NUR 308 Final Practice Questions
A nurse in a prenatal clinic is providing education to a client who is in the 8th week of gestation. The client states that she does not like milk. Which of the following foods should the nurse recommend as a good source of calcium? A. Dark green leafy vegetables B. Deep red or orange vegetables C. White breads and rice D. Meat, poultry, and fish
. A. Dark green leafy vegetables
A nurse is teaching a client who is at 6 weeks of gestation about common discomforts during pregnancy. Which of the following findings should the nurse include in the teaching? (SATA) A. Breast tenderness B. Urinary frequency C. Epistaxis D. Dysuria E. Epigastric pain
A, B, C
A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? (SATA) A. Gonorrhea B. Chlamydia C. HIV D. Group B strep E. TORCH infection
A, B, C, D
A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? (SATA) A. Joint pain B. Malaise C. Rash D. Urinary frequency E. Tender lymph nodes
A, B, C, E
A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds, and have beat-to-beat variability of 20/min. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? (SATA) A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia
A, B, D
A nurse is caring for a client who reports indications of preterm labor. Which of the following findings are risk factors of this condition? (SATA) A. Urinary tract infection B. Multifetal pregnancy C. Oligohydramnios D. Diabetes mellitus E. Uterine abnormalities
A, B, D, E
A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (SATA) A. Fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension
A, C, D
A nurse in admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? (SATA) A. Episiotomy B. Oxytocin infusion C. Forceps D. Cesarean birth E. Internal fetal monitoring
A, C, E
A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3, T1, P0, A1, L1. How should the nurse interpret this information? (SATA) A. Client has delivered one newborn at term B. Client has experienced no preterm labor C. Client has been through active labor D. Client has had two prior pregnancies E. Client has one living child
A, D, E
A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (SATA) A. Apply breast milk to the nipples before each feeding B. Place breast pads inside the nursing bra C. Massage the breasts and nipples prior to feeding D. Start breastfeeding with the nipple that is less sore E. Change the infant's position on the nipples
A, D, E
A nurse in a health clinic is reviewing contraception use with a group of adolescent clients. Which of the following statements by an adolescent reflects an understanding of the teaching? A. "A water soluble lubricant should be used with condoms" B. "A diaphragm should be removed 2 hours after intercourse" C. "Oral contraceptives can worsen a case of acne" D. "A contraceptive patch is replaced once a month"
A. "A water soluble lubricant should be used with condoms"
A nurse is reinforcing teaching with a group of adolescent females are pregnant about expected changes related to pregnancy. Which of the following client statements indicates understanding of the teaching? A. "It is normal to have a white vaginal discharge" B. "I should recognize fetal movement by 12 weeks" C. "I will take fluid pills if my ankles begin to swell" D. "My nipples and areolae will become pale as my breasts enlarge"
A. "It is normal to have a white vaginal discharge"
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position B. Apply a fetal scalp electrode C. Insert an IV catheter D. Perform a vaginal exam
A. Assistthe client into the left-lateral position
A nurse is caring for a client who experienced a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? A. At the level of the umbilicus B. 2 cm above the umbilicus C. One fingerbreadth above the symphysis pubis D. To the right of the umbilicus
A. At the level of the umbilicus
A client who is receiving magnesium sulfate has a urine output of 20 mL/hr. Which of the following medications should the nurse expect to administer? A. Calcium gluconate B. Flumazenil C. Naloxone D. Protamine
A. Calcium gluconate
A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse anticipate the provider will prescribe? A. Ceftriaxone B. Fluconazole C. Metronidazole D. Zidovudine
A. Ceftriaxone
A nurse midwife is examining a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? A. Cervical dilation B. Report of pain above the umbilicus C. Brownish vaginal discharge D. Amniotic fluid in the vaginal vault
A. Cervical dilation
A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? A. Contractions lasting longer than 90 seconds B. Contractions occurring every 3 to 5 min C. Contractions are strong in intensity D. Client reports feeling contractions in lower back
A. Contractions lasting longer than 90 seconds
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? A. Discontinue the medication infusion B. Prepare for an emergency cesarean birth C. Assess maternal blood glucose D. Place the client in Trendelenburg position
A. Discontinue the medication infusion
A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client B. Notify the client's provider C. Increase the frequency of fundal massage D. Encourage the client to empty her bladder
A. Document the findings and continue to monitor the client
A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include in the teaching? A. Eat crackers or plain toast before getting out of bed B. Awaken during the night to eat a snack C. Skip breakfast and eat lunch after nausea has subsided D. Eat a large evening meal
A. Eat crackers or plain toast before getting out of bed
A nurse in the labor and delivery unit is caring for a client in labor and applies and external fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are occurring every 8 min and 30-40 seconds in duration. The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at -2 station. Which of the following stages and phases of labor is this client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. Second stage of labor
A. First stage, latent phase
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? A. Fundus firm to palpation B. Increase in blood pressure C. Increase in lochia D. Report of absent breast pain
A. Fundus firm to palpation
A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy? A. Gradual lordosis B. Increased abdominal muscle tone C. Posterior neck flexion D. Decreased mobility of pelvic joints
A. Gradual lordosis
A nurse is caring for a client who is pregnant and states that her last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15
A. January 8
A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? A. Painless red vaginal bleeding B. Increasing abdominal pain with a nonrelaxed uterus C. Abdominal pain with scant red vaginal bleeding D. Intermittent abdominal pain following passage of bloody mucus
A. Painless red vaginal bleeding
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of the contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? A. Place the client in the lateral position B. Increase the rate of maintenance IV infusion C. Elevate the client's legs D. Administer oxygen using a nonrebreather mask
A. Place the client in the lateral position
A nurse is planning a teaching session about hysterosalpingography for a client who has a diagnosis of infertility. The nurse should include which of the following information in the teaching plan? A. The client might experience shoulder pain following the procedure B. The client should anticipate scheduling the procedure 5 days prior to menstruation C. The client might experience diarrhea as a result of the procedure D. The client should be on a liquid diet for 1 day following the procedure
A. The client might experience shoulder pain following the procedure
A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as -1. Which of the following interpretations of this finding should the nurse make? A. The presenting part is 1 cm above the ischial spines B. The presenting part is 1 cm below the ischial spines C. The cervix is 1 cm dilated D. The cervix is effaced 1 cm
A. The presenting part is 1 cm above the ischial spines
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? A. Uteroplacental insufficiency B. Maternal bradycardia C. Umbilical cord compression D. Fetal head compression
A. Uteroplacental insufficiency
A nurse is caring for a client who is pregnant and reviewing signs of complications the client should promptly report to the provider. Which of the following complications should the nurse include in the teaching? A. Vaginal bleeding B. Swelling of the ankles C. Heartburn after eating D. Lightheadedness when lying on back
A. Vaginal bleeding
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? A. Variable decelerations are due to umbilical cord compression B. Variable decelerations are caused by uteroplacental insufficiency C. Variable decelerations are a result of the administration of IV narcotic analgesics D. Variable decelerations are related to fetal head compression
A. Variable decelerations are due to umbilical cord compression
A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (SATA) A. "I am likely to have a fever during the first week I am home" B. "I will resume taking my prenatal vitamins" C. "I will call my provider if I have discharge from my incision" D. "I should not have unrelieved pain in my abdomen" E. "I will rest in a recliner until my incision is healed"
B, C, D
A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probably signs of pregnancy. Which of the following findings should the nurse expect? (SATA) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening
B, C, D
A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (SATA) A. Tinnitus B. Irregular vaginal bleeding C. Weight gain D. Breast changes E. Gingival hyperplasia
B, C, D
A nurse is providing care for a client who is diagnosed with a marginal abruptio placentae. The nurse is aware that which of the following findings are risk factors for developing this condition? (SATA) A. Fetal position B. Blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking
B, C, E
A nurse is reviewing findings of a client's biophysical profile. The nurse should expect which of the following variables to be included in this test? (SATA) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Fetal position E. Amniotic fluid volume
B, C, E
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include in the teaching? (SATA) A. "It is considered a noninvasive procedure" B. "It can detect abnormal fetal heart tones early" C. "It can determine the amount of amniotic fluid you have" D. "It allows for accurate readings with maternal movement" E. "It can measure uterine contraction intensity"
B, D, E
A client who is at 8 weeks of gestation tells the nurse that she isn't sure she is happy about being pregnant. Which of the following responses should the nurse make? A. "I will inform the provider that you are having these feelings" B. "It is normal to have these feelings during the first few months of pregnancy" C. "You should be happy that you are going to bring new life into the world" D. "I am going to make an appointment with the counselor for you to discuss these thoughts"
B. "It is normal to have these feelings during the first few months of pregnancy"
A nurse is caring for a client who is receiving magnesium sulfate to treat severe preeclampsia and asks the nurse "is the medication working?" Which of the following responses should the nurse make? A. "The medication is working because there are no contractions" B. "The medication is working because there is no seizure activity" C. "The medication is working because all your lung fields are clear" D. "The medication is working because your blood pressure is normal"
B. "The medication is working because there is no seizure activity"
A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? To: A. "You should go ahead and push to assist the delivery" B. "You should try to pant as the delivery proceeds" C. "You should try to perform slow-paced breathing" D. "You should take a deep, cleansing breath and breathe naturally"
B. "You should try to pant as the delivery proceeds"
A nurse is providing education to a client who is in labor and has a prescription for a continuous IV infusion of oxytocin. Which of the information should the nurse include? A. "This medication will help prevent nausea and vomiting" B. "Your contractions will become stronger and more frequent" C. "I will remove the electronic fetal monitor once contractions are regular" D. "You can push the button on the control device to administer more medication"
B. "Your contractions will become stronger and more frequent"
A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? A. 1.8 kg (4 lb) weight gain and is in her first trimester B. 3.6 kg (8lb) weight gain and is in her first trimester C. 6.8 kg (15 lb) weight gain and is in her second trimester D. 11.3 kg (25 lb) weight gain and is in her third trimester
B. 3.6 kg (8lb) weight gain and is in her first trimester
A nurse is caring for a client during a nonstress test. At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? A. A negative test B. A nonreactive test C. A positive test D. A reactive test
B. A nonreactive test
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? A. The client is exhibiting early indications of mastitis B. Additional interventions are not needed at this time C. Application of a heating pad to the breasts is indicated D. The client should be advised to remove her nursing bra
B. Additional interventions are not needed at this time
A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? A. A male condom B. An intrauterine device (IUD) C. An oral contraceptive D. A diaphragm with spermicide
B. An intrauterine device (IUD)
A nurse is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? A. Observe color and consistency of fluid B. Assess the fetal heart rate pattern C. Assess the client's temperature D. Evaluate client for the presence of chills and increased uterine tenderness using palpation
B. Assess the fetal heart rate pattern
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not". Which of the following should the nurse recognize as a sign of true labor? A. Rupture of the membranes B. Changes in the cervix C. Station of the presenting part D. Pattern of contractions
B. Changes in the cervix
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? A. Expulsion of a blood-tinged mucous plug B. Continuous contraction lasting 2 min C. Pressure on the perineum causing the client to bear down D. Expulsion of clear fluid from the vagina
B. Continuous contraction lasting 2 min
A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? A. Saturated perineal pad in 30 min B. Deep tendon reflexes 4+ C. Fundus at level of umbilicus D. Approximated edges of episiotomy
B. Deep tendon reflexes 4+
A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? A. Decrease the rate of infusion of the maintenance IV solution B. Discontinue the infusion of the IV oxytocin C. Increase the rate of infusion of the IV oxytocin D. Slow the client's rate of breathing
B. Discontinue the infusion of the IV oxytocin
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? A. Anaphylactoid syndrome of pregnancy B. Disseminated intravascular coagulation C. Preeclampsia D. Puerperal infection
B. Disseminated intravascular coagulation
A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? A. Blood-tinged sputum B. Dizziness C. Pallor D. Somnolence
B. Dizziness
A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect? A. Fundus soft, 1 cm to the right of the umbilicus B. Fundus firm, at the level of the umbilicus C. Fundus present, to the left of the umbilicus D. Fundus soft, 2 cm above the umbilicus
B. Fundus firm, at the level of the umbilicus
A nurse is assessing a client who is 8 hours postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? A. Moderate lochia rubra B. Fundus three fingerbreadths above the umbilicus C. Moderate swelling of the labia D. Blood pressure 130/84 mm Hg
B. Fundus three fingerbreadths above the umbilicus
A nurse in labor and delivery unit is completing an admission assessment for a client who is at 39 weeks gestation. The client reports that she has been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum hemorrhage D. Hydramnios
B. Infection
A client experiences a large gush of fluid from her vagina while walking in the hallway of the birthing unit. Which of the following actions should the nurse take first? A. Check the amniotic fluid for meconium B. Monitor FHR for distress C. Dry the client and make her comfortable D. Monitor uterine contractions
B. Monitor FHR for distress
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus B. Palpate the fundus of the uterus C. Grasp lower uterine segment between thumb and fingers D. Stand facing client's feet with fingertips outlining cephalic prominence
B. Palpate the fundus of the uterus
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? A. Elevate the client's legs B. Position the client on her side C. Administer oxygen via face mask D. Increase the infusion rate of the IV fluid
B. Position the client on her side
A nurse in a clinic is teaching a client about her new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (SATA) A. "Weight loss can occur" B. "You are protected against STI's" C. "You should increase your intake of calcium" D. "You should avoid taking antibiotics" E. "Irregular vaginal spotting can occur"
C, D
A nurse is teaching a group of women who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include in the teaching? (SATA) A. Avoid any lifting B. Perform Kegel exercises twice a day C. Perform the pelvic rock exercise every day D. Use proper body mechanics E. Avoid constrictive clothing
C, D
A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (SATA) A. Eczema B. Psoriasis C. Linea nigra D. Chloasma E. Striae gravidarum
C, D, E
A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make? A. "You are so young. Are you ready for the responsibilities of a sexual relationship?" B. "Because of your age, I think that a barrier method would be the best choice." C. "Before I can help you, I need to know more about your sexual activity." D. "A provider can help you with that after a physical examination."
C. "Before I can help you, I need to know more about your sexual activity."
A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of effective communication among family members? A. "If you keep saying that, I will tell everyone what you did last night" B. "She is always bossing me around. Should she do that?" C. "Can you tell me the reason you get upset each time I go to the mall?" D. "Please do not raise your voice at the children. I am the one who left dishes in the sink"
C. "Can you tell me the reason you get upset each time I go to the mall?"
A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client is an indication of inhibition of parental attachment? A. "He's got my husband's nose, that's for sure." B. "I don't need a baby bath demonstration. I know how to do it." C. "I wish he had more hair. I will keep a hat on his head until he grows some." D. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?"
C. "I wish he had more hair. I will keep a hat on his head until he grows some."
A nurse at a family practice clinic receives a call from a client who is prescribed oral contraceptives but forgot to take one dose. The client reports she is in the first week of a 28-day cycle pack. Which of the following instructions should the nurse provide? A. "Do not have vaginal intercourse until after your next period" B. "Stop taking the pills and switch to a different contraceptive method" C. "Take the missed dose now, then continue the medication as ordered" D. "Take a home pregnancy test"
C. "Take the missed dose now, then continue the medication as ordered"
A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A. "This is due to an increase in blood volume" B. "This is due to pressure from the uterus on the diaphragm" C. "This is due to the weight of the uterus on the vena cava" D. "This is due to increased cardiac output"
C. "This is due to the weight of the uterus on the vena cava"
A nurse is teaching a client who is at 23 weeks gestation about immunizations. Which of the following statements should the nurse include in the teaching? A. "You should not receive the rubella vaccine while breastfeeding." B. "You should receive a varicella vaccine before you delivery" C. "You can receive an influenza vaccination during pregnancy" D. "You cannot receive the Tdap vaccine until after your deliver"
C. "You can receive an influenza vaccination during pregnancy"
A nurse is conducting nutritional counseling with a client who is in her second trimester of pregnancy. The nurse should recommend the client increase her caloric intake by how many calories during this trimester? A. 110 cal/day B. 225 cal/day C. 340 cal/day D. 450 cal/day
C. 340 cal/day
A nurse is teaching a client about positive signs of pregnancy. Which of the following findings should the nurse include? A. Breast tenderness B. Fatigue C. Fetal heart tones detected by ultrasound D. Positive urine pregnancy test
C. Fetal heart tones detected by ultrasound
A nurse is caring for a client who is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? A. Assess the client's blood pressure B. Assess the bladder for distention C. Massage the client's fundus D. Prepare to administer a prescribed oxytocic preparation
C. Massage the client's fundus
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following action should the nurse take? A. Apply fundal pressure B. Observe for the presence of a nuchal cord C. Observe for crowning D. Prepare to administer oxytocin
C. Observe for crowning
A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? A. Ballottement B. Lightening C. Quickening D. Chloasma
C. Quickening
A nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest? A. Increase her caloric intake by 600 kcal/day B. Increase her fluid intake to 2.5 L/day C. Reduce her intake of iron D. Avoid shellfish
C. Reduce her intake of iron
A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Headaches
C. Shortness of breath
A nurse is making a home visit to a client who has Alzheimer's Disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain? A. The partner has placed locks at the top of the doors leading to the outside B. The partner has hired a house cleaner C. The partner has lost 20 lbs in the past 2 months D. The partner redirects the client when the client is frustrated
C. The partner has lost 20 lbs in the past 2 months
A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The client is very irritable and feels the urge to have a bowel movement. She states, "I've had enough, I can't do this anymore. I want to go home right now." Which of the following stages of labor is the client experiencing? A. Second stage B. Fourth stage C. Transition phase D. Latent phase
C. Transition phase
A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th week of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with? A. Ice water B. Low-fat or whole milk C. Tea or coffee D. Orange juice
D Orange Juice
A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? A. "Obtain an immunization against rubella early in pregnancy" B. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy" C. "A woman should avoid crowded places during pregnancy" D. "A woman should avoid consuming undercooked meat while pregnant"
D. "A woman should avoid consuming undercooked meat while pregnant"
A nurse is leading a therapeutic group for clients at an outpatient mental health clinic. Which of the following client statements indicates a problem with role transition? A. "If my husband had gone to the doctor like I told him to, he'd be alive today." B. "I am so angry with my husband's attitude. He thinks he knows everything." C. "I want to have an intimate relationship, but I end up breaking off relationships as soon as they begin." D. "I just can't seem to find any energy to take care of my children since my husband divorced me."
D. "I just can't seem to find any energy to take care of my children since my husband divorced me."
A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? A. "I should drink about 2 liters of fluid each day" B. "I should not drink alcoholic beverages during pregnancy" C. "I can have a moderate amount of caffeine daily" D. "I should increase my calcium intake to 1500 mg per day"
D. "I should increase my calcium intake to 1500 mg per day"
A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam" B. "I cannot get an IUD until after I've had a child" C. "I should plan on regaining fertility 5 months after the IUD is removed" D. "I will check to be sure the strings of the IUD are still present after my periods"
D. "I will check to be sure the strings of the IUD are still present after my periods"
A nurse is reviewing postpartum nutrition needs with a group of new mothers who are breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? A. "I am glad I can have my morning coffee" B. "I should take folic acid to increase my milk supply" C. "I will continue adding 330 calories per day to my diet" D. "I will continue my calcium supplements because I don't like milk"
D. "I will continue my calcium supplements because I don't like milk"
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching? A. "I'll let my baby drain one breast at each feeding." B. "I'll try drinking an herbal tea to reduce the engorgement" C. "I'll apply cold compresses 20 minutes before each feeding." D. "I'll feed my baby every 2 hours"
D. "I'll feed my baby every 2 hours"
A nurse in a clinic receives a phone call from a client who believes she is pregnant and would like to be tested in the clinic to confirm her pregnancy. Which of the following information should the nurse provide to the client? A. "You should wait until 4 weeks after conception to be tested" B. "You should be off any medications for 24 hours prior to the test." C. "You should be NPO for at least 8 hours prior to the test" D. "You should collect urine from the first morning void"
D. "You should collect urine from the first morning void"
A nurse is reviewing contraception options to four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives? A. A 26-year-old client who has migraine headaches at the start of each menstrual cycle B. A 28-year-old client who has a history of pelvic inflammatory disease C. A 32-year-old client who has benign breast disease D. A 38-year-old client who reports smoking one pack of cigarettes every day
D. A 38-year-old client who reports smoking one pack of cigarettes every day
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? A. Encourage the client to perform Kegel exercises B. Encourage the client to move to the left lateral position C. Ask the client to rate her pain D. Assist the client to the bathroom to void
D. Assist the client to the bathroom to void
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? A. Prepare for a cesarean birth B. Assist the client to an upright position C. Prepare for an immediate vaginal delivery D. Assist the client to turn onto her side
D. Assist the client to turn onto her side
A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin C. Nifedipine D. Betamethasone
D. Betamethasone
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? A. Apply a fetal scalp electrode B. Increase the rate of the IV infusion C. Administer oxygen at 10 L/min via a nonrebreather mask D. Change the client's position
D. Change the client's position
A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? A. Maintain the client in the lithotomy position B. Perform vaginal examinations frequently C. Remind the client to bear down with each contraction D. Encourage the client to empty her bladder every 2 hour
D. Encourage the client to empty her bladder every 2 hour
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? A. Cover the cord with a sterile, moist saline dressing B. Prepare the client for an immediate birth C. Place the client in knee-chest position D. Insert a gloved hand into the vagina to relieve pressure on the cord
D. Insert a gloved hand into the vagina to relieve pressure on the cord
A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? A. Use a condom with sexual intercourse B. Avoid bubble bath solution when taking a tub bath C. Wipe from the back to front when performing perineal hygiene D. Keep a daily record of fetal kick counts
D. Keep a daily record of fetal kick counts
A nurse is caring for a client who is 2 hours postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather mask at 10 L/min which of the following actions should the nurse take next? A. Insert an indwelling urinary catheter B. Administer oxytocin by continuous IV infusion C. Tilt the client onto her right side with her legs elevated to at least 30 degrees D. Massage the client's fundus to promote contractions
D. Massage the client's fundus to promote contractions
A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? A. Iron deficiency anemia B. Poor bone formation C. Macrosomic fetus D. Neural tube defects
D. Neural tube defects
A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? A. Have the client stand at the bedside with her arms at her side B. Administer a 500 mL bolus of 5% dextrose in water prior to induction C. Inform the client the anesthetic effect will last for approximately 6 hours D. Obtain a 30 min electronic fetal monitoring strip prior to induction
D. Obtain a 30 min electronic fetal monitoring strip prior to induction
A nurse is reviewing the electronic monitor tracing of a client who should know that a fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions
D. Relaxation between uterine contractions
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? A. Tachycardia B. Absence of clonus C. Polyuria D. Report of headache
D. Report of headache
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time B. The client is immune to the rubella virus C. The client requires a rubella vaccination at this time D. The client requires a rubella immunization following delivery
D. The client requires a rubella immunization following delivery
A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context? A. The sens of self among individual family members B. The future goals of the family C. The roles of family members D. The family's religious practices
D. The family's religious practices
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? A. The fetal head is in the left occiput posterior position B. The largest fetal diameter has passed through the pelvic outlet C. The posterior fontanel is palpable D. The lowermost portion of the fetus is at the level of the ischial spines
D. The lowermost portion of the fetus is at the level of the ischial spines
A nurse in the labor and delivery unit receives a phone call from a client who reports that her contractions started about 2 hours ago, did not go away when she had two glasses of water and rested, and became stronger since she started walking. Her contractions occur every 10 min and last about 30 seconds. She hasn't had any fluid leak from her vagina. However, she saw some blood when she wiped after voiding. Based on this report, which of the following clinical findings should the nurse recognize that the client is experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions
D. True contractions
A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. The nurse should recognize that this client is at risk for which of the following postpartum complications? A. Puerperal infection B. Retained placental fragments C. Thrombophlebitis D. Uterine atony
D. Uterine atony
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? A. Early decelerations B. Accelerations C. Late decelerations D. Variable decelerations
D. Variable decelerations