HESI OB MATERNITY

The healthcare provider prescribes zidovudine 100mg po 5x daily for a pregnant woman who is HIV positive. The drug is available in a 240mL bottle labeled, "50mg/5mL." How many mL should the nurse administer? A. 8.5 B. 8 C. 10.5 D. 10

10

A 38-week primigravida is admitted to labor and delivert after a non-reactive stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the health care provider. A. A pattern of fetal late decelerations. B. Fetal heart rate accelerations with fetal movement. C. Absence of uterine contractions within 20 minutes. D. Spontaneous rupture of membranes.

A pattern of fetal late decelerations

The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period? A. A multiparous client who lives with her husband and his family members. B. A primiparous woman who has recently immigrated to the U.S. with her spouse. C. A multiparous female with a large family living in the community. D. A primiparous adolescent living at home with her parents and significant other.

A primiparous woman who has recently immigrated to the U.S. with her spouse

A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse? A. Dizziness when standing. B. Sinus tachycardia. C. Absent patellar reflexes. D. Lower back pain.

Absent patellar reflexes

A primiparous woman presents in labor with the following labs. hemoglobin 10.9 g/dl (109 g/dl) Hematocrit 29% (0.29) hepatitis surface antigen positive, Group B Streptococcus positive and rubella non-immune. which intervention should the nurse implement? A. Transfuse 2 units packs red blood cells. B. Give measles mumps rubella vaccine 0.5 ML. C. Administer ampicillin 2 grams intravenously. D. Inject hepatitis B immune globulin 0.5 milliliters.

Administer ampicillin 2 grams intravenously

Examination reveals that the laboring clients cervix is dilated to 2 centimeters, 70% effaced with the presenting part at -2 station the client tells the nurse I need my epidural now, this hurts, the nurses response to the client is based on which information. A. The client will need to be catheterized before the epidural can be administered. B. Administering an epidural at this point would slow down labor process. C. The client should be dilated to at least 8 centimeters before receiving an epidural. D. The baby needs to be at a zero station before an epidural can be administered.

Administering an epidural at this point would slow down labor process.

A client tells the nurse she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant. A. Morning sickness. B. Breast tenderness. C. Amenorrhea D. Hegar's Sign

Amenorrhea

What should be the primary focus of nursing care in the transitional phase of Labor for a client who anticipates an unmedicated delivery. A Assessing the strength of uterine contractions B Re-evaluate the need for medication C Remind her to push 3 times with each contraction. D Assessing her to maintain control.

Assessing the strength of uterine contractions

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take? A. Administer misoprostol every 2hrs. B. Ambulate the client after administration of misoprostol. C. Start oxytocin infusion immediately. D. Begin oxytocin 4hrs after misoprostol is given.

Begin oxytocin 4hrs after misoprostol is given

The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor which maternity description is most important in preventing this fetus from developing respiratory distress syndrome. A Ampicillin 1 gram IV push q8h B Betamethasone 12 mg deep IM C Terbutaline 0.25 mg subcutaneously q 15 minutes X 3 D Butorphanol tartrate 1mg IV push q2h PRN.

Betamethasone 12 mg deep IM

The nurse places one hand above the symphysis while massaging the fundus of a multiparous client who's uterine tone is boggy 15 minutes after delivering a 7 pounds 10 ounces 3220 grams infant which information should the nurse try to provide the client about those finding. A The uterus should be firm to prevent an intrauterine infection B Both the lower uterine segment and the fundus must be massaged C A firm uterus prevents the endometrial lining from being sloughed D Clots may form inside a boggy uterus and needs to be expelled

Both the lower uterine segment and the fundus must be massaged

A newborn's head circumference is 12inches and his chest measurement is 13 inches. The nurse notes that this infant has no molding, and was a breech presentation delivered by Cesarean section. What action should the nurse take based on these data? A. No action need be taken. It is normal for an infant born by Cesarean section to have a small head circumference. B. Notify the pediatrician immediately. These findings support the possibility of hydrocephalus. C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal. D. Record the findings on the chart. They are within normal limits.

Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal

A newborn's head circumference is 12 inches (30.5cm), and his chest measurement is 13 inches (33cm). The nurse notes that this infant has no molding, and was at breech presentation delivery by c section. What action should the nurse take based on these data? A. No action needs to be taken, it is normal for an infant born by caesarean section to have a small head circumference. B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus. C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal. D. Record the findings on the chart. They are within normal limits.

Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.

The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse documents in the medical record? A Caput succedaneum B Hydrocephalus C Cephalhematoma D Microcephaly

Cephalhematoma

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first? A. Assess cervical dilation. B. Administer oxygen via facemask. C. Change the client's position. D. Turn off the oxytocin infusion.

Change the client's position

A client in the first trimester of pregnancy calls the prenatal clinic to report she's nauseated, and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? select all that applies. A. Come to the clinic today. B. Drink a full glass of tea with each iron tablet. C. Increase the consumption of milk while taking iron. D. Changes in color and consistency of stool are normal. E. Take iron supplement at bedtime.

Changes in color and consistency of stool are normal

A client at 35 weeks gestation complains of a "pain whenever the baby moves". On assessment, the nurse notes the client's temperature to be 101.2F with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of which condition? A. Round ligament strain. B. Viral infection C. Abruptio placenta D. Chorioamnionitis

Chorioamnionitis

A new mother who is a lacto-ovo vegetarian plans to breast feed her infant. Which information should the nurse provide prior to discharge? A Continue prenatal vitamins with B12 While breastfeeding B Avoid using Lanolin-based nipple cream or ointment. C Offer iron fortified supplemental formula daily. D Weigh the baby weekly to evaluate the newborns growth.

Continue prenatal vitamins with B12 While breastfeeding

Following a traumatic delivery an infant receives an initial Apgar score of 3. which intervention is most important for the nurse to implement. A Page the pediatrician STAT B Continue resuscitative efforts C Repeat the Apgar assessment in 5 minutes D Inform the parents of the infant's condition.

Continue resuscitative efforts

A newborn with a respiratory rate of 40 breathes per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take. A. Assess bowel sounds B. Continue to monitor C. Assist with intubation D. Rub infants back

Continue to monitor

A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and contractions are occurring irregularly every 10-15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time? A. Contractions decrease with walking. B. 2+ pitting edema in lower extremities. C. Cervical dilations is 1cm. D. Membranes are intact.

Contractions decrease with walking

An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivers a 7-pound infant 12 hours ago is reporting a severe headache. The client blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/minute, heart rate is 74 bpm, and temperature is 98.6F. The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first? A. Notify the healthcare provider of the assessment findings. B. Obtain a STAT hemoglobin and hematocrit. C. Assign a practical nurse (PN) to reassess the client's vital signs. D. Determine if the client received anesthesia during delivery.

Determine if the client received anesthesia during delivery

The healthcare provider prescribes 10 units per liters of oxytocin via IV drip to augment a client's labor because she's experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin. A. Contraction duration of 100 seconds. B. For contractions in 10 minutes. C. Uterus is soft. D. Early deceleration of fetal heart rate.

Early deceleration of fetal heart rate

At 6 weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? A. Early postpartum, within 72hrs of delivery. B. Immediately, at 6-weeks gestation, to protect this fetus. C. After the client reaches 20-weeks gestation. D. After the client stops breastfeeding.

Early postpartum, within 72hrs of delivery

An ambulatory client at 39-weeks gestation presents to the emergency center with an obvious injury to her arm that occurred as the result of a fall. Which concurrent symptom is a priority for the nurse to assess. A. Ecchymotic knees. B. Dribbling urine. C. 1+ pedal edema. D. Pain in the forearm.

Ecchymotic knees

A 17 year old client gave birth 12 hours ago she states that she doesn't know how to care for her baby. To promote parent infant attachment behaviors which intervention should the nurse implement. A. Ask if she has help to care for the baby at home. B. Provide a video on newborn safety and care. C. Explored the basis of fears with the client. D. Encourage rooming in while in the hospital.

Encourage rooming in while in the hospital

A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first? A. Increase the intravenous fluid to 150ML/hr. B. Call the health care provider. C. Encourage the client to void. D Administer ibuprofen 800 milligrams by mouth.

Encourage the client to void

The nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is important for the nurse to take? A. Explain reasons consent for an infant autopsy is needed. B. Encourage the mother to hold and spend time with her baby. C. Determine if the mother desires a visit from her clergy. D. Create a memory box of baby's footprints and photographs.

Encourage the mother to hold and spend time with her baby

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement? A. Ensure that they have the pediatric clinic's phone number. B. Provide the results of the infant's hearing test to the parents. C. Request a return demonstration of a diaper change. D. Evaluate infant feeding technique prior to discharge.

Evaluate infant feeding technique prior to discharge

A client at 31 weeks gestation with a fundal height measurement of 25 c is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide. A. Assessment for congenital anomalies. B. Recalculation of gestational age. C. Evaluation of fetal growth. D. Determination of fetal presentation.

Evaluation of fetal growth

A client with 26 weeks gestation was informed this morning that she has an elevated alpha fetal protein (AFP) level. After the health care provider leaves the room, the client asks what she should do next. What information should the nurse provide. A. Reassured the client that the AFP results are likely to be a false reading. B. Explain that his sonogram should be scheduled for definitive results. C. Inform her that a repeat alpha fetoprotein AFP should be evaluated. D. Discuss options for intrauterine surgical correction of congenital defects.

Explain that his sonogram should be scheduled for definitive results.

A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. which assessment warrants immediate intervention by the nurse. A Fetal Heart rate 60 beats per minute B Ruptured amniotic membrane C onset of uterine contractions D leaking amniotic fluid.

Fetal Heart rate 60 beats per minute

The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of eight pounds 3629 grams at 36 weeks gestation. This amniocentesis is being performed to obtain which information? A. Presence of a neural tube defect. B. Chromosomal abnormalities. C. Gender of the fetus. D. Fetal lung maturity.

Fetal lung maturity

On the first postpartum day the nurse examines the breast of a new mother. Which condition is the nurse most likely to find. A Firm larger and very tender to touch. B Slightly firm with immediate let-down response. C Soft with no change from before delivery. D Filling and secreting colostrum.

Filling and secreting colostrum

A newborn's assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication? A. Folic acid deficiency B. Preeclampsia C. Tobacco use D. Short interval pregnancy

Folic acid deficiency

A 3-hour old male infants hands and feet as cyanotic, and has an axillary temperature of 96.5 degrees Fahrenheit 35.8 degrees centigrade a respiratory rate of 40 breaths per minute and a heart rate of 165 beats per minute what nursing action should nurse implement. A Administer oxygen by mouth at 2L/min B Gradually warm the infant under a radiant heat source. C Notify the pediatrician of the infant's vital signs D Perform a heel-stick to maintain blood glucose level

Gradually warm the infant under a radiant heat source

A pregnant client presents to the antepartum clinic complaining of brownish vaginal bleeding. The nurse notes that she has a greatly enlarges uterus and is complaining of severe nausea. The client reports that her period was "about 2 and a half months ago". Vital signs are: temperature 98.7F, pulse rate 70bpm, rr 18, and bp 190/110 mmHg. Based on these findings, what laboratory value should the nurse review? A. HcG values. B. Hematocrit. C. Vaginal secretions culture. D. Glucose in the urine.

HcG values

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority? A. Hyperbilirubinemia B. Polycythemia C. Hyperthermia D. Hypoglycemia

Hypoglycemia

The more of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right she tells the nurse, "Now my daughter is not getting enough to eat" which response would be best for the nurse to make. A. Feed your baby hourly until you feel confident that your child is receiving enough milk. B. Don't worry soon your milk will come in and you will feel how full your breasts are. C. Since you are so concerned you should probably supplement breastfeeding with formula. D. If your baby's urine is straw colored, she's getting enough milk.

If your baby's urine is straw colored, she's getting enough milk

A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement? A. Inform her that a decreased need for insulin occurs while breastfeeding. B. Counsel her to increase her caloric intake. C. Advise the client to breastfeed more frequently. D. Schedule an appointment for the client with the diab

Inform her that a decreased need for insulin occurs while breastfeeding.

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? A. Ensure preoperative lab results are available. B. Inform the anesthesia care provider. C. Start prescribed IV with Lactated Ringer's. D. Contact the client's obstetrician.

Inform the anesthesia care provider

At 12 hours after the birth of a healthy infant the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. which action should nurse take? A Check the suprapubic area for distention. B Inform the client to take a warm sitz bath C Inspect clients perineal and rectal areas D Apply a fresh pad and check in 1 hour.

Inspect clients perineal and rectal areas

A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contraction 5 minutes apart while the client is in the bathroom changing into a hospital gown the nurse hears the noise of a baby what should the nurse take first? A Push the call light for help B Inspect the clients perineum C Notify a health care provider D Turn on the infant warmer

Inspect the clients perineum

A new born nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a new born admission. What action should the nurse take to ensure adequate installation of the client. A Instill a thin ribbon into each lower conjunctival sac B Occlude the inner canthus after retracting the eyelids C Mummy wrap the infant before instilling the ointment D Stabilize the instilling hand on the neonate's head

Instill a thin ribbon into each lower conjunctival sac

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3cm. The nurse's assessment findings and electronic fetal monitoring(EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribed and oxytocin drip. Which data is most important for the nurse to monitor? A. Preparation for emergency cesarean birth. B. Client's hourly blood pressure. C. Checking the perineum for bulging. D. Intensity, interval, and length of contractions.

Intensity, interval, and length of contractions.

A 16 year old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? A. Assess temperature every hour. B. Monitor blood pressure, pulse, and respirations every 4 hours. C. Keep an airway at the bedside. D. Allow family visitation

Keep an airway at the bedside

If primigravida at 36 weeks gestation who is RH negative experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider? A Fetal heart rate at 162 beats /minute B Mild contractions every 10 minutes. C Trace of protein in the urine D Positive fetal hemoglobin testing

Mild contractions every 10 minutes

The nurse is receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite? A. Begin a pad count. B. Prepare to start an IV. C. Take the clients temperature. D. Monitor amniotic fluid for meconium.

Monitor amniotic fluid for meconium

Four client at full term present to the labor and delivery unit at the same time. which client should a nurse access first. A Multipara with contractions occurring every three minutes. B Multiple scheduled for non stress test and biophysical profile. C Primipara with vaginal show and leaking membranes. D Primipara with burning on urination and urinary frequency.

Multipara with contractions occurring every three minutes

A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor. What is the priority nursing action for this client? A. Gently massage the fundus every 4 hours. B. Observe for signs of uterine hemorrhage. C. Encourage direct contact with the infant. D. Assess the blood pressure for hypertension.

Observe for signs of uterine hemorrhage.

A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the records and observes there has been a rapid weight gain over 6 weeks. Which action should the nurse implement next? A. Ask for a 24 hour diet recall. B. Obtain a blood pressure. C. Inspect for pedal edema. D. Listen to fetal heart rate.

Obtain a blood pressure

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old infant has a gestational age of 42-weeks. Based on this finding, which intervention is most important for the nurse to implement? A. Provide blow-by oxygen B. Draw arterial blood gases C. Obtain a capillary blood glucose D. Apply a pulse oximeter to the foot

Obtain a capillary blood glucose

The nurse is caring for a client whos is 10 weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take? A. Measure vital signs. B. Recommend bed rest. C. Collect urine sample urinalysis. D. Obtain human chronic gonadotropin levels.

Obtain human chronic gonadotropin levels

A client who is 24 weeks gestatoin arrives to the clinic reporting swollen hands. On examination the nurse notes the clients as had a rapid weight gain over six weeks. which action should a nurse implements next? A. Review previous blood pressures in the chart. B. Obtain the clients blood pressure. C. Observe and time the client's contractions. Examined the client for pedal edema. D. Examine the client for pedal edema

Obtain the clients blood pressure

The nurse is caring for a multiparous client who is 8 centimeters dilated 100% effaced and the fetal head is at 0 station. The clients is shivering and states extreme discomfort with the urge to bear down. which intervention should the nurse implement? A Administer IV pain medication B Perform a vaginal exam C Reposition to side lying D Encourage pushing with each contraction.

Perform a vaginal exam

The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist arrival on the unit, which action should the nurse perform? A. Cleanse the spinal injection site. B. Place procedure equipment at bedside. C. Apply an abdominal binder. D. Insert an indwelling Foley catheter.

Place procedure equipment at bedside

Upon admission to the nursery, the nurse places a newborn supine under a radiant warmer, an external heat source. What intervention should the nurse implement to ensure safe thermoregulation? A. Wrap the infant in two blankets and place the radiant warmer on low. B. Dry the newborn's scalp and place a stockinet cap on the head. C. Move temperature probe over the ribs when turning to a lateral position. D. Place temperature probe on the abdomen in line with the radiant heat source.

Place temperature probe on the abdomen in line with the radiant heat source

A mother spontaneously delivers a newborn infant in the taxicab while on the way to the hospital the emergency room nurse reported the mother as active herpes (H5V III) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery? A. Documents the temperature on the flow sheet. B. Place the newborn in the isolation area of the nursery C. Obtain blood specimen for serum glucose level. D. Administer the vitamin K injection.

Place the newborn in the isolation area of the nurser

A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse assessment reveals approximately 30ML of bright red vaginal bleeding. Fetal rate of 130 - 140 beats per minute, no contractions and no complaints of pain what is the most likely cause of these client's bleeding. A Abruptio Placenta B Placenta Previa C Normal bloody show indicting induction of labor D A ruptured blood vessel in the vaginal vault.

Placenta Previa

The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first? A. Assess the infant's blood glucose level. B. Nipple feed 1oz 5% glucose in water. C. Place the infant in a side-lying position. D. Position a radiant warmer over the crib.

Position a radiant warmer over the crib

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication? A. Improve insufficient dietary intake. B. Stimulate the immune system. C. Prevent hemorrhagic disorders. D. Help an immature liver.

Prevent hemorrhagic disorders.

A primipara client at 42 weeks gestation is admitted for induction. within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75 second duration. when nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20 second duration. Which intervention should the nurse implement? A. Notify nursery about the client's response. B. Check for clonus in both feet. C. Stop oxygen per cannula. D. Restart oxytocin infusion rate per protocol.

Restart oxytocin infusion rate per protocol

A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7 pounds infant 4 hours ago by cesarean delivery. Which nursing problem has the highest priority? A. Risk for injury related to uterine atony. B. Ineffective breastfeeding related to fatigue. C. Acute pain related to abdominal incision. D. Impaired parenting related to inexperience.

Risk for injury related to uterine atony

A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond? A. "That is called caput succedaneum. It will have to be drained." B. "That is called caput succedaneum. It will absorb and cause no problems." C. "That is called a cephalhematoma. It will cause no problems." D. "That is called a cephalhematoma. It can cause jaundice as it is absorbed."

That is called caput succedaneum. It will absorb and cause no problems

The nurse is conducting a home health visit of a client who delivered 3 weeks ago and is formula feeding the infant. Which observations should the nurse find most concerning? A. The client notes infant feeds every 2-3 hours and voids 5-6 times per day. B. The client is in pajama's and infant is freshly bathed. C. Used bottles are in the kitchen and infant is in a swing. D. The clients eyes are red from crying and infant is fussing in the crib.

The clients eyes are red from crying and infant is fussing in the crib

A gravida 3 para 3 who is Rh negative delivers a full infant at home with assistance of a nurse midwife. Two days later, the client calls the clinic to ask if it is necessary to see the health care provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. A.The newborn's blood type should be tested to determine the need for RhoGAM B.It is likely that the husband is Rh-negative, and if so RhoGam C.RhoGam injections must be administered within 24 hours after delivery

The newborn's blood type should be tested to determine the need for RhoGAM

Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mmHg and heart rate is 130 bpm. Which action should the nurse implement first? A. Palpate the abdomen for contractions. B. Tilt the backboard sideways to displace the uterus laterally. C. Obtain a blood sample for complete blood count. D. Infuse 1,000 mL normal saline using a large bare IV.

Tilt the backboard sideways to displace the uterus laterally

A pregnant client mentions in a history that she changes cats litter box daily. Which test should the nurse anticipate the health care provider to prescribe. A Biophysical profile. B Fern test. C Amniocentesis. D Torch screening.

Torch screening

The nurse is caring for a 35-week gestation infant delivered by cesarean section 2 hours ago. The nurse observes the infant's respiratory rate is 72 breaths/minute with nasal flaring, grunting, and retractions. The nurse should recognize these findings indicate which complication? A. Persistent pulmonary hypertension of the newborn. B. Transient tachypnea of the newborn. C. Meconium aspiration syndrome. D. Bronchopulmonary dysplasia.

Transient tachypnea of the newborn

A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client? A. After ceasing breastfeeding, the diaphragm should be resized. B. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated. C. If no more than 20 pounds was gained during pregnancy, the diaphragm is safe to use. D.Use an alternate form of contraceptive until a new diaphragm is obtained.

Use an alternate form of contraceptive until a new diaphragm is obtained.

A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of testing provides the greatest degree of accuracy? A. Visualization of implantation by vaginal ultrasound. B. Presence of amenorrhea for 2 months. C. Maternal blood serum tests positive for alpha-fetoprotein. D. Complaints of feeling tired all of the time.

Visualization of implantation by vaginal ultrasound

A client who delivered a healthy newborn an hour ago asked the nurse when can she go home. Which information is most important for the nurse to provide the client. A After the baby no longer demonstrates acrocyanosis. B After the vitamin K injection is given to the baby. C When ambulating to avoid does not cause dizziness. D When there is no significant vaginal bleeding.

When there is no significant vaginal bleeding

A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. the nurse should recognize the clients is prohibiting symptoms of which condition? 1. German measles 2. herpes simplex virus 3. syphilis 4. genital warts

herpes simplex virus