HESI Practice Test OB

Put the following actions in order to prevent hypotension in the pregnant client: 1. reposition the client 2. provide oxygen via face mask 3. increase IV fluid 4. call the healthcare provider

1. reposition the client 2. increase the IV fluid 3. provide oxygen via face mask 4. call the healthcare provider.

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate? A. "A home pregnancy test can be used right after your first missed period." B. "These tests are most accurate after you have missed your second period." C. "Home pregnancy tests often give false positives and should not be trusted." D. "The test can provide accurate information when used right after ovulation."

A. "A home pregnancy test can be used right after your first missed period."

A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes and hyperclonus B. periorbital edema, flashing lights, and aura C. epigastric pain in the third trimester D. recent decreased urinary output

A. 3+ deep tendon reflexes and hyperclonus

On admission to the prenatal clinic, a 23-year old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be A. November 22 B. November 8 C. December 22 D. October 22

A. November 22

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? A. choking, coughing, and cyanosis B. projectile vomiting and cyanosis C. apneic spells and grunting D. scaphoid abdomen and anorexia

A. choking, coughing and cyanosis

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of the greatest concern? A. edema, basilar rates, and an irregular pulse B. increased urinary output and tachycardia C. shortness of breath, bradycardia, and hypertension D. regular heart rate and hypertension

A. edema, basilar rates, and an irregular pulse

The healthcare provider prescribes terbutalne (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A. gestational diabetes B. elevated blood pressure C. urinary tract infection D. swelling in lower extremities

A. gestational diabetes

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. have the client empty her bladder B. request the client lie on her left side C. Perform Leopold's maneuvers first D. Give the client some cold juice to drink

A. have the client empty her bladder

Which nurse intervention would be most helpful in relieving postpartum uterine contractions or "afterpains?" A. lying prone with a pillow on the abdomen B. using a breast pump C. massaging the abdomen D. giving oxytocic medications

A. lying prone with a pillow on the abdomen

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply) A. mood swings B. panic attacks C. tearfulness D. decreased need for sleep E. disinterest in the infant

A. mood swings C. tearfulness

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. patellar reflex 4+ B. blood pressure 158/80 C. four-hour urine output 240 mL D. respiration 12/minute

A. patellar reflex 4+. a 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of impending seizure.

A 4 week old premature infant has been receiving epoetin alfa (Epogen) for the last 3 weeks. Which assessment finding indicates to the nurse that the drug is effective? A. slowly increasing urinary output over the last week B. respiratory rate changes from the 40s to the 60s. C. changes in apical heart rate from the 180s to the 140s D. change in indirect bilirubin from 12 mg/dl to 8 mg/dl

A. slowly increasing urinary output over the last week

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs A. two weeks before menstruation B. immediately after menstruation C. immediately before menstruation D. three weeks before menstruation

A. two weeks before menstruation

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? A. administer oxygen by face mask B. notify the healthcare provider of the client's symptoms C. have the client breathe into her cupped hands D. check the client's blood pressure and fetal heart rate

C. Have the client breathe into her cupped hands.

A newborn infant is brought to the nursery from the bathing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? A. notify the pediatrician B. suction the infant's nares, then the oral cavity C. check the infant's oxygen saturation rate D. position the infant on the right side.

C. check the infant's oxygen saturation rate

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? A. wear a cotton bra B. increase nursing time gradually C. correctly place the infant on the breast D. manually express a small amount of milk before nursing

C. correctly place the infant on the breast

A client with no prenatal care arrives at the labor unit screaming, "the baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain? A. gravidity and parity B. time and amount of last oral intake C. date of last normal menstrual period D. frequency and intensity of contractions

C. date of last normal menstrual period

The total bilirubin level of a 36 hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? A. provide phototherapy for 30 minutes q8h B. feed the newborn sterile water hourly C. encourage the mother to breastfeed frequently D. assess the newborn's blood glucose level

C. encourage the mother to breastfeed frequently

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A. insert an internal fetal monitor B. assess for cervical changes q1h C. monitor for bleeding from IV sites D. perform Leopold's maneuvers

C. monitor for bleeding from IV sites. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding.

A client at 32 weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue and a moist cough. Which question is most important for the nurse to ask this client? A. "Which symptom did you experience first?" B. "Are you eating large amounts of salty foods?" C. "Have you visited a foreign country recently?" D. "Do you have a history of rheumatic fever?"

D. "Do you have a history of rheumatic fever?" Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in the client's record? A. 31203 B. 41203 C. 21212 D. 31103

D. 31103. The client has been pregnant 3 times including the current pregnancy (G3); She had one full-term infant (T1); She also had a preterm (P1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity); There were no abortions (A0), so this client has a total of 3 living children.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. encourage the mother to provide total care for her infant B. provide privacy so the mother can develop a relationship with the infant. C. encourage the father to provide most of the infant's care during hospitalization. D. Meet the mother's physical needs and demonstrate warmth toward the infant.

D. Meet the mother's physical needs and demonstrate warmth toward the infant.

The nurse is planning preconception care for a new female client. Which information should the nurse provide to the client? A. discuss various contraceptive methods to use until pregnancy is desired B. provide written or verbal information about prenatal care C. ask the client about risk factors associated with complications of pregnancy D. encourage healthy lifestyles for families desiring pregancy

D. encourage healthy lifestyles for families desiring pregancy

An off-duty nurse finds a woman in a supermarket parking lot delivery an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. use a thread to tie off the umbilical cord. B. provide as much privacy as possible for the woman. C. reassure the husband and try to keep him calm D. put the newborn to breast.

D. put the newborn to breast. Putting the newborn to breast will help contract the uterus and prevent a postpartum hemorrhage - this intervention has the highest priority.

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succadeaneum. Which additional information should the nurse provide this new mother? A. the infant should be positioned to reduce the swelling B. the swelling is a subperiosteal collection of blood C. the pediatrician will aspirate the blood if it gets larger D. the scalp edema will subside in a few days after birth.

D. the scalp edema will subside in a few days after birth. Caput succadeaneum is edema of the fetal scalp that crosses over the suture lines and is caused by pressure on the fetal head against the cervix during labor. It will subside in a few days after birth without treatment.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6 inch diameter pool of blood. Which action should the nurse implement next? A. cleanse the perineum B. obtain a blood pressure C. palpate the firmness of the fundus D. inspect the perineum for lacerations.

Palpate the firmness of the fundus. A firm fundus is needed to control bleeding from the placental site of attachment on the uterine wall. The nurse should first assess for firmness and massage the fundus as indicated.

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? A. apply cold compresses to both breasts for comfort. B. instruct the client to run warm water on her breasts C. wear a loose-fitting bra to prevent nipple irritation D. express small amounts of milk to relieve pressure

A. apply cold compresses to both breasts for comfort.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide the client? A. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." B. "We want your baby to be healthy, and this is the only way we can make sure that will happen." C. "I know you're upset. Would you like to talk about some things you could do while in bed." D. "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties."

A. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue."

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn B. The client's educational background C. The order in which the information is presented D. The extent to which the pregnancy is planned

A. The client's readiness to learn

Twenty four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line in a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications C. molding, caused by pressure during labor and will disappear within 2 to 3 days D. a subdural hematoma which can result in lifelong damage

A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? Select all that apply A. admission weight of 4 pounds, 15 ounces (2244 grams) B. head to heel length of 17 inches (42.5 cm) C. Frontal occipital circumference of 12.5 in (31.25 cm) D. Skin smooth with visible veins and abundant vernix E. Anterior plantar crease and smooth heel surfaces F. Full flexion of all extremities in resting supine position

A. admission weight of 4 pounds, 15 ounces (2244 grams) B. head to heel length of 17 inches (42.5 cm) C. Frontal occipital circumference of 12.5 in (31.25 cm). The normal full-term appropriate for gestational age (AGA) newborn should fall between the measurement ranges of weight 6-9 pounds, length 19-21 inches, FOC 13-14 inches. This neonate's parameters plot below the 10% percentile, which indicate that the infant is SGA.

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? A. bathe the infant with an antimicrobial soap B. measure the head and chest circumference C. obtain the infant's footprints D. administer vitamin K (AquaMEPHYTON)

A. bathe the infant with an antimicrobial soap. To reduce direct contact with the Human immuno-virus in blood and body fluids on the newborn's skin, a bath with an antimicrobial soap should be administered first.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. between the time the temperature falls and rises B. between 36 and 48 hours after the temperature rises C. when the temperature falls and remains low for 36 hours D. within 72 hours before the temperature falls

A. between the time the temperature falls and rises

A multigravida client at 41 weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? A. biophysical profile (BPP) B. ultrasound for fetal anomalies C. maternal serum alpha-fetoprotein (AF) screening D. percutaneous umbilical blood sampling (PUBS)

A. biophysical profile (BPP). This test provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to the aging placenta.

A client at 28 weeks gestation calls the antepartal clinical and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. come to the clinic today for an ultrasound B. go immediately to the emergency room C. lie on your left side for about one hour and see if the bleeding stops D. bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection

A. come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound.

A multigravida client arrives at the labor and delivery unit and tells the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140-150 bpm. What action should the nurse implement next? A. complete a sterile vaginal exam B. take maternal temperature every 2 hours C. prepare for an immediate cesarean birth D. obtain sterile suction equipment

A. complete a sterile vaginal exam. This is done to determine the presence of a prolapsed umbilical cord.

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply) A. dark, red vaginal bleeding B. lower back pain C. premature rupture of the membranes D. increased uterine irritability E. bilateral pitting edema F. a rigid abdomen

A. dark, red vaginal bleeding D. increased uterine irritability

A 35-year old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity? A. deep tendon reflexes 2+ B. blood pressure 140/90 C. respiratory rate 18/min D. urine output 90 mL/4 hours

A. deep tendon reflexes 2+

A woman with type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? A. Describe diet changes that can improve the management of her diabetes B. inform the client that oral hypoglycemic agents are teratogenic during pregnancy C. Demonstrate self-administration of insulin D. evaluate the client's ability to do glucose monitoring

A. describe diet changes that can improve the management of her diabetes

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks gestation. What type of emotional response should the nurse anticipate? A. grief related to her perceptions about the loss of this child B. Relief of ambivalent feelings experienced with this pregnancy C. Shock because she may not have realized that she was pregnant D. guilt because she had not followed her healthcare provider's instructions

A. grief related to her perceptions about the loss of this child

Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 bpm and respirations of 20 breaths/min. What action should the nurse perform next? A. initiate positive pressure ventilation B. intervene after the one minute Apgar is assessed C. initiate CPR on the infant D. assess the infant's blood glucose level

A. initiate positive pressure ventilation because the infant's vital signs are not within the normal range and oxygen deprivation leads to cardiac depression in infants. The normal newborn pulse is 100-160 bpm and respirations are 40-60 breaths/minute.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? A. raise the foot of the bed B. assess for vaginal bleeding C. evaluate the fetal heart rate D. take the client's blood pressure

A. raise the foot of the bed. These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (Trendelenburg position) will increase venous return and provide blood to the vital areas.

The nurse is providing discharge for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? A. reduce activity level and notify the healthcare provider B. go to bed and assume a knee-chest position C. massage the uterus and go to the emergency room d. do not worry as this is a normal occurance

A. reduce activity level and notify the healthcare provider

A 42 week gestational client is receiving an intraenous infusion of oxytocin (pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? A. transition labor with contractions every 2 minutes, lasting 90 seconds each. B. early labor with contractions every 5 minutes, lasting 40 seconds each C. Active labor with contractions every 31 minutes, lasting 60 seconds each D. Active labor with contractions every 2-3 minutes, lasting 70-80 seconds each

A. transition labor with contractions every 2 minutes, lasting 90 seconds each. When oxytocin causes uterine hyperstimulation as evidence by inadequate resting time between contractions, the oxytocin infusion should be discontinued because placental perfusion is impeded.

The nurse is assessing a 3 day old infant with a cephaloheatoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? A. Yellowish tinge to the skin B. Babinski reflex present bilaterally C. pink papular rash on the face D. Moro reflex noted after a loud noise

A. yellowish tinge to the skin. Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Due to the breakdown of the red blood cells within a hematoma, the infant is at a greater risk for jaundice so it should be reported.

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? A. "Your current dose of insulin should be maintained throughout your pregnancy." B. "Maintain blood sugar levels in a constant range within normal limits during pregnancy." C. "The course and outcome of your pregnancy is not an achievable goal with diabetes." D. "Expect an increase in insulin dosages by 5 units/wk during the first trimester."

B. "Maintain blood sugar levels in a constant range within normal limits during pregnancy."

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation will the nurse provide? A. "weigh the baby daily, and if she is gaining weight, she is eating enough." B. "your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times/day." C. "Offer the baby extra bottle milk after her feeding and see if she is still hungry." D. "If you're concerned, you might consider bottle feeding so that you can monitor her intake."

B. "your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times/day."

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distending bladder could be traumatized during labor, as well as prolong the progress of labor C. urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. frequent voiding minimizes the need for catheterization which increases the chance of bladder infection

B. An over-distending bladder could be traumatized during labor, as well as prolong the progress of labor

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. she eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body

B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be A. January 14-15 B. January 22-23 C. January 30-31 D. February 6-7

B. January 30-31. This woman can expect her next period to begin 36 days from the first day of her last menstrual period - the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, began on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele's rule, what is the estimated date of delivery? A. April 25, 2007 B. May 9, 2007 C. May 29, 2007 D. June 2, 2007

B. May 9, 2007

A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse have available for signs of potential toxicity? A. oxytocin (pitocin) B. calcium gluconate C. terbutaline (Brethine) D. naloxone (narcan)

B. calcium gluconate

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to the infant. The nurse's response should be based on what information? A. males inherit the disorder with a greater frequency than females B. each pregnancy carries a 50% chance of inheriting the disorder C. the disorder occurs in 25% of pregnancies D. all children will be carriers of the disorder

B. each pregnancy carries a 50% chance of inheriting the disorder

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. ask if she takes a daily calcium tablet B. extend the leg and dorsiflex the foot C. lower the leg off the side of the bed D. elevate the leg above the heart

B. extend the leg and dorsiflex the foot. "Toes to the nose"

A primigravida at 40 weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? A. dehydration B. hyperstimulation C. galactorrhea D. fetal tachycardia

B. hyperstimulation. Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? A. length of labor and method of delivery B. infant's condition at birth and treatment received C. feeding method chosen by the parents D. history of drugs given to the mother during labor

B. infant's condition at birth and treatment received

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. supplementary iron is more efficiently utilized during pregnancy B. it is difficult to consume 18 mg of additional iron by diet alone. C. iron absorption is decreased in the GI tract during pregnancy D. iron is needed to prevent megaloblastic anemia in the last trimester

B. it is difficult to consume 18 mg of additional iron by diet alone.

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores B. lower birth weights C. respiratory distress D. a higher rate of congenital anomalies

B. lower birth weights

A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg SQ. Which assessment is the highest priority for the nurse to monitor during the adminstration of this drug? A. maternal blood pressure and respirations B. maternal and fetal heart rates C. hourly urinary output D. deep tendon reflexes

B. maternal and fetal heart rates

A 30 year old gravida, 2 para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? A. maternal blood pressure and respirations B. maternal and fetal heart rates C. hourly urinary output D. deep tendon reflexes

B. maternal and fetal heart rates

The nurse identifies crepitus when examining the chest of the newborn who was delivered vaginally. Which further assessment should the nurse perform? A. elicit a positive scarf sign on the affected side B. observe for an asymmetrical Moro (startle) reflex C. Watch for swelling of fingers on the affected side D. Note paralysis of affected extremity and muscles

B. observe for an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if the infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.

The nurse should explain to a 30 year old gravid client that alpha fetoprotein testing is recommended for which purpose? A. detect cardiovascular disorders B. screen for neural tube defects C. monitor for placental functioning D. assess for maternal pre-eclampsia

B. screen for neural tube defects

A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? A. the length of labor and method of delivery B. the infant's condition at birth and treatment received C. the feeding method chosen by the parents D. the history of drugs given to the mother during labor

B. the infant's condition at birth and treatment received

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head" Which response by the nurse is best? A. "This is not an unusual shaped head, especially for a first baby." B. "It may look funny to you, but newborn babies are often born with heads like your baby's." C. "That is normal, the head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the baby's head had to adjust to the birth canal."

C. "That is normal, the head will return to a round shape within 7 to 10 days."

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? A. Herpes B. Staphylococcus C. Gonorrhea D. Syphilis

C. Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, and infection caused by gonorrhea, and including conjunctivitis,, an infection caused by chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.

A 38-week primagravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings B. Reduce salt in her diet C. Move about every hour D. Avoid constrictive clothing

C. Move about every hour

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7-10 days B. Meconium is the first stool and is usually yellow gold in color C. Vernix is a white, cheesy substance, predominantly located in the skin folds D. Pseudostrabismus found in newborns is treated by minor surgery.

C. Vernix is a white, cheesy substance, predominantly located in the skin fold

A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? A. 4+ reflexes B. urinary output of 50 mL per hour C. a decrease in respiratory rate from 24 to 16 D. a decreased body temperature

C. a decrease in respiratory rate from 24 to 16

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is A. shortness of breath B. joint pain C. a persistent cold D. organomegaly

C. a persistent cold

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (select all that apply) A. litmus paper B. fetal scalp electrode C. a sterile glove D. an amnihook E. sterile vaginal speculum F. lubricant

C. a sterile glove D. an amnihook F. lubricant

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (select all that apply) A. Litmus paper B. fetal scalp electrode C. a sterile glove D. an amniotic hook E. sterile vaginal speculum F. a Doppler

C. a sterile glove D. an amniotic hook F. a Doppler

A 24-hour old newborn has a pink papular rash with vesicles superimposed on the thorax, back and abdomen. What action should the nurse implement? A. notify the healthcare provider B. move the newborn to an isolation nursery C. document the finding in the infant's record D. obtain a culture of the vesicles

C. document the finding in the infant's record. Erythema Toxicum (or erythema neonatorium) is a newborn rash that is commonly referred to as "flea bites." but is a normal finding that is documented in the infant's record and requires no further action.

A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment is most indicative of an impending convulsion? A. 3+ deep tendon reflexes B. periorbital edema C. epigastric pain D. decreased urine output

C. epigastric pain. Epigastric pain is indicative of an edematous liver or pancreas which is an early warning sign of an impending convulsion (eclampsia) and requires immediate attention.

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? A. begin as soon as your baby is born to establish a four-hour feeding schedule B. resting helps with milk production. Ask that your baby be fed at night in the nursery C. feed your baby every 2 to 3 hours or on demand, whichever comes first. D. do not allow your baby to nurse any longer than the prescribed number of minutes

C. feed your baby every 2-3 hours or on demand, whichever comes first

At 14 weeks gestation, a client arrives at the emergency center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 bpm, and a blood pressure of 86/48. Which action should the nurse implement next? A. check the hematocrit results B. administer pain medication C. increase the rate of IV fluids D. monitor client for contractions

C. increase the rate of IV fluids. The client is demonstrating symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at approximately 14 weeks gestation when embryonic growth expands the fallopian tube causing its rupture and can result in hemorrhage and hypovolemic shock. Increasing the IV infusion rate provides intravascular fluid to maintain blood pressure.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick and high. Based on this data, which intervention should the nurse implement first? A. provide oral hydration B. have a complete blood count (CBC) drawn C. obtain a specimen for urine analysis D. place the client on strict bedrest

C. obtain a specimen for urine analysis. This should be done first because preterm clients with uterine irritability and contractions are often suffering from a UTI, and this should be ruled out first.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? A. heart rate of 100 bpm B. variable fetal heart rate C. onset of uterine contractions D. burning on urination

C. onset of uterine contractions. Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take? A. notify the healthcare provider or anesthesiologist immediately. B. continue to assess the blood pressure q5 minutes C. place the woman in a lateral position D. turn off the continuous epidural

C. place the woman in a lateral position. The nurse should immediately turn the woman to a lateral position, place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases ,the anesthesiologist/healthcare provider should be notified immediately. Turning off the continuous epidural may also be warranted, but such action is based on hospital protocol.

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? A. cuddles the baby close to her B. rocks and soothes the infant in her arms C. places the infant prone in the bassinet D. wraps the baby in a warm blanket after bathing

C. places the infant prone in the bassinet. This is associated with an increased incidence of sudden infant death syndrome (SIDS)

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that that woman's fallopian tubes are patient? A. back pain B. abdominal pain C. shoulder pain D. leg cramps

C. shoulder pain

A 26-year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg SQ to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? A. drowsiness and bradycardia B. depressed reflexes and increased respirations C. tachycardia and a feeling of nervousness D. a flushed, warm feeling and a dry mouth

C. tachycardia and a feeling of nervousness

A 23 year old client who is receiving Medicaid is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? A. refer the client to a social worker to arrange for home care B. recommend prenatal care from an obstetrician, not a nurse midwife C. teach the client why keeping prenatal care appointments is important D. Advise the client that neonatal intensive care may be needed

C. teach the client why keeping prenatal care appointments is important

The nurse should encourage the laboring client to begin pushing when A. there is only an anterior or posterior lip of cervix left. B. the client describes the need to have a bowel movement. C. the cervix is completely dilated D. the cervix is completely effaced

C. the cervix is completely dilated

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? A. two vessels: one artery and one vein B. two vessels: two arteries and no veins C. three vessels: two arteries and one vein D. three vessels: Two veins and one artery

C. three vessels: two arteries and one vein

A client who is in the second trimester tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? A. "Herbs are a cornerstone of good health to include in your treatment." B. "Touch is also therapeutic in relieving discomfort and anxiety." C. "Your healthcare provider should direct treatment options for herbal therapy." D. "It is important that you want to take part in your care."

D. "It is important that you want to take part in your care."

A 30-year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter. I don't know who I'll ever manage both children when I get home." How should the nurse respond? A. "Tell the older child that he is a big boy now and should love his new sister." B. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him." C. "Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the newborn." D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this time."

D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this time." Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep habits, as a method of seeking attention so the parents should distribute their attention between the children and include the preschooler during infant care.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot". Which explanation should the nurse give to this anxious client? A. "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." B. "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot. C. "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair."

D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair." The anterior fontanel or "large soft spot" normally closes at 12-18 months of age.

The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure? A. a gravida 6, para 5 who is 38 years of age an in early labor B. a 37 week primigravida who presents at 100% effacement, 3 cm cervical dilation and a -1 station. C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to post dates D. A 40-wk primigravida who is at 6 cm dilation and the presenting part is not engaged

D. A 40-wk primigravida who is at 6 cm dilation and the presenting part is not engaged. When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the cord can descent before the fetus causing a prolapsed cord, which is an emergency situation.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby B. Ask the client to describe why she was unsuccessful with breastfeeding her last child C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery

The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? A. August 1 B. August 10 C. September 3 D. September 8

D. September 8

After each feeding, a 3-day old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac Soy Isomil Formula, a soy protein isolate based on infant formula. What information should the nurse provide to the mother about the newly prescribed formula? A. The new formula is a coconut milk formula used with babies with impaired fat absorption B. Enfamil Formula is a demineralized whey formula that is needed with diarrhea C. the new formula is a casein protein source that is low in pheynylalanine. D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose.

D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose. The nurse should explain that the newborn's feeding intolerance may be related to the lactose found in cow's milk formula and is being replaced with the soy-based formula that contains sucrose which is well-tolerated in infants with milk allergies and lactose intolerances

A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A. Exercise regimen of both partners includes running 4 miles each morning B. history of having sexual intercourse 2-3x/wk. C. The woman's menstrual period occurs every 35 days D. They use lubricants with each sexual encounter to decrease friction

D. They use lubricants with each sexual encounter to decrease friction. The use of lubricants has the potential to affect fertility because some lubricants interfere with sperm motility.

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? A. cervical dilation of 5 cm with 90% effacement B. WBC of 12,000/mm3 C. hemoglobin of 12 mg/dl and hematocrit of 38%. D. a platelet count of 67,000/mm3

D. a platelet count of 67,000/mm3. This low amount places the client at risk for bleeding from an epidural

In developing a teaching plan for expectant parents, the nurse plans to including information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2-4 months and the posterior by the end of the first week B. anterior fontanel closes at 5-7 months and the posterior by the end of the second week C. anterior fontanel closes at 8-11 months and the posterior by the end of the first month D. anterior fontanel closes at 12-18 months and the posterior by the end of the second month.

D. anterior fontanel closes at 12-18 months and the posterior by the end of the second month.

A 40 week gestation primigravada client is being induced with an oxytocin (pitocin) secondary infusion and complains pain in her lower back. Which intervention should the nurse implement? A. discontinue the oxytocin (Pitocin) infusion B. place the client in a semi-Fowler's position C. inform the healthcare provider D. apply firm pressure on the sacral area.

D. apply firm pressure on the sacral area

The nurse is assessing a client who is having a non-stress test (NST) at 41 weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occuring. What action should the nurse take? A. check the client for urinary bladder distension B. notify the healthcare provider of the nonreactive results C. have the mother stimulate the fetus to move D. ask the client if she has felt any fetal movement

D. ask the client if she has felt any fetal movement. An NST is used to determine fetal well-being and is often implemented when postmaturity is suspected. A 'reactive' NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus' own movement, and is "nonreacctive" if no FHR acceleration occurs in response to fetal movement. The client should empty her bladder before starting the test, but bladder distention does not impede fetal movement. The client should be quizzed about fetal movement before determining that the NST is nonreactive. If no movement has occurred in the last 20-30 minutes, it is likely that the fetus is sleeping. Providing the mother with orange juice often wakes the infant, and then the NST should be conducted again.

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. at 16 weeks gestation B. at 20 weeks gestation C. at 24 weeks gestation D. at 30 weeks gestation

D. at 30 weeks gestation

One hour after giving birth to an 8 pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 bpm and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM x 1. What action should the nurse take immediately? A. give the medication as prescribed and monitor for efficacy B. encourage the client to breast feed rather than bottle feed C. have the client empty her bladder and then massage the fundus D. call the healthcare provider to question the prescription

D. call the healthcare provider to question the prescription. Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription.

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? A. blood glucose level of 45 mg/dl B. blood pressure of 82/45 C. non-bulging anterior fontanel D. central cyanosis when crying

D. central cyanosis when crying. An infant who demonstrates central cyanosis when crying is manifesting poor adaption to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? A. monitor urinary output via an indwelling catheter B. assess the abdominal dressings for drainage C. give the Ringer's lactated infusion at 125 ml/hr. D. check the firmness of the uterus every 15 minutes

D. check the firmness of the uterus every 15 minutes. A client's risk for postpartal hemorrhage is decreased when the uterus is firm after delivery of the infant. Assessment of fundus consistency q15 min provides frequent intervals to stimulate the fundus to contract and prevent bleeding.

A woman who had a miscarriage 6 months ago became pregnant. Which instruction is most important for the nurse to provide this client? A. Elevate lower legs while resting B. increase caloric intake by 200-300 calories per day C. increase water intake to 8 full glasses per day D. take prescribed multivitamin and mineral supplements

take prescribed multivitamin and mineral supplements