Maternity

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/min. On the basis of this finding, what is the priority nursing action? 1. Document the finding 2. Check mom's hr 3. Notify the health care provider 4. Tell the client that the for is normal

3

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-fowler's position with a pillow under the knees

1

A non stress test is performed on a client and the results of the test indicate nonreactive findings. the health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a C section

1

A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent

1

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. What can i do for you? 2. Now you have an angel in heaven 3. Don't worry, there is nothing you could have done to prevent this from happening 4. We will see to it that you have an early discharge so the you don't have to be reminded of this experience

1

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting HIV? 1. A client w a hx of iv drug use 2. A client who has a significant other who is heterosexual 3. A client who has a hx of sexually transmitted infections 4. A client who has had one sexual partner for the past 10 years

1

The nurse has performed a non stress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? 1. Normal 2. Abnormal 3. The need for further evaluation 4. That finding were difficult to interpret

1

The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understand that which finding would be normal for a client in the second trimester? 1. Increase in pulse 2. Increase in bp 3. Frequent bowel elimination 4. Decrease in rbc production

1

The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? SATA 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provide an exchange of nutrients and waste products between the mother and the fetus

1, 2, 3, 4

The home care nurse is monitoring a pregnant client with gestational HTN who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? SATA 1. Proteinuria 2. HTN 3. Low-grade fever 4. Generalized edema 5. Increased pulse 6. Increased RR

1, 2, 4

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nagele's rule, which expected date of delivery should the nurse document in the clients chart? 1. July 12, 2014 2. July 26, 2015 3. August 12, 2015 4. August 26, 2015

2

A client in the first trimester arrives at a health care clinic and states that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement by the client indicates a need for further instruction? 1. I will watch for the evidence of the passage of tissue 2. I will maintain strict bedrest throughout the remainder of the pregnancy 3. I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad 4. I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding

2

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? 1. I will record the number of movements or kicks 2. I need to lie flat on my back to perform the procedure 3. If I count fewer than 10 kicks in a 2-hour period I should count the kicks again over the next 2 hours 4. I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks

2

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations 2. Assess the baseline FHR 3. Determine the intensity of the contractions 4. Determine the frequency of the contractions

2

The nurse is assisting a client undergoing induction of labor at 41 weeks gestation. The client's contractions are moderate and occurring every 2-3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline FHR has been 120-122 for the past hour. What is the priority nursing action? 1. Notify health care provider 2. Discontinue pitocin 3. Place O2 on at 8 to 10 L/min via face mask 4. Contact eh client's primary support person if not currently present

2

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. 3 - 2, 0, 0, 1 2. 2-1, 0, 0, 1 3. 1 - 1, 1, 0, 1 4. 2 -0, 0, 0, 1

2

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hgb 11 2. FHR 180 3. Maternal pulse 85 4. WBC 12,000

2

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding? 1. 22 cm 2. 30 cm 3. 36 cm 4. 40 cm

2

The nurse is providing instructions to a client in the first trimester regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? 1. Avoid wearing a bra 2. Wash the breasts with warm water and keep them dry 3. Wear tight-fitting blouses or dresses to provide support 4. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion

2

A rubella result for a 1-day postpartum client is less than 1:8, and rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which info to the client about the vaccine? SATA 1. Breast-feeding needs to be stopped for 3 months 2. Pregnancy needs to be avoided for 1-3 months 3. The vaccine is administered by subcut 4. Exposure to immunosuppressed individuals needs to be avoided 5. A hypersensitivity reaction can occur if the client has an allergy to eggs 6. The area of the injection needs to be covered with a sterile gauze for 1 week

2,3,4,5

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepare to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 1. Less pressure on the cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal bp monitoring

3

A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cave

3

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate? 1. Contact the health provider 2. instruct the client to maintain bed rest for the remainder of the pregnancy 3. inform the client that these contractions are common and may occur throughout the pregnancy 4. Call the maternity unit and inform them that the client will be admitted in a pre labor condition

3

A pregnant client tell the nurse she's been ingesting daily amounts of white clay dirt from her backyard. Lab studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? 1. Hct 38% 2. Glu 86 3. Hgb 9.1 4. WBC 12,400

3

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement made by the client indicates a need for further teaching? 1. I should stay on the diabetic diet 2. I should perform glucose monitoring at home 3. I should avoid exercise because of the negative effects on insulin production 4. I should be award of any infections and report signs of infection immediately to my health care provider

3

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being the most risk for developing DIC? 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida 2 who has just been diagnosed with dead fetus syndrome 4. A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood

3

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 finger breadth below the symphysis pubis

3

The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan? 1. One artery carries oxygenated blood from the placenta to the fetus 2. Two arteries carry oxygenated blood from the placenta to the fetus 3. Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta 4. Two veins carry blood that is high in carbon dioxide and other waste products away form the fetus to the placenta

3

Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. FHR pattern 4. Maternal bp

3

Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? 1. It cushions and protects baby 2. It maintains the temperature of the baby 3. It is the way the baby gets food and O2 4. It prevents all antibodies and viruses from passing to the baby

3

A pregnant client asks the nurse in the clinic when she will be able to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 2. 8 and 10 3. 10 and 12 4. 14 and 18

4

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? 1. I should avoid between-meal snacks 2. I should lie down for an hour after eating 3. I should use spices for cooking rather than using salt 4. I should avoid eating foods that produce gas and fatty foods

4

The health care provider is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action? 1. Auscultate for fetal heart sounds 2. Assess the cervix for compressibility 3. Palpate the abdomen for fetal movement 4. Initiate a gentle upward tap on the cervix

4

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider? 1. Urinary output has increased 2. Dependent edema has resolved 3. Bp reading is at the prenatal baseline 4. The client complains of a headache and blurred vision

4

The nurse evaluates the ability of a hepatitis B-pos mother to provide safe bottle-feeding to her newborn during postpartum hospitalizations. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feedings 2. The mother holds the newborn properly during feeding and burping 3. The mother tests the temperature of the formula before initiating feeding 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding

4

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understand the signs of true labor if she makes which statement? 1. I won't be in labor until my baby drops 2. My contractions will be felt in my abdominal area 3. My contractions will not be as painful if I walk around 4. My contractions will increase in duration and intensity

4

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further understanding? 1. I will begin abdominal exercises immediately 2. I will notify the health care provider if I develop a fever 3. I will turn on my side and push up with my arms to get out of bed 4. I will lift nothing heavier than my baby for at least 2 weeks

1

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. We want to attend a support group 2. We never want to try to have a baby again 3. We are going to try to adopt a child immediately 4. We are okay, and we are going to try to have another baby immediately

1

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late decel on the monitor strip. What is the most appropriate nursing action? 1. Administer O2 via face mask 2. Place the mother in supine position 3. Increase the rate of pitocin 4. Document the findings and continue to monitor the fetal patterns

1

The nurse is assessing a pregnant client with DM1 about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. I will need to increase my insulin dosage during the first 3 months of pregnancy 2. My insulin dose will likely need to be increased during the second and third trimesters 3. Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy 4. My insulin needs should return to normal within 7-10 days after birth if I am bottle feeding

1

The nurse is monitoring a client in active labor and notes the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the FHR between contractions is 100 bpm. Which nursing action is most appropriate? 1. Notify the health care provider 2. Continue monitoring the fetal heart rate 3. Encourage the client to continue pushing with each contraction 4. Instruct the client's coach to continue to encourage breathing techniques

1

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sing. this finding is most closely associated with which characteristic? 1. A softening cervix 2. The presence of fetal movement 3. The presence of hcg in the urine 4. a soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus

1

The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy? SATA 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. braxton hicks 5. FHR detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

1,2,3,4

The nurse should include which statement to a pregnant client found to have a gynecoid pelvis? 1. Your type of pelvis has a narrow pubic arch 2. Your type of pelvis is the most favorable for labor and birth 3. Your type of pelvis is a wide pelvis, but has a short diameter 4. You will need a c section because this type of pelvis is not favorable for a vaginal delivery

2

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular 2. The membranes have ruptured 3. The cervix is dilated completely 4. The client begins to expel clear vaginal fluid

3

The nurse is conducting a prenatal class on the female reproductive system. when a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. It promotes the fertilized ovum's chances of survival 2. It promotes the fertilized ovum's exposure to estrogen and progesterone 3. It promotes the fertilized ovum's normal implantation in the top portion of the uterus 4. It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone

3

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic dyrubg her second trimester. Which finding concerns the nurse and indicates the need for follow-up? 1. Quickening 2. Braxton hicks 3. FHR 180 beats/min 4. Consistent increase in fundal height

3

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure 2. hospitalization is necessary for 24 hours after the procedure 3. An informed consent needs to be signed before the procedure 4. A fever is expected after the procedure because of the trauma to the abdomen

3

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 1. I should wear panty hose 2. I should wear support hose 3. I should wear flat nonslip shoes that have good support 4. I should wear knee-high hose, but i should not leave them on longer than 8 hours

4

The nurse is caring for a client in labor and is monitoring the FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the heath care provider of the findings 2. Reposition the mother and check the monitor for changes 3. Take the mother's vital signs and tell the other that bed rest is required to conserve O2 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being

4

The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which is most closely associated with a complication of this diagnosis? 1. Enlargement of breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura

4

The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester. Which statement by the client indicates a need for further instruction? 1. I should avoid straining during bowel movements 2. I can gently replace the hemorrhoids into the rectum 3. I can apply ice packs to the hemorrhoids to reduce the swelling 4. I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink

4

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. what should the nurse tell the client to provide relief from the leg cramps? 1. Bend your foot toward your body while flexing the knee when the cramps occur 2. Bend your foot toward your body while extending the knee when the cramps occur 3. Point your foot away from your body while flexing the knee when the cramps occur 4. Point your foot away from your body while extending the knee when the cramps occur

2

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that he has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. Come to the clinic immediately 2. The vaginal discharge may be bothersome, but is a normal occurrence 3. Report to the emergency department at the maternity center immediately 4. Use tampons if the discharge is bothersome, but to be sure to change the tampon q 2 hours

2

The nurse is providing instructions to a pregnant client with genital herpes about eh measures that are needed to protect the fetus. which instruction should the nurse provide to the client? 1. Total abstinence from sexual intercourse is necessary during the entire pregnancy 2. Sits baths need to be taken q 4 hours while awake if vaginal lesions are present 3. Daily administration of acyclovir is necessary during the entire pregnancy 4. A c section will be necessary if vaginal lesions are present at the time of labor

4