OB HESI BS

While assessing a pregnant woman at 39 weeks who is admitted to labor and delivery, which finding is most important to report to the healthcare provider? +1 pedal edema 130/70 BP 101.2 oral temp +1 proteinuria

101.2 oral temperature

A client at 38 weeks complains of severe abdominal pain. Upon palpation the nurse notes that the abdomen is rigid. How should the nurse document the findings? Abruptio placenta Placenta previa Chorioamnionitis Oligohydramnios

Abruptio placenta

The nurse is providing information to a postpartum client who is asking about the intrauterine device form of contraception. Which statements demonstrate the pt understands info about IUDs? Women who plan to have future pregnancies should not use an IUD The IUD works by causing an implanted zygote to be expelled Contraindications for the use of the IUD include age over 35 An IUD must be inserted by a health care professional

An IUD must be inserted by a health care professional

When planning care for a laboring client, the nurse identifies the need to withhold solid foods while the client is in labor. What is the most important reason for this? Nausea occurs from analgesics Autonomic nervous system stimulation during labor decreases peristalsis An increased risk of aspiration can occur if general anesthesia is needed Gastric emptying time decreases during labor

An increased risk of aspiration can occur if general anesthesia is needed

The nurse is caring for a newborn infant who was recently diagnosed with a congenital heart defect. Which assessment finding warrants immediate interventions by the nurse? Bluish tinge to the tongue Increased RR Weak peripheral pulses Sweating during feedings

Bluish tinge to the tongue

While caring for a laboring client on continuous monitoring the nurse notes a fetal HR pattern that falls and rises abruptly with a V shaped appearance. What action should the nurse take first? Prepare for potential C section Allow client to begin pushing Administer O2 Change maternal position

Change maternal position

A pregnant woman in the first rimester of pregnancy has a hemoglobin of 8.6 and a hematocrit of 25.1. What food should the nurse encourage the client to include in her diet? Yogurt Cheese Chicken Carrots

Chicken

A client at 20-weeks gestation comes to the antepartal clinical complaining of vaginal warts (HPV). What info should the nurse provide this client? Client should be treated with Penicillin G Client should be treated with acyclovir Termination of pregnancy should be considered Pregnancy complications are not linked to HPV

Client should be treated with Penicillin G

A new mother who is a lactose-ovo vegetarian plans to breastfeed her infant. What info should the nurse provide prior to discharge? Continue prenatal vitamins with B12 while breastfeeding Offer iron-fortified supplemental formula daily Weight the baby weekly to evaluate the newborn's growth Avoid using lanolin-based nipple cream or ointment

Continue prenatal vitamins with B12 while breast feeding

The healthcare provider prescribes 10 units of Pitocin via IV drip to augment a clients labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin? Four contractions in 10 minutes Uterus is soft Contraction duration of 100 seconds Early deceleration of FHR

Contraction duration of 100 seconds

A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin (Pitocin) infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? A) Color of amniotic fluid B) Deep tendon reflexes C) Maternal temp D) Maternal BP

D) maternal blood pressure

A young Jewish woman is planing to become pregnant and asks the nurse if she should be tested for any genetic disorders. Which action should the nurse implement? Explain the risk for carrying genes for Tay-Sachs disease Determine if fam history includes hemophilia in males Reassure her that she is not at risk Discuss amniocentesis as an option to screen for genetic disorders

Discuss amniocentesis as an option to screen for genetic disorders

The current vital signs for a primipara who delivered vaginally during the previous shift are: temp 100.4, HR 58, RR 16, and BP 130/74. What action should the nurse implement?

Document the VS in the record

At 6 weeks gestation the rubella titer of a client indicates that she is non-immune. When is the best time to administer a rubella vaccine to the client? Immediately at 6 weeks to protect the fetus After the client stops breastfeeding After the client reaches 20 weeks Early postpartum, within 72 hr of delivery

Early postpartum, within 72 hr of delivery

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

Ensure that AZT is given within 6 hours after birth

When teaching a gravid client how to perform kick counts, which instruction should the nurse include? Exercise for 15 min before starting the counting to help increase fetal movement If 10 kicks are not felt within 1 hour, drink OJ and count for another hour Count the movements once daily for one hour before breakfast Avoid caffeinated drinks for 24 hr before conducting the kick test

Exercise for 15 min before starting the counting to help increase fetal movement

A pt at 30 weeks reports she hasn't felt baby move in last 24 hr. She arrive in a panic at the OB clinic where she is immediately sent to hospital. Which assessment finding warrants immediate interventions by nurse? Ruptured amniotic membrane Onset of uterine contractions Fetal HR of 60 Leaking amniotic fluid

Fetal HR of 60

While assessing a 40-week gestation primigravida in active labor, the client's membranes rupture spontaneously and the nurse notes that the amniotic fluid is meconium stained. Which additional finding is most important for the nurse to report to the healthcare provider?

Fetal heart rate of 100 to 110 beats/minute

A 34 week gestation multigravida comes to the clinic for her bimonthly apt. Which assessment finding should the nurse report to the healthcare provider? Fundal height of 30cm Fetal HR of 110 bpm Weight gain of 2 pounds 1+ edema on her lower extremities

Fundal height of 30cm

A 3 hour old male infant's hands and feet are cyanotic and he has an axillary temp of 96.5, a RR of 40, and HR of 165. What nursing intervention is best for the nurse to implement? Gradually warm the infant under a radiant heat source Perform a heel stick to monitor blood glucose level Notify pediatrician of infant's unstable VS Administer O2 by mask at 2 L/min

Gradually warm infant under a radiant heat source

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds 14 ounces, has a head circumference of 13 inches, and chest circumference of 10 inches. Based on these findings which condition has the highest priority? Polycythemia Hyperthermia Hypoglycemia Hyperbilirubinemia

Hypoglycemia

A new mother who is breast-feeding her 4 week old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement? Inform her that a decreased need for insulin occurs while breastfeeding Schedule an apt for the client with the diabetic nurse educator Advise the client to breastfeed more frequently Counsel her to increase her caloric intake

Inform her that a decreased need for insulin occurs while breastfeeding

Following vaginal delivery of LGA infant, woman is admitted to ICU due to postpartum hemorrhage. The pt's medical record lists the pt's religion as Jehovah's Witness. What action should the nurse take? Prepare to infuse multiple units of fresh frozen plasma Clarify the pt's wishes about receiving blood Obtain consent from fam to infuse RBCs Inform pt of critical need for blood transfusion

Inform pt of critical need for blood transfusion

At 0600 while admitting a woman for a scheduled repeat C section the client tell the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Start prescribed IV with LR's Contact the client's obstetrician Inform the anesthesia care provider Ensure preoperative lab results are available

Inform the anesthesia care provider

The nurse is preparing a client with Type 1 diabetes who is at 35 weeks for an amniocentesis. After obtaining maternal vital signs and a baseline FHR which nursing intervention has the highest priority? Obtain a baseline completely blood count Provide family support Review maternal Rh factor status Initiate a heparin lock

Initiate a heparin lock

A 33 year old client at 9 weeks tells the nurse that while she has cut down she still has at least one alcoholic drink every evening before bedtime. What intervention should the nurse implement? Notify child protective services of the client's illicit drug use and probable child endagerment Praise the client for her actions and offer to discuss ways to decrease consumption even more Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit Refer client to an outpatient alcohol abuse program

Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit

A term multigravida who is receiving Pitocin is requesting pain meds. Review of the pt's record indicates that she was medicated 30 min ago with butoprhanol (Stadol) 2 mg and promethazine 25 mg IV push. Vaginal exam reveals that the pt is at 3 cm, 70% effaced, and 0 station. What action should the nurse implement? Notify HCP D/c Pitocin infusion Instruct pt to use deep breathing during contraction Medicate pt with additional 1 mg of Stadol

Instruct pt to use deep breathing during contraction

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurses assessment findings and EFM are consistent with hypotonic dystocia, and the healthcare provider prescribes a Pitocin drip. Which data is most important for the nurse to monitor? Client's hourly BP Preparation for emergency C section Intensity, interval and length of contractions Checking the perineum for bulging

Intensity, interval and length of contractions

A client at 28 weeks who hemoglobin is 10.7 and hematocrit is 32.3 tells the nurse that she eats plenty of green vegetables. When the client asks the nurse about how the pregnancy might effect the lab findings, what info should the nurse provide? Plasma volume increases, making the blood count appear low It might be necessary to take an iron supplement twice daily Almost all women at 28 weeks have anemia Increasing intake of protein might improve these value

It might be necessary to take an iron supplement twice daily

Following a precipitous labor a postpartum client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that this sign may indicate which condition? Expected course in fourth stage of labor A full urinary bladder Laceration on the cervix Early postpartum hemorrhage

Laceration on cervix

A woman who delivery a normal newborn 24 hours ago complains I seem to be urinating every hour or so. is that Ok? Which action should the nurse implement? Catheterize the client for residual urine volume Obtain a specimen for urine culture and sensitivity Evaluate for normal involution then massage the fundus Measure the next voiding then palpate the client's bladder

Measure the next voiding then palpate the client's bladder

Assessment finding of a 4 hour old newborn: axillary temp 96.8, HR 150 with soft murmur, irregular RR 64, jitteriness, hypotonic, and weak cry. Based on these what action should the nurse take? Swaddle in warm blanket Document findings Place pulse ox on heel Obtain a heel stick blood glucose

Obtain a heel stick blood glucose

Using the Ballard Gestational Age Assessment Tool the nurse determines that a 15-minutes old infant has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement? Provide blow-by O2 Apply pulse ox to the foot Obtain capillary blood glucose Draw arterial blood gases

Obtain capillary blood glucose

A female pt comes to the clinical because it has been 6 weeks since her last menstrual period. Her medical hx includes the birth of one set of twins at 36 weeks, a second set of twins at 28 weeks, one miscarriage at 14 weeks, and a singleton birth at 39 weeks. How should the nurse document the patient's parity? Para 3 Para 5 Para 6 Para 4

Para 3

The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision? Wrap the infant in warm receiving blankets Place petroleum gauze dressings on site Offer pacifier dipped in glucose water Give PRN dose of liquid acetaminophen

Place petroleum gauze dressings on site

A postpartum client who is Rh-negative refuses to receive RhoGAm after delivery of an infant who is Rh-positive. Which information should the nurse provide this client

RhoGam prevents maternal antibody formation for future Rh-positive babies

The nurse is planning are for pt at 30 weeks who is experiencing preterm labor. What maternal prescription is most important in preventing fetus from developing respiratory distress syndrome? Betamethasone 12 mg deep IM Butorphanol 1 mg IV push q2h PRN pain Ampicillin 1 g IV push q 8h Terbutalline 0.25 mg subq q15 min X3

Terbutalline 0.25 mg subq q15 min X3

During routine prenatal health assessment for pt in third trimester, the pt reports that she had fluid leakage on her way to apt. Which technique should the nurse implement to evaluate leakage? Test fluid with nitrazine strip Scan bladder for urinary retention Palpate suprapubic area for fetal head position Insert straight Cath to drain bladder

Test fluid with nitrazine strip

A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond? That is called a cephalhematoma. It will cause no problems That is called caput succedaneum. It will have to be drained. That is called caput succedaneum. It will absorb and cause no problems. That is called a cephalhematoma. It can cause jaundice as it is absorbed.

That is called caput succedaneum. It will absorb and cause no problems.

Which findings of depression in the postpartum client require additional action by the nurse? Select all that apply Trouble falling asleep Feelings of sadness Engorged, painful breasts Return of loch rubra Decreased appetite

Trouble falling asleep Feelings of sadness Decreased appetite

A pt who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which info is most important for the nurse to provide the client? When ambulating to void doesn't cause dizziness After the bit K injection is given to baby After baby no longer demonstrates acrocyanosis When there is no significant vaginal bleeding

When there is no significant vaginal bleeding