Key

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? A) Suction the oral and nasal passages B) Give oxygen by positive pressure C) Stimulate the infant to cry D) Turn the infant onto the right side

A) Suction the oral and nasal passages

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 HR of 80 beats/minute and respirations of 20 breaths/min. What action should be performed next? A. Initiate positive pressure ventilation B . Intervene after one min Apgar is assessed. C. Initiate CPR on the infant D. Assess the infant's blood glucose level

A. Initiate positive pressure ventilation

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important at time the infusion rate is increased? A.Contraction pattern B.Blood pressure C.Infusion site D.Pain level

A.Contraction pattern

During a prenatal visit, a client at 30-weeks gestation reports persistent heartburn during the past two weeks. The nurse notes the client has 3+ bilateral, pitting, pedal edema. Which action should the nurse implement?

Ask if blurred vision and headache have occurred.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression?

Avoids eye contact. ● Interacts with a flat affect. ● Reports feeling sad. ● Expresses suicidal thoughts

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important to implement? A) Provide a bottle of electrolyte solution B) Infuse normal saline intravenously C) Administer an antipyretic rectally D) Apply external cooling blanket

B) Infuse normal saline intravenously

A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, MENOPUR®), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately? A) Episodes of headache and irritability B) Nausea and vomiting C) Rapid increase in abdominal girth D) Persistent daytime fatigue

B) Nausea and vomiting

A 38-week gestational age infant of a diabetic mother (IDM) is admitted to the newborn nursery wearing 8 pounds and 2 ounces, and is transitioning without respiratory distress. Within the first hours of transition after birth, what priority nursing assessment is necessary for this infant? A. Congenital anomalies. B. Hypoglycemia. C. Birth injuries. D. Hyperbilirubinemia.

B. Hypoglycemia.

What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula? A.) body temperature B.) level of pain C.) time of first void D.) number of vessels in the cord

Body temperature

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

C) Intensity, interval, and length of contractions

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage? A) Palpate suprapubic area for fetal head position B) Insert straight urinary catheter to drain bladder C) Test the fluid with a nitrazine strip D) Scan the bladder for urinary retention

C) Test the fluid with a nitrazine strip

At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse that she is feeling fetal movement. Fundal height measurement is 20 cm, and the client's only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? A. Presence of fetal movement. B. Leakage from breasts. C. Gestational weight gain. D. Fundal height measurement.

C. Gestational weight gain.

At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse that she is feeling fetal movement. Fundal height measurement is 20 cm, and the clients only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? A. Presence of fetal movement. B. Leakage from breasts. C. Gestational weight gain. D. Fundal height measurement.

C. Gestational weight gain.

insulin therapy is initiated for 12 year old child who is admitted with diabetic ketoacidosis. Which is important for the nurse to include in the child's plan of care? A. Monitor serum glucose for adjustment in infusion rate of regular insulin B. determine the childs compliance schedule subq insulin C. demonstrate to parents how to program an insulin pen for daily glucose regulation D. Consult with healthcare provider about use of insulin detemir

C. demonstrate to parents how to program an insulin pen for daily glucose regulation

A pregnant woman in the first trimester of pregnancy has a Hb 8.6 mg/dL and HCT 25.1%. What food should the nurse encourage this client to include in her diet?

Chicken

The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? A) Place the infant in side-lying position to facilitate the exam B) Hold the penis and retract the foreskin gently C) Cleanse the penis with an antiseptic-soaked pad D) Place the infant in a warm room and use a calm approach

D) Place the infant in a warm room and use a calm approach

The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the healthcare provider immediatly? A) Bilirubin of 1.5 mg/dl B) Glucose of 80 mg/dl C) Potassium of 4.5 mEq/L D) Sodium of 119 mEq/L

D) Sodium of 119 mEq/L

A 6-year old with heart failure gained 2 pounds in the last 24 hours. Which intervention is most important for the nurse to implement? a. Decrease IV flow rate b. Restrict intake of oral fluids C. graph the daily weight for the past week D. assess bilateral lung sound

D. assess bilateral lung sound

Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority?

Have a meconium aspirator available at delivery

A young Ashkenazi Jewish woman is planning to become pregnant and asks the nurse if she should be tested for any genetic disorders. What action should the nurse implement?

Explain the risk for carrying genes for Tay-Sachs disease

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry without tears. Which prescription is most important to implement?

Infuse normal saline intravenously (because he is dehydrated)

What is the most important assessment for the nurse to conduct the following the administration of epidural anesthesia to a client who is at 40 weeks gestation?

Maternal blood pressure

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 the care plan?

Monitor Blood pressure, pulse, and respirations q4h.

An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?

Place the infant in a knee-chest position

A postpartum who is breastfeeding arrives for her 6-week postpartum visit and reports that she is still having vaginal discharge. How should the nurse respond?

Please describe the discharge

The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the healthcare provider immediately?

Potassium of 4.5mEg/L

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?

Record the finding on the chart. They are within normal limits.

A client in the third trimester of pregnancy complains of frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5cm during the pregnancy. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?

Record the respiratory finding in the client's record as normal

A postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client?

RhoGam prevents maternal antibody formation for future Rh-positive babies

A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse-midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare 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. Which response should the nurse provide?

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

A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?

Ultrasonography and nonstress test.

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?

Use alternative form of birth control until new diaphragm can be obtained.

A new mother asks the nurse why her infant son has a needle mark on his leg. Which response is best for the nurse to provide the mother?

Your baby was given an injection of vitamin K to prevent bleeding

The nurse is receiving a report for a laboring client who arrived in the ER with ruptured membranes that the client did not recognize. What is the priority nursing action to implement when the client is admitted to the labor and delivery suite. a. Prepare to start at IV b. take the clients temp c. begin a pad count d. monitor amniotic fluid for meconium

a. Prepare to start at IV

A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention? a. ask the client if she has experienced any recent changes in vaginal discharge b. ask the client's mother to call an ambulance for transport to the hospital immediately. c. determine what physical activities the client has performed for the past 24 hours d. teach the client how to perform pelvic rock exercises and observe for correct feedback

a. ask the client if she has experienced any recent changes in vaginal discharge

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first? a. check the differential, since the WBC is normal for this client b. notify the HCP, since this finding is indicative of infection c. assess the client's temperature, pulse and respirations q4h d. assess the clients perineal area for signs of perineal hematoma

a. check the differential, since the WBC is normal for this client *

.A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per minute. What intervention is most important for the nurse to perform? a. encourage the client to empty her bladder b. determine the maternal pulse rate c. instruct the client to drink a glass a juice d. place the client in a supine position

a. encourage the client to empty her bladder

38.A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per minute. What intervention is most important for the nurse to perform? a. encourage the client to empty her bladder b. determine the maternal pulse rate c. instruct the client to drink a glass a juice d. place the client in a supine position

a. encourage the client to empty her bladder *

A full-term infant is admitted to the newborn nursery 2 hours after delivery. The delivery record indicates that the mother is positive for HIV and received zidovudine AZT IV during labor. What action should the nurse implement? a. ensure that AZT is given within 6 hours after birth b. assess for the presence of the Moro reflex c. collect venous specimen for serum glucose level d. obtain consent for the Hep B vaccine

a. ensure that AZT is given within 6 hours after birth

Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum? a. pudendal block b. epidural block c. saddle block d. paracervical block

a. pudendal block

A pregnant client mentions in her history that she changes a cat's litter box daily. Which test should the nurse anticipate the HCP to prescribe? a. Biophysical profile b. TORCH screening c. Fern Test d. amniocentesis

b. TORCH screening

A 39-week gestational multigravida is admitted to labor and delivery spontaneous rupture of membranes and contraction occurring 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6cm, 90% effaced and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate has ranged between 170 and 180 beats/minute. What action should the nurse implement? a. Obtain a blood specimen for hemoglobin b. Take an oral maternal temperature c. Straight Catheterize client d. Send amniotic fluid for analysis

b. Take an oral maternal temperature

A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond? a. encourage the mother to schedule a developmental assessment of the infant b. advise the mother to wait at least another month before starting any solid foods c. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal d. reassure the mother that the infant is old enough to eat iron-fortified cereal

b. advise the mother to wait at least another month before starting any solid foods

A primigravida at 40 weeks gestation is contracting q2 minutes and her cervix is 9 cm dilated and 100% effaced. The FHR is 120 beats/minute. The client is screaming, and her husband is alarmed. Which intervention should the nurse implement? a. notify the rapid response team b. have delivery table set up c. ask the husband to step out d. administer a PRN narcotic

b. have delivery table set up

An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? a. provide 100% oxygen b. knee-chest position c. Start IV fluids d. Administer morphine

b. knee-chest position

A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the hospital. Which instruction should the nurse include in the discharge teaching plan? a. breastfeed infant every 4 hours b. monitor skin and eyes for yellow tinge c. reposition the infant every 2 hours d. change diapers every hour

b. monitor skin and eyes for yellow tinge

A client at 34 weeks gestation is scheduled to travel for business using a commercial airline. Which instruction is most important for the nurse to provide this client? a. explore the availability of medical care at the destination site b. request an aisle seat in a row that is not designated as an exit row c. perform ankle flexion and extension several times throughout the trip d. wear non-constricting clothing to prevent edema of the feet and hands

b. request an aisle seat in a row that is not designated as an exit row

The nurse is caring for a client following an emergency cesarean delivery under a general anesthesia. Which assessment finding, occurring in the first 8 hours after delivery, is more critical and requires immediate intervention? a. mild nausea and anorexia b. uterine atony c. a positive Homan's sign d. Respiratory rate 12

b. uterine atony *

Vaginal examination reveals that a laboring clients' cervix is dilated to 2 cm, 70% effaced, with the presenting part at -2 stations. The client tells the nurse, "I need my epidural now! This hurt!" the nurses' response to the client should be based on what information? a. the client should be dilated to at least 8 cm before receiving an epidural b. the baby needs to be at a zero station before an epidural can be administered c. Administering an epidural at this point would slow the labor process d. the client will need to be catheterized before the epidural can be administered.

c. Administering an epidural at this point would slow the labor process *

A client at 40-weeks' gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. What information is most important for the nurse to obtain first? a. the estimated amount of fluid b. time the membranes ruptured c. color and consistency of the fluid d. any odor noted when membranes ruptured.

c. color and consistency of the fluid

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 finding warrants immediate intervention by the nurse? a. the onset of uterine contractions b. leaking amniotic fluid c. fetal heart rate 60 beats/min d. ruptured amniotic membrane

c. fetal heart rate 60 beats/min*

A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some "heart damage." The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing diagnosis has the highest priority? a. sleep deprivation b. risk for infection c. fluid volume excess d. nausea and vomiting

c. fluid volume excess *

A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, menopur) and HCG. Which side effect should the nurse tell the client to report immediately? a. persistent daytime fatigue b. rapid increase in abdominal girth c. nausea and vomiting d. episodes of headache and irritability

c. nausea and vomiting

At 39-weeks gestation, a multigravida is having a nonstress test. The fetal heart rate has remained non-reactive during 30 minutes of evaluation. Based on the finding, which action should the nurse implement? a.observe the FHR pattern for 30 more minutes b.schedule a biophysical profile c.place an acoustic simulator on the abdomen d. initiate an IV infusion

c.place an acoustic simulator on the abdomen

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 what condition? a. Round ligament strain. b. Abruptio placenta. c. Viral infection d. Chorioamnionitis

d. Chorioamnionitis

4A pregnant woman who is at 10-weeks' gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? a. an amniocentesis conducted at 24 weeks' gestation confirms or denies Down Syndrome in the fetus b. maternal serum Human Chorionic Gonadotropic (HCG) can identify Down Syndrome at 6 weeks of gestation c. Weekly fundal height measurements are a noninvasive method used to check for Down Syndrome d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome

d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome

45.After delivery of a normal infant, the mother tells the nurses that she would like to use oral contraceptive. Which finding in the client's health history is a contraindication of the use of contraceptives? a. Previously used intrauterine device (IUD) b. Reported history of stroke within family c. Diagnosed with diabetes mellitus 2 years ago d. Smoked cigarettes prior to becoming pregnant

d. Smoked cigarettes prior to becoming pregnant

. A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client? a. postpartum psychosis b. hard, painful uterine afterpains c. placenta accreta d. disseminated intravascular coagulation

d. disseminated intravascular coagulation*

.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 demise protocol and identification procedures. What action is most important for the nurse to take? a. Explain reasons consent for an infant autopsy is needed b. create a memory box of a baby's footprints and photographs c. determine if the mother desires a visit from the clergy d. encourage the mother to hold and spend time with her baby

d. encourage the mother to hold and spend time with her baby

Assessment findings of a 3-hour old newborn include: axillary temperature of 97.7 F, heart rate of 140 beats/min with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement? a. record findings in electronic medical record b. obtain venous blood sample for glucose level c. attach a pulse oximeter on the heel d. place the infant under the radiant warmer

d. place the infant under the radiant warmer

A postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client? a. RhoGAM is not necessary unless all her pregnancies are Rh-positive b. RhoGAM prevents maternal antibody formation for future Rh-positive babies c. the mother should receive RhoGAM when the baby is Rh-negative d. the R-positive factor from the fetus threatens her blood cells

d. the R-positive factor from the fetus threatens her blood cells

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin E drug. How should the nurse respond? a. you may have an increased chance of having preeclampsia b. this medication will have no effect on your unborn child c. you may experience postpartum hemorrhage after delivery d. you may be at higher risk for having a spontaneous miscarriage

d. you may be at higher risk for having a spontaneous miscarriage

The mother of a breastfeeding 24 hr 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, "I just know my daughter is not getting enough to eat." What 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 is getting enough milk

d.if your baby's urine is straw-colored, she is getting enough milk*

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 post procedure complaint indicates that the fallopian tubes are patent?

shoulder