N482 Unit 3 HESI

A client who is having a difficult labor is diagnosed with cephalopelvic disproportion. Which medical orders should the nurse question? a) Maintain NPO status b) Start peripheral IV of ¼ NS c) Record fetal heart tones every 15minutes d) Piggyback another 10-unit bag of oxytocin (Pitocin)

d) Piggyback another 10-unit bag of oxytocin (Pitocin)

Which answer would the nurse give to a client who asks what is the common cause of a spontaneous abortion? a. physical trauma b. unresolved stress c. congenital defects d. embryonic defects

d. embryonic defects

A registered nurse is teaching an adolescent female client with irregular menstruation about contraception. Which statements made by the client indicates the need for further education? Select all that apply. "The calendar method of oral contraception is best suitable for me." "The withdrawal method of contraception has high incidences of failure." "Condoms do not offer protection against sexually transmitted infections." "Oral contraceptive pills offer protection from sexually transmitted diseases." "Three-month injectable contraceptive medications may cause weight gain and decreased bone density.

"The calendar method of oral contraception is best suitable for me." "Condoms do not offer protection against sexually transmitted infections." "Oral contraceptive pills offer protection from sexually transmitted diseases."

A woman who gave birth to a second child 3 weeks ago is depressed and having difficulty caring for her children. At the end of the day both of the children are dirty, wet, and crying. The woman tells her husband that she "just can't take this anymore." The husband calls the women's health clinic and asks what he should do. What is the best response by the nurse? 1. Telling him that his wife may be suffering from depression and needs emergency care 2. Telling him that fatigue is expected and that his wife needs to take rest periods during the day 3. Reassuring him that his wife is experiencing 4. Advising him to make an appointment for his wife to see her practitioner if the problem continues

1. Telling him that his wife may be suffering from depression and needs emergency care

At 37 weeks' gestation a client's membranes spontaneously rupture but she does not have contractions. What action is most important in the nursing plan of care for this client? 1Assessing maternal temp 2Monitoring for signs of preeclampsia 3Monitoring for heavy vaginal bleeding 4Making preparations for fetal scalp pH sampling

1Assessing maternal temp

A client at 28 weeks' gestation has a sonogram. The results reveal a small-for-gestational age fetus and a low-lying placenta. For what complication should the nurse assess this client during the last trimester of pregnancy? 1 Preterm labor 2 Placenta previa 3 Premature separation of the placenta 4 Premature rupture of the membranes

2 Placenta previa

A client in her 36th week of gestation is admitted with vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. For which intervention would the nurse prepare? 1. A high-forceps birth 2. An immediate cesarean birth 3. Insertion of an internal fetal monitor 4. Administration of an oxytocin infusion

2. An immediate cesarean birth

A client admitted with preeclampsia is receiving magnesium sulfate. Which assessment finding indicates that a therapeutic level of the medication has been reached? 1Increased fetal activity 2Decreased urine output 3Deep tendon reflexes of +2 4Respiratory rate of 12 breaths/min

3Deep tendon reflexes of +2

Despite medication, a client's preterm labor continues, her cervix dilates, and birth appears inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival? 1Carboprost tromethamine 2Misoprostol 3Nalbuphine HCl 4Betamethasone

4Betamethasone

The nurse is caring for a preterm infant who is receiving oxygen therapy. What should the nurse do to prevent retinopathy of prematurity (ROP)? 1Cover the neonate's eyes with a shield 2Place the neonate in an elevated side-lying position 3Assess the neonate every hour with a pulse oximeter 4Support the neonate's oxygen saturation while providing minimal FiO2

4Support the neonate's oxygen saturation while providing minimal FiO2

Which action would the nurse take before birth when meconium staining is present? 1Monitoring the neonate's heart rate 3Assessing the neonate's respiratory effort 4Suctioning the neonate's mouth and nose 5Gathering equipment for neonatal resuscitation

5Gathering equipment for neonatal resuscitation

After a client gives birth, what physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled? A sudden gush of blood

A sudden gush of blood

The nurse is assessing her assignment of four postpartum clients. Which conditions increase the risk for postpartum hemorrhage? Select all that apply. A. Twin birth B. Overdistended bladder C. Hypertonic uterine dystocia D. Retained placental fragments E. Mild gestational hypertension

A. Twin birth B. Overdistended bladder D. Retained placental fragments

Which intervention would the nurse anticipate when caring for a postpartum mother who is AB negative, had a negative Coombs test, and delivered a neonate whose blood group is B positive? a. Administering Rho(D) immune globulin IV to the mother within 1 week of delivery b. Administering Rho(D) immune globulin intramuscularly to the mother within 72 hours of delivery c. Administering Rho(D) immune globulin intramuscularly to the mother within 1 week of delivery d. Administering Rho(D) immune globulin IV to the mother within 72 hours of delivery

B. Administering Rho(D) immune globulin intramuscularly to the mother within 72 hours of delivery

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. Headache Constipation Abdominal pain Vaginal bleeding Visual disturbances

Headache Abdominal pain Visual disturbances

A client with preeclampsia is admitted to the labor and birthing suite. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. Headache Constipation Right upper quadrant pain Vaginal bleeding Nausea and vomiting

Headache Right upper quadrant pain Nausea and vomiting

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time? Helping the client change her position Informing the client of the problem with the fetus Administering oxygen by mask. Readjusting placement of the fetal monitor on the client's abdomen

Helping the client change her position

The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? Insulin needs will increase during the second trimester. Insulin needs will decrease during the second trimester. Insulin needs will not change during the second trimester. Insulin will be switched to an oral antidiabetic medication during the second trimester.

Insulin needs will increase during the second trimester.

What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy?Average for gestational age, term Small for gestational age, preterm Large for gestational age, postterm Large for gestational age, near term

Large for gestational age, near term

Which client is at increased risk for postpartum hemorrhage? One who breast-feeds in the birthing room One who receives a pudendal block for the birth One whose third stage lasts less than 10 minutes One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

A 28-year-old woman seeks advice about oral contraceptives from the nurse in her company health office. What should the nurse tell her if she is a smoker? Oral contraceptives can cause thrombophlebitis. Oral contraceptives can be used with other methods. Some oral contraceptives can be used without concern. Some oral contraceptives are safe while others are not safe

Oral contraceptives can cause thrombophlebitis.

A newborn is diagnosed as having neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? Administering an opioid antagonist Limiting fluid intake to inhibit vomiting Assessing for age-appropriate developmental level Reducing environmental stimuli to promote relaxation

Reducing environmental stimuli to promote relaxation

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? Reposition the client from supine to left lateral Increase the IV flow rate from 125 to 150 mL/hr. Administer oxygen at a rate of 8-10 L/min by way of facemask. Assess the maternal blood pressure for a systolic BP of < 100.

Reposition the client from supine to left lateral

A newborn is being treated with phototherapy for hyperbilirubinemia. What is the nurse's role when providing phototherapy? 1 Turning the infant every 2 hours 2 Measuring the bilirubin level every 2 hours 3 Maintaining the infant on daily 24-hour phototherapy 4 Applying a sterile gauze pad to the infant's umbilical stump

Turning the infant every 2 hours

The nurse is assessing a pregnant client at the end of her second trimester. Which clinical finding causes the nurse to suspect that the client has preeclampsia? Progressive weight gain Two urine samples showing proteinuria Dependent ankle edema during the late afternoon Blood pressure fluctuations on three successive measurements

Two urine samples showing proteinuria

A nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. What other parameter can the nurse use to estimate blood loss in a postpartum client? Odor of the lochia Color of the lochia Presence of small clots on the pad Weighing blood stained pads and items

Weighing blood stained pads and items

Which method is a barrier type of contraception? SATA. a. condom b. diaphragm c. lea's shield d. spermicidal foam e. coitus interruptus

a. condom b. diaphragm c. lea's shield

In which circumstance would newborn blood incompatibility be most likely to occur if the mother has blood type O and Rh factor positive? a. the newborn has type A or B blood b. The newborn is preterm c. The newborn has diabetes d. The newborn has blood type O and Rh factor positive

a. the newborn has type A or B blood

Which medication is indicated for evacuation in case of a miscarriage? a. clomiphene b. Dinoprostone c. methylergonovine d. magnesium sulfate

b. Dinoprostone

The nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. Which is the physiological mechanism of this therapy? a. stimulates the liver to dispose of the bilirubin b. breaks down the bilirubin into a conjugated form c. facilitates the excretion of bilirubin by activating vitamin K d. dissolves the bilirubin, allowing it to be excreted by the skin

b. breaks down the bilirubin into a conjugated form

Which would the nurse expect to find when assessing a client suspected of having abruptio placentae? a. bright-red vaginal bleeding and multiple clots b. uterine tenderness and increased fetal activity c. cessation of contractions and decreased uterine size d. concealed hemorrhage and fetal heart rate accelerations

b. uterine tenderness and increased fetal activity

Which assessment finding would the nurse identify as significant in an infant of a diabetic mother who is LGA? a. temp < 98 b. HR 110 bpm c. BG < 40 d. increasing bilirubin during first 24 hours

c. BG < 40

A client expresses a desire to postpone her first pregnancy for at least 5 years. She smokes 1.5 packs of cigarettes a day, has never been pregnant, and does not want to use a barrier method. Which method does the nurse anticipate the primary healthcare provider will recommend? a. a birth control patch b. a vaginal ring c. Medroxyprogesterone d. combined oral contraceptive pills

c. Medroxyprogesterone

The parents of a newborn who is undergoing phototherapy ask a nurse why their baby's eyes are covered with eye patches. What information should the nurse remember before responding? a. They keep the baby's eyes closed b. They reduce overstimulation from bright lights c. They prevent injury to the conjunctiva and retina d. They limit excessive rapid eye movements and anxiety.

c. They prevent injury to the conjunctiva and retina

A client comes to the emergency room reporting severe abdominal cramping and heavy bleeding at 10 weeks gestation. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experiencing? a. missed b. complete c. inevitable d. threatened

c. inevitable