maternity questions

a nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm. which of the following interventions should the nurse include? a. avoid IM injections b. assess the client for ecchymosis once per shift c. do not allow the client to have visitors d. encourage daily flossing between teeth

a. avoid IM injections

a nurse is reinforcing teaching about dietary changes with a client who is pregnant and has pregestational diabetes. which of the following statements should the nurse include in the teaching? a. carbs should make up 55% of your diet b. protein should make up 70% of your diet c. fats should make up 45% of your diet d. fiber should make up 10% of your diet

a. carbs should make up 55% of your diet

a nurse is assisting with the care of a client who is in labor. which of the following findings should the nurse report to the provider? a. fetal heart rate of 90bpm b. maternal temp of 37.8 (100F) c. uterine relaxation of 1 min in between contractions d. uterine contractions increasing in intensity

a. fetal heart rate of 90bpm

a nurse is providing teaching to a client who is 1 hr postpartum about using the perineal squeeze bottle. which of the following instructions should the nurse include? a. fill the perineal bottle with warm water prior to use b. squeeze the perineal botte while standing up in the bathroom to clean the perineum c. only use half of the bottle for cleansing d. wipe the perineum with toilet paper from back to front after using the perineal bottle

a. fill the perineal bottle with warm water prior to use

a nurse is reviewing the laboratory report of a newborn who has type B negative. the mothers blood type is type O negative, the lab results indicate the direct antiglobulin test is positive. which of the following complications should the nurse anticipate? a. hyperbilirubemia b. central cyanosis c. intracranial hemorrhage d. cardiomyopathy

a. hyperbilirubemia

a nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. after conducting a risk assessment, the nurse should identify which of the following factors as increasing the clients breast cancer risk? (select all that apply) a. increased breast density b. BMI of 32 c. having given birth to 5 children d. undergoing hormonal replacement therapy for 10 years e. having 1-2 alcoholic drinks per week

a. increased breast density b. BMI of 32 d. undergoing hormonal replacement therapy for 10 years

a nurse is assisting with the are of a pt. in active labor whose fetus is in the occipital brow presentation. which of the following complications should he nurse anticipate as a result of this presentation? a. precipitous labor b. prolonged labor c. hypertonic uterine dysfunction d. umbilical cord prolapse

b. prolonged labor

a nurse is planning for a client who is receiving chemotherapy and has a protein deficiency. which of the following interventions should the nurse include in the plan of care? (select all that apply) a. mix powdered skim milk into liquid milk b. add a raw egg to fruit smoothies c. add a slice to cheese to hot vegetables d. add honey to hot tea e. mix yogurt into fresh fruit

a. mix powdered skim milk into liquid milk c. add a slice to cheese to hot vegetables e. mix yogurt into fresh fruit

a nurse is caring for a client who received spinal anesthesia 30 minutes ago. the client reports feeling dizzy, and the nurses note that the client blood pressure is 84/54 mmHg. which of the following actions should the nurse take? a. place the client in the head-down position b. assess the placement of the catheter c. prepare the administer in IV reversal agent d. assist the client in passive range of motion movements

a. place the client in the head-down position

a nurse is planning care for a newborn with hyperbilirubemia and a new prescription for phototherapy. which of the following interventions should the nurse include in the plan? a. reposition the newborn every 3 hours b. apply lotion to the newborns exposed skin daily c. feed the newborn 1 oz of glucose water every 2 hours d. dress the newborn in a diaper and a thin cotton tshirt

a. reposition the newborn every 3 hours

a nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. which of the following pieces of information should the nurse include in the teaching? (select all that apply) a. take your temperature twice a day b. you may return to school, if you feel strong enough c. it is important to wear shoes always d. clean your toothbrush weekly with alcohol e. avoid using tampons

a. take your temperature twice a day c. it is important to wear shoes always e. avoid using tampons

the guardian of a 3 day old female newborn tells a nurse that he noticed a small amount of blood-tinged mucus discharge on the newborns labia. which of the following responses should the nurse make? a. the blood tinged mucus is a result of pseudomenstration b. the blood tinged mucus indicates a urinary tract infection c. the blood tinged mucus is due to uric acid crystals d. the blood tinged mucus is a result of the initial genital examination

a. the blood tinged mucus is a result of pseudomenstration

a nurse is caring for a client who is postpartum and reports her episiotomy incision is pulling and stinging. which of the following actions should the nurse take? a. encourage the client to ambulate b. provide a warm sitz bath wait warm water for the client c. instruct the client to perform kegel exercises d. apply the anesthetic cream topically every hour

b. provide a warm sitz bath

a nurse is admitting a child who has acute lymphocytic leukemia. which of the following lab values should the nurse expect? a. platelets 500,000/mm b. RBCs 2.5 million/uL c. WBCs 4,000/mm d. hct 60%

b. RBCs 2.5 million/uL

a nurse is contributing to the plan of care for 4 high-risk newborns who were discharged yesterday. which of the following newborns should the nurse care for first? a. a 1 week old who needs another phenylketonuria screening test b. a 4 day old newborn who has an elevated bilirubin level and requires phototherapy c. a 10 day old newborn who is small for gestational age and requires daily weighing d. a 2 week old who was born at 35 weeks gestation and weighed 5lb at discharge

b. a 4 day old newborn who has an elevated bilirubin level and requires phototherapy

a nurse is assisting with the care of a client who is in labor. She received merperidine for one hour prior to entering the second stage of labor. which of the following actions should the nurse take? a. assess the pt. reflexes b. assess the newborn for respiratory depression c. assess the pt. for bradycardia d. assess the newborn for opiate withdrawal

b. assess the newborn for respiratory depression

a nurse is collecting data from a client who is 1 day postpartum. which of the following findings is a sign of potential complication? a. dark red lochia with clots b. deep tendon reflexes 4+ c. urine output since birth 3,000ml d. soft pink hemorrhoid's

b. deep tendon reflexes 4+

a nurse is collecting data from a client who is at 36 weeks gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? a. varicose veins b. double vision c. leukorrhea d. flatulence

b. double vision

a nurse is assessing a newborn immediately after birth. the newborn is pink and crying and has a heart rate of 108/min. which of the following actions should the nurse take? a. initiate chest compressions b. dry the newborn on moms chest c. administer epinephrine to newborn d. apply an oxygen saturation monitor

b. dry the newborn on moms chest

a nurse in an oncology clinic is assessing a client who has early stage Hodgkins lymphoma. which of the following findings should the nurse expect? a. bone and joint pain b. enlarged lymph nodes c. intermittent hematuria d. productive cough

b. enlarged lymph nodes

a nurse is assessing a child who has stage 1 Hodgkin disease. which of the following findings should the nurse expect? a. generalized petechiae b. enlarged lymph nodes c. chronic vomiting d. dependent edema

b. enlarged lymph nodes

a nurse is collecting data on the respiratory status of a newborn who was born 2 hours ago. which of the following findings should the nurse identify as a manifestation of respiratory distress? a. acrocyanosis b. expiratory grunting c. resp. rate of 56/min d. irregular respirations

b. expiratory grunting

a nurse is reinforcing teaching with a parent about how to care for a newborns circumcision site? which of the following client statements indicates an understanding of the teaching? a. i should clean the circumcision site with half-strength hydrogen peroxide twice a day b. i should apply the diaper loosely until the circumcision is healed c. i should notify the doctor if a yellow discharge forms on head of penis d. newborns typically do not experience pain from this procedure

b. i should apply the diaper loosely until the circumcision is healed

a nurse is caring for a patient who is at 28 weeks gestation and is experiencing preterm labor. which of the following medications should the nurse plan to administer? a. oxytocin b. nifedipine c. dinoprostone d. misoprostol

b. nifedipine

a nurse is assessing a 12-hr old newborn notes mild jaundice of the face and trunk. which of the following actions should the nurse take? a. administer phytonadione IM b. obtain a stat prescription for a bilirubin level c. obtain a bagged urine specimen d. perform a gestational age assessment

b. obtain a stat prescription for a bilirubin level

a nurse is caring for a client who has hemophilia. the client reports pain and swelling in a joint following an injury. which of the following actions should the nurse take? a. obtain blood samples to test platelet function b. prepare for replacement of the missing clotting factor c. administer aspirin for the clients pain d. place the bleeding joint in the dependent position

b. prepare for replacement of the missing clotting factor

A nurse is collecting data from a client who is in labor and has received epidural anesthesia for pain control. which of the following manifestations should the nurse identify as an adverse effect of epidural anesthesia? a. polyuria b. pruritus c. hypertension d. dry mouth

b. pruritus

a nurse is collecting data from a newborn who was born with meconium-stained amniotic fluid. which of the following findings should the nurse report as an indication of meconium aspiration syndrome? a. high apgar score b. rapid respirations c. flushed skin d. elevated po2

b. rapid respirations

a nurse is providing education about newborn skin care for a group of new parents. which of the following instructions should the nurse include? a. gently retract the foreskin to wash the glans with soap and water b. sponge bathe the newborn every other day c. use an antimicrobial soap for bathing d. bathe the newborn with water between 115-120F

b. sponge bathe the newborn every other day

a nurse is caring for a client who has breast cancer and is receiving a combination medications. the client expresses confusion about the therapy. which of the following explanations should the nurse provide? a. the risk of renal toxicity is lessened when a combination of chemotherapy is used b. the chemotherapy medications act at different stages of cell division so more tumor cells are destroyed c. the use of more chemotherapy medications will shorten the time you have to be in treatment d. the combination of chemotherapy medications will eliminate the potential for bone marrow suppression

b. the chemotherapy medications act at different stages of cell division so more tumor cells are destroyed

a nurse is collecting a health history from a client. which of the following findings is the highest risk factor for the client developing bladder cancer. a. the client is a hairdresser b. the client uses tobacco c. the client is over 60 years of age. d. the client has frequent urinary tract infections.

b. the client uses tobacco

a nurse is reinforcing education with a client who is at 34 weeks gestation about a non-stress test. which of the following pieces of info should the nurse include? a. it will take about 10 minutes to complete the test b. you might have to drink orange juice during the test c. during the test you will be asked to massage your nipples d. during the test you will receive a medication to relax your uterus

b. you might have to drink orange juice during the test

a nurse is teaching a client who is postpartum about the rubella vaccine. which of the following statements should the nurse include? a. you must not take this immunization if you've had chickenpox b. you must not become pregnant for 28 days after receiving this immunization c. you must not breastfeed because the virus is passed in breastmilk d. you must not receive other vaccines at the same time as the rubella

b. you must not become pregnant for 28 days after receiving this immunization

a nurse in a clinic is reinforcing teaching with a client who is 37 weeks gestation and is scheduled for an external cephalic version. which of the following statements should the nurse make? a. your provider will insert a hand into your uterus and turn your baby around b. you will receive a medication to relax your uterus prior to the procedure c. this procedure will be performed in the clinic at your next visit d. your baby's heartbeat will be monitored occasionally throughout the procedure

b. you will receive a medication to relax your uterus prior to the procedure

a nurse is assisting with the care of a client who is in labor and experienced a spontaneous rupture of membranes. which of the following findings requires intervention by the charge nurse? a. intense contractions lasting less than 30 sec b. rest periods between contractions lasting > 90 seconds c. FHR decreased by 15/min d. maternal temp of 37.8 (100F) after rupture of membranes

c. FHR decreased by 15/min

a nurse is reinforcing teaching about oxytocin with a client who is in the third trimester of pregnancy and has pre-eclampsia. which of the following is a contraindication for use of this medication? a. prolonged rupture of membranes at 38 weeks gestation b. intrauterine growth restriction c. active genital herpes d. post term pregnancy

c. active genital herpes

a nurse is assessing a client on the first postpartum day. findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate locia rubra with small clots, temperature 37.3C (99.2F), and pulse rate 52/min. which of the following actions should the nurse take? a. report the vital signs to the provider b. massage the fundus c. ask the client when she last voided d. administer an oxytocic agent

c. ask the client when she last voided

a nurse is talking with a group of women at a community center about the current recommendations for early detection of breast cancer. the nurse should explain which of the following options? a. begin monthly breast self-examinations at age 40 b. have a clinical breast examination each year after age 30 c. begin annual mammograms at age 40 d. have breast magnetic resonance imaging every 5 years after age 50

c. begin annual mammograms at age 40

a nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. the newborn is pink with acrocyanosis. which of the following actions should the nurse take? a. administer oxygen b. place the newborn in an isolette c. continue to monitor the newborn routinely d. assess the newborns blood glucose

c. continue to monitor the newborn routinely

a nurse administers betamethasone to a pt. who is at 33 weeks gestation to stimulate fetal lung maturity. when assisting with the plan of care for the newborn, the nurse should identify which of the following conditions as an adverse effect of this medication? a. hyperthermia b. irritability c. decreased blood sugar d. rapid pulse rate

c. decreased blood sugar

a nurse is collecting data from a client who has placenta previa and is at 27 weeks gestation. which of the following manifestations should the nurse expect? a. severe abdominal pain b. increased blood pressure c. decreased urinary output d. cool, clammy skin

c. decreased urinary output

a nurse is reviewing lab findings for a newborn. which of the following findings should the nurse report to the provider? a. hgb 20g/dL b. hct 55% c. glucose 29mg/dL d. wbc 7000/mm

c. glucose 29mg/dL

a nurse is collecting data from a newborn. which of the following findings should the nurse report to the provider? a. respiratory rate of 52/min b. weight 2500g (5.5 lb) c. head circumference 28cm (11in) d. blood sugar 48mg/dL

c. head circumference 28cm (11in)

a nurse is reinforcing teaching with a client about a non-stress test. which of the following statements by the client indicates an understanding of the teaching? a. i know not to eat anything after midnight b. i will have medication given to me to cause contractions c. i should press the button on the handheld marker when the baby moves d. i will have to stimulate my breast to cause contractions

c. i should press the button on the handheld marker when the baby moves

a nurse is providing discharge teaching to the parent of a school-aged child who has leukemia and is receiving chemotherapy. which of the following statements by the parent indicates an understanding of the teaching? a. i will take my childs rectal temperature daily b. i will make sure my child gets his MMR vaccine c. i will inspect my childs mouth everyday for sores d. i will allow my child to ride his bicycle tomorrow

c. i will inspect my childs mouth everyday for sores

a charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. which of the following effects should the charge nurse include in the teaching? a. newborn respiratory depression at birth b. impaired ability of the neonate to maintain body temperature c. impaired placental perfusion d. decreased FHR variability

c. impaired placental perfusion

a nurse is assisting with the care of a client who has been experiencing mild contractions for a few days. the nurse places an external fetal monitor on the client. the client asks "what will the monitor show you?". which of the following responses should the nurse make? a. it will indicate if you are in active labor b. it will measure your heart rate c. it indicates if your baby is receiving adequate amount of oxygen d. it indicates the intensity of the contractions you are having

c. it indicates if your baby is receiving adequate amount of oxygen

a nurse is performing a physical assessment of a newborn. which of the following actions should the nurse take? a. measure he newborns length from anterior fontanel to the heel b. measure the newborns weight while he is wearing a clean diaper c. measure the circumference of the newborns head with a tape measure just above the eyebrow d. measure the circumference of the newborns chest with a tape measure 2cm bellow the nipple line

c. measure the circumference of the newborns head with a tape measure just above the eyebrow

a nurse is collecting data from a newborn. for which of the following findings should the nurse report to the provider? a. heart rate 136/min b. acrocyanosis c. mottling d. respiratory rate 60/min

c. mottling

a nurse is collecting data from a newborn. which of the following findings should the nurse report immediately to the provider? a. milia b. Epstein pearls c. nasal flaring d. meconium stools

c. nasal flaring

a nurse is collecting data from a newborn who was circumcised 24hr ago. which of he following findings should the nurse report to the provider? a. a scant amount of serosanguinous drainage noted in diaper b. the newborns circumcision site is covered with yellow exudate c. newborn hasn't urinated since circumcision d. newborn fusses during diaper change

c. newborn hasn't urinated since circumcision

a nurse is assessing a postpartum client who observes a steady trickle of bright red blood from the clients vagina. the uterus is palpated as firm, midline, and located 1 cm below the umbilicus. which of the following actions should the nurse take? a. massage the fundus b. instruct the client to empty her bladder c. notify the provider d. teach the clients to perform a sitz bath

c. notify the provider

a nurse is assessing a client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. the nurse should plan to administer which of the following medications? a. terbutaline b. mag sulfate c. oxytocin d. methylergonovine

c. oxytocin

a nurse is assisting with the care of a postpartum client who has preeclampsia and excessive uterine bleeding. the nurse should plan to administer which of the following medications? a. terbutaline b. mag sulfate c. oxytocin d. methylergonovine

c. oxytocin

a nurse is caring for a client who is receiving chemotherapy to treat cancer. which of the following adverse effects should the nurse anticipate from the chemotherapy? a. gingival hyperplasia b. hirsutism c. pancytopenia d. weight gain

c. pancytopenia

a nurse is monitoring a pt. who is receiving IV oxytocin for the induction of labor. the nurse identifies early decelerations on the fetal heart monitor. which of the following actions should the nurse take? a. increase rate of IV fluid infusion b. discontinue oxytocin infusion c. re evaluate FHR tracing in 15 mins d. request prescription for an amnioinfusion

c. re evaluate FHR tracing in 15 mins

a nurse is reviewing the lab results of a term newborn. for which of the following findings should the nurse notify the provider? a. hematocrit 55% b. platelet count 250,000/mm c. serum glucose 120 mg/dL d. arterial blood gas pH 7.35

c. serum glucose 120 mg/dL

a nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. which of the following findings should the nurse investigates further as an indication of child maltreatment? a. bruising of the right elbow b. dislocated left shoulder revealed by xray c. thin, frail extremities d. abrasions on both wrists

c. thin, frail extremities

a nurse is assessing a client who is in the fourth stage of labor. which of the following findings should the nurse expect? a. breast engorgement b. hypothermia c. urinary retention d. rupture of membranes

c. urinary retention

a nurse is teaching a client who has leukemia and has developed thrombocytopenia. which of the following instructions should the nurse include in the teaching? a. limit flossing your teeth to once a week b. gently blow your nose if needed c. use an electric shaver when having d. wear shoes that have a soft sole

c. use an electric shaver when having

a nurse is obtaining a clients health who has history who has cancer of the cervix. which of the following manifestations should the nurse expect? a. weight gain b. oliguria c. vaginal bleeding d. back pain

c. vaginal bleeding

a nurse is assisting in the care of a client who has developed hemorrhagic shock. which of the following manifestations should the nurse expect? a. urinary output of 40ml/hr b. deep abdominal breathing c. week and irregular pulse d. warm, dry hands with prompt capillary refill

c. week and irregular pulse

a nurse is reinforcing teaching with a postpartum client who is breastfeeding. which of the following pieces of information should the nurse include in the teaching? a. you should supplement your baby with formula until you notice your breasts become full b. you should adhere to a schedule when feeding your baby to ensure she is getting enough to eat c. your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery d. it is typical for your nipples to hurt the first few weeks while breastfeeding

c. your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery

a nurse in a newborn nursery has received reports on 4 newborns. which of the following newborns should the nurse identify as requiring intervention? a. a newborn who has acrocyanosis b. w a newborn who has a macular, papular, vesicular rash on the torso c. a newborn who has a blood glucose level of 54 d. a newborn whose axillary temperature is 96.9F

d. a newborn whose axillary temperature is 96.9F

a nurse is reinforcing teaching to a client who is postpartum and breastfeeding. which of the following statements should the nurse include? a. you will need to wait 3 months before sexual intercourse b. you don't need to use contraception until you are 4 months pp c. as long as you breastfeed, you will experience an overproduction of vaginal lubrication d. a reduction in sexual interest could indicate post partum depression

d. a reduction in sexual interest could indicate post partum depression

a nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. the client reports a lightheaded feeling and tingling of the fingers. which of the following actions should the nurse take? a. instruct the client to hold her breath and bear down b. ensure the clients breathing rate is more than twice her normal rate c. apply counter pressure to the clients lower back d. assist the client in breathing into a paper bag

d. assist the client in breathing into a paper bag

A nurse is assisting with the care of a client in the third stage of labor who is receiving oxytocin IV. Which of the following actions should the nurse take? a. discontinue the infusion b. check pt. vital signs every 30 mins c. massage he fundus once every 90 mins d. clean the pt. perineum with warm sterile water

d. clean the pt. perineum with warm sterile water

a nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. which of the following instructions should the nurse include in the teaching? a. apply the diaper tightly over the circumcised area b. remove the yellow exudate with each diaper c. use prepackaged commercial wipes to clean the circumcision area d. encourage non-nutritive sucking for pain relief

d. encourage non-nutritive sucking for pain relief

a nurse is collecting data from a client who is at 37 weeks gestation and is HIV positive. which of the following orders should the nurse clarify with the provider? a. intermittent auscultation b. biophysical profile c. non-stress test d. fetal scalp electrode

d. fetal scalp electrode

a nurse is reinforcing teaching about mastitis who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? a. i will limit breastfeeding to 5 mins per breast b. i will not breastfeed is I start to have flu-like symptoms c. i will shop for an underwire nursing bra d. i will avoid any of my family members who are ill

d. i will avoid any of my family members who are ill

a nurse is assisting with the care of a client who is in the early stage of labor and has preeclampsia with severe features. which of the following interventions should the nurse preform? a. assess the fetal heart rate and contractions hourly b. encourage oral intake of clear, low-sodium fluids c. instruct the client to ambulate during the early phase of labor d. implement seizure precautions

d. implement seizure precautions

a nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. which of the following actions should the nurse take? a. ask the child if his parents are responsible for abuse b. notify the facility's risk manager c. interview the child with his parents present d. report the suspected abuse to the local authorities

d. report the suspected abuse to the local authorities

the nurse is collecting data about the newborns reflex responses. which of the following findings should the nurse expect when assessing the moro reflex? a. abduction and extension of arms are asymmetric b. the opposite leg flexes while a leg is extended and sole of foot is stimulated c. toes hyperextend with dorsiflexion of great toe d. the legs move in similar pattern of response to the arms

d. the legs move in similar pattern of response to the arms

a nurse is preparing to administer vitamin k IM to a newborn. which of the following actions should the nurse plan to take? a. identify the injection site on the dorsogluteal muscle b. apply sterile gloves prior to administration c. insert the needle at a 30 degree angle d. withdraw the needle quickly after administration

d. withdraw the needle quickly after administration

a nurse is reinforcing teaching with a client who has a BMI of 32. which o the following statements should the nurse make? a. you should have considered losing weight before getting pregnant b. your baby has a higher chance of low birth weight due to your BMI c. you might want to consider a weight-restriction diet d. you might be at risk for a longer hospital stay than planned

d. you might be at risk for a longer hospital stay than planned

a nurse is reinforcing teaching with a client who is pregnant. which of the following instructions should the nurse include? a. take 600mg ibuprofen as needed for discomfort b. you should eat soft cheeses to increase calcium intake c. you should roll your nipples daily to ensure they're everted d. you should use fluoride-based toothpaste to prevent dental cavities

d. you should use fluoride based toothpaste to prevent dental cavities