ago c. A gravida 5 who has just been diagnosed with dead fetus syndrome d. A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood e. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia
c. A gravida 5 who has just been diagnosed with dead fetus syndrome
1. The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? a. A primiparous client who delivered 4 hours ago b. A multiparous client who delivered 6 hours ago c. A multiparous client who delivered a large baby after oxytocin induction d. A primiparous client who delivered 6 hours ago and had epidural anesthesia
c. A multiparous client who delivered a large baby after oxytocin induction
1. The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? a. Strict bed rest is required after the procedure. b. Hospitalization is necessary for 24 hours after the procedure. c. An informed consent needs to be signed before the procedure.
c. An informed consent needs to be signed before the procedure.
1. The nurse is conducting an intake assessment on a pregnant adolescent who reports consuming small amounts of alcohol on a daily basis. On the basis of the information provided, what should the nurse do? a. Notify the local police department to report her underage drinking b. Counsel her on the type of deformity she can expect to see in her baby once born c. Counsel her on the effect alcohol can have on the fetus d. Tell her small amounts of alcohol will not affect the pregnancy
c. Counsel her on the effect alcohol can have on the fetus
1. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. a. Avoid stimulation. b. Decrease fluid intake. c. Expose all of the newborn's skin. d. Monitor skin temperature closely. e. Reposition the newborn every 2 hours. f. Cover the newborn's eyes with eye shields or patches.
c. Expose all of the newborn's skin. d. Monitor skin temperature closely. e. Reposition the newborn every 2 hours. f. Cover the newborn's eyes with eye shields or patches.
1. A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. a. Less pressure on her cervix b. Decreased number of contractions c. Increased efficiency of contractions d. The need for increased maternal blood pressure monitoring e. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
c. Increased efficiency of contractions e. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
1. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? a. Contact the health care provider. b. Instruct the client to maintain bed rest for the remainder of the pregnancy. c. Inform the client that these contractions are common and may occur throughout the pregnancy. d. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition
c. Inform the client that these contractions are common and may occur throughout the pregnancy.
1. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? a. Raise the head of the client's bed. b. Obtain hemoglobin and hematocrit levels. c. Instruct the client to request help when getting out of bed. d. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.
c. Instruct the client to request help when getting out of bed.
1. Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. a. It cushions and protects the baby. b. It maintains the temperature of the baby. c. It is the way the baby gets food and oxygen. d. It prevents all antibodies and viruses from passing to the baby. e. It provides an exchange of nutrients and waste products between the mother and developing fetus.
c. It is the way the baby gets food and oxygen. e. It provides an exchange of nutrients and waste products between the mother and developing fetus.
1. On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? a. Document the findings. b. Elevate the client's legs. c. Massage the fundus until it is firm. d. Push on the uterus to assist in expressing clots
c. Massage the fundus until it is firm.
1. The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? a. Document the finding b. Check the mother's heart rate c. Notify the health care provider (HCP) d. Tell the client that the fetal heart rate is normal
c. Notify the health care provider (HCP)
1. The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? a. Record the findings. b. Massage the fundus. c. Notify the health care provider (HCP). d. Place the client in Trendelenburg's position
c. Notify the health care provider (HCP).
1. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? a. Document the findings. b. Reassess the client in 2 hours. c. Notify the health care provider (HCP). d. Encourage increased oral intake of fluids
c. Notify the health care provider (HCP).
1. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? a. Monitor fetal heart rate continuously. b. Monitor maternal vital signs frequently. c. Perform a vaginal examination every shift. d. Administer an antibiotic per HCP prescription and per agency protocol
c. Perform a vaginal examination every shift.
1. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? a. The client is measuring large for gestational age. b. The client is measuring small for gestational age. c. The client is measuring normal for gestational age. d. More evidence is needed to determine size for gestational age.
c. The client is measuring normal for gestational age.
1. The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. a. Fatigue b. Drowsiness c. Uterine hyperstimulation d. Late decelerations of the fetal heart rate e. Early decelerations of the fetal heart rate
c. Uterine hyperstimulation d. Late decelerations of the fetal heart rate
1. The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? a. "I should increase my sodium intake during pregnancy." b. "I should lower my blood volume by limiting my fluids." c. "I should maintain a low-calorie diet to prevent any weight gain." d. "I should drink adequate fluids and increase my intake of high-fiber foods."
d. "I should drink adequate fluids and increase my intake of high-fiber foods."
1. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? a. "I should breast-feed every 2 to 3 hours." b. "I should change the breast pads frequently." c. "I should wash my hands well before breastfeeding." d. "I should wash my nipples daily with soap and water."
d. "I should wash my nipples daily with soap and water."
1. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? a. "I won't be in labor until my baby drops." b. "My contractions will be felt in my abdominal area." c. "My contractions will not be as painful if I walk around." d. "My contractions will increase in duration and intensity."
d. "My contractions will increase in duration and intensity."
1. The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? a. "Your newborn needs the medicine to develop immunity." b. "The medicine will protect your newborn from being jaundiced." c. "Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." d. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
d. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."
1. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? a. Initiate an intravenous line. b. Assess the client's blood pressure. c. Prepare to administer morphine sulfate. d. Administer oxygen, 8 to 10 L/minute, by face mask.
d. Administer oxygen, 8 to 10 L/minute, by face mask.
1. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? a. Slow the intravenous flow rate. b. Continue the oxytocin drip if infusing. c. Place the client in a high Fowler's position. d. Administer oxygen, 8 to 10 L/minute, via face mask.
d. Administer oxygen, 8 to 10 L/minute, via face mask.
1. Rho (D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? a. Having Rh-positive blood b. Developing a rubella infection c. Developing physiological jaundice d. Being affected by Rh incompatibility
d. Being affected by Rh incompatibility
1. The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. a. Uterine rigidity b. Uterine tenderness c. Severe abdominal pain d. Bright red vaginal bleeding e. Soft, relaxed, non-tender uterus f. Fundal height may be greater than expected for gestational age
d. Bright red vaginal bleeding e. Soft, relaxed, non-tender uterus
1. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? a. Document the finding. b. Encourage the client to ambulate. c. Encourage the client to increase fluid intake. d. Contact the health care provider (HCP) and inform the HCP of this finding.
d. Contact the health care provider (HCP) and inform the HCP of this finding.
1. The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. a. Flushing b. Hypertension c. Increased urine output d. Depressed respirations e. Extreme muscle weakness f. Hyperactive deep tendon reflexes
d. Depressed respirations e. Extreme muscle weakness
1. The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? a. Notify the health care provider of the findings. b. Reposition the mother and check the monitor for changes in the fetal tracing. c. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. d. Document the findings and tell the mother that the pattern on the monitor indicates fetal wellbeing.
d. Document the findings and tell the mother that the pattern on the monitor indicates fetal wellbeing.
1. The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? a. Enlargement of the breasts b. Complaints of feeling hot when the room is cool c. Periods of fetal movement followed by quiet periods d. Evidence of bleeding, such as in the gums, petechiae, and purpura
d. Evidence of bleeding, such as in the gums, petechiae, and purpura
1. The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F. What is the priority nursing action? a. Document the findings. b. Retake the temperature in 15 minutes. c. Notify the health care provider (HCP). d. Increase hydration by encouraging oral fluids.
d. Increase hydration by encouraging oral fluids.
1. The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? a. Allow the newborn to establish own sleep-rest pattern. b. Maintain the newborn in a brightly lighted area of the nursery. c. Encourage frequent handling of the newborn by staff and parents. d. Monitor the newborn's response to feedings and weight gain pattern
d. Monitor the newborn's response to feedings and weight gain pattern
1. The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? a. Provide pain relief measures. b. Prepare the client for an amniotomy. c. Promote ambulation every 30 minutes. d. Monitor the oxytocin infusion closely
d. Monitor the oxytocin infusion closely
1. Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the health care provider who prescribed the medication if which condition is documented in the client's medical history? a. Hypotension b. Hypothyroidism c. Diabetes mellitus d. Peripheral vascular disease
d. Peripheral vascular disease
1. The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? a. Maternal fatigue b. Coordinated uterine contractions c. Progressive changes in the cervix d. Persistent non-reassuring fetal heart rate
d. Persistent non-reassuring fetal heart rate
1. The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? a. Encourage ambulation hourly. b. Assess vital signs every 4 hours. c. Measure fundal height every 4 hours. d. Prepare an ice pack for application to the area
d. Prepare an ice pack for application to the area
1. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? a. Protects the newborn's eyes from possible infections acquired while hospitalized. b. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. c. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. d. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.
d. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.
1. The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? a. At the level of the true pelvis b. At the level of the introitus c. At the level of the ishial spines d. Slightly above the ishial spines
d. Slightly above the ishial spines
1. The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? a. Urinary output has increased. b. Dependent edema has resolved. c. Blood pressure reading is at the prenatal baseline. d. The client complains of a headache and blurred vision.
d. The client complains of a headache and blurred vision.
1. The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? a. The client with mild after pains b. The client with a pulse rate of 60 beats/minute c. The client with colostrum discharge from both breasts d. The client with lochia that is red and has a foul smelling odor
d. The client with lochia that is red and has a foul smelling odor
1. The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? a. The mother requests that the window be closed before feeding. b. The mother holds the newborn properly during feeding and burping. c. The mother tests the temperature of the formula before initiating feeding. d. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.
d. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.
1. The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression of which is noted on the external monitor tracing during a contraction? a. Variability b. Accelerations c. Early decelerations d. Variable decelerations
d. Variable decelerations
