OB HESI Practice

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Put the following actions in order to prevent hypotension in the pregnant client: 1. reposition the client 2. provide oxygen via face mask 3. increase IV fluid 4. call the healthcare provider

1,3,2,4

A 42 week gestational client is receiving an intraenous infusion of oxytocin (pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? A. transition labor with contractions every 2 minutes, lasting 90 seconds each. B. early labor with contractions every 5 minutes, lasting 40 seconds each C. Active labor with contractions every 31 minutes, lasting 60 seconds each D. Active labor with contractions every 2-3 minutes, lasting 70-80 seconds each

A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes and hyperclonus B. periorbital edema, flashing lights, and aura C. epigastric pain in the third trimester D. recent decreased urinary output

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. patellar reflex 4+ B. blood pressure 158/80 C. four-hour urine output 240 mL D. respiration 12/minute

A multigravida client arrives at the labor and delivery unit and tells the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140-150 bpm. What action should the nurse implement next? A. complete a sterile vaginal exam B. take maternal temperature every 2 hours C. prepare for an immediate cesarean birth D. obtain sterile suction equipment

A multigravida client at 41 weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? A. biophysical profile (BPP) B. ultrasound for fetal anomalies C. maternal serum alpha-fetoprotein (AF) screening D. percutaneous umbilical blood sampling (PUBS)

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan?S A. Observe the parents applying a Pavlik harness. B. Provide a referral for an orthopedic surgeon. C. Schedule a physical therapy follow-up home visit. D. Teach the parents to check for hip joint mobility.

A nurse explains to a nursing class that the efficiency of the basal body temperature method of contraception depends on fluctuation of the basal body temperature. Which factor can alter the effectiveness of this method? a. Stress b. Length of abstinence c. Age of those involved d. Frequency of intercourse

A nurse is caring for a client in preterm labor who is receiving a course of corticosteroids to promote fetal lung maturity. What test may be used to most accurately determine fetal lung maturity? a. Amniocentesis b. Ultrasonography c. Radioreceptor assay d. Chorionic villus sampling

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide the client? A. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." B. "We want your baby to be healthy, and this is the only way we can make sure that will happen." C. "I know you're upset. Would you like to talk about some things you could do while in bed." D. "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties."

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? a. Complete bedrest decreases oxygen needs and demands on the heart muscle b. We want your baby to be healthy, and this is the only way we can make sure that will happen again c. I know you're upset. Would you like to talk about somethings you could so while in bed? d. Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? A. bathe the infant with an antimicrobial soap B. measure the head and chest circumference C. obtain the infant's footprints D. administer vitamin K (AquaMEPHYTON)

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? A. apply cold compresses to both breasts for comfort. B. instruct the client to run warm water on her breasts C. wear a loose-fitting bra to prevent nipple irritation D. express small amounts of milk to relieve pressure

After feeding a newborn, how should the nurse position the infant in the crib? A) On the right side. B) Supine in a slight Trendelenburg. C) Supine with the head elevated. D) Prone with the foot of the crib elevated.

Because of the increased discomfort level during the transition phase of labor, nursing care should be directed toward what? a. Helping the client maintain control b. Decreasing the rate of intravenous fluid c. Administering the prescribed medication d. Having the client breathe in a uniform pattern

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn B. The client's educational background C. The order in which the information is presented D. The extent to which the pregnancy is planned

Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client? A. The client's investment in what is being taught B. The couple's highest levels of education C. The order in which the information is presented D. The extent to which the pregnancy was planned

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain

a,c,e

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply) A. dark, red vaginal bleeding B. lower back pain C. premature rupture of the membranes D. increased uterine irritability E. bilateral pitting edema F. a rigid abdomen

a,d,f

The primary healthcare provider prescribes a contraction stress test (CST) for a client whose nonstress test (NST) was nonreactive. Which maternal complications should prompt the nurse to question the prescription? Select all that apply. a. Hypertension b. Preterm labor c. Drug addiction d. Incompetent cervix e. Premature rupture of membranes

b,c,d,e

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A. Remove all ice from the client's room. B. Ask the client what foods she might consider eating. C. Remind the client that what she eats affects her baby. D. Notify the health care provider.

A pregnant client has a history of multiple preterm births followed by neonatal deaths. Which is the most significant impending sign of danger that the client must be taught to report? a. Leg cramps b. Pelvic pressure c. Nausea after 11 am d. No fetal movement at 12 weeks

A pregnant client is now in the third trimester. The client tells the nurse, "I want to be knocked out for the birth." How should the nurse respond? a. "You are worried about too much pain." b. "You don't want to be awake during the birth." c. "I can understand that because labor is uncomfortable." d. "I will tell your healthcare provider about this request."

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele's Rule, what is the estimated date of delivery? a. April 25, 2007 b. May 9, 2007 c. May 29, 2007 d. June 2, 2007

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A. Cephalhematoma, which is caused by forceps trauma B. Subarachnoid hematoma, which requires immediate drainage C. Molding, which is caused by pressure during labor D. Subdural hematoma, which can result in lifelong damage

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele's rule, what is the estimated date of delivery? A. April 25, 2007 B. May 9, 2007 C. May 29, 2007 D. June 2, 2007

What information does the nurse need to teach a client in order for her to perform an accurate breast self-examination? a. Squeeze the nipples to examine for discharge. b. Use the right hand to examine the right breast. c. Place a pillow under the shoulder opposite the examined breast to raise it. d. Compress breast tissue to the chest wall with the palm to palpate for lumps.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. have the client empty her bladder B. request the client lie on her left side C. Perform Leopold's maneuvers first D. Give the client some cold juice to drink

Which nurse intervention would be most helpful in relieving postpartum uterine contractions or "afterpains?" A. lying prone with a pillow on the abdomen B. using a breast pump C. massaging the abdomen D. giving oxytocic medications

Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)? A) Using relaxation breathing techniques. B) Using a breast pump. C) Massaging the abdomen. D) Giving oxytocic medications.

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" a. Lying prone with a pillow on the abdomen b. Using a breast pump c. Massaging the abdomen d. Giving oxytocic medications

A pregnant woman is admitted in active labor. What should the nurse instruct her coach to do when the client complains of back pain? a. Position her with her legs elevated. b. Apply pressure to the sacrum during contractions. c. Encourage performance of a panting-breathing pattern. d. Encourage her to do Kegel exercises between contractions.

A primigravida at 40 weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? A. dehydration B. hyperstimulation C. galactorrhea D. fetal tachycardia

The school nurse is teaching a group of 16-year-old girls about the female reproductive system. One student asks how long after ovulation it is possible for conception to occur. The most accurate response by the nurse is based on the knowledge that an ovum is no longer viable after when? a. 12 hours b. 24 hours c. 48 hours d. 72 hours

A client at 38 weeks' gestation is admitted to the high-risk prenatal unit with a diagnosis of severe preeclampsia. The nurse obtains the vital signs, performs a health history and physical assessment, and reviews the client's laboratory results. What is the priority nursing intervention at this time? a. Monitoring intake and output b. Providing a dark private room c. Measuring the extent of edema d. Preparing for an immediate cesarean birth

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied. B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C. Breastfeed on the unaffected breast only until the mastitis subsides. D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.

A client at 28 weeks gestation calls the antepartal clinical and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. come to the clinic today for an ultrasound B. go immediately to the emergency room C. lie on your left side for about one hour and see if the bleeding stops D. bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency department. C. Lie on your left side for about 1 hour and see if the bleeding stops. D. Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).

A client at 37 weeks' gestation is in active labor. Her contractions are now 2 to 3 minutes apart and lasting approximately 60 seconds. The fetal heart rate (FHR) averages around 100 beats/min between contractions. What is the nurse's priority intervention at this time? a. Notify the primary healthcare provider. b. Monitor the fetal heart rate continuously. c. Check the client's perineum for a prolapsed cord. d. Document the findings in the client's medical record.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? a. patellar reflexes 4+ b. blood pressure 158/80 c. four hour urine output 240 mL d. respirations 12 bpm

A client on her first prenatal clinic visit is at 6 weeks' gestation. She asks how long she may continue to work and when she should plan to quit. How should the nurse respond? a. "What activities does your job entail?" b. "How do you feel about continuing to work?" c. "Most women work throughout their pregnancies." d. "Usually women quit work at the start of their third trimester."

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? A. raise the foot of the bed B. assess for vaginal bleeding C. evaluate the fetal heart rate D. take the client's blood pressure

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? A. choking, coughing, and cyanosis B. projectile vomiting and cyanosis C. apneic spells and grunting D. scaphoid abdomen and anorexia

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? A) Choking, coughing, and cyanosis. B) Projectile vomiting and cyanosis. C) Apneic spells and grunting. D) Scaphoid abdomen and anorexia.

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate? A. "A home pregnancy test can be used right after your first missed period." B. "These tests are most accurate after you have missed your second period." C. "Home pregnancy tests often give false positives and should not be trusted." D. "The test can provide accurate information when used right after ovulation."

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? a. "A home pregnancy test can be used right after your first missed period." b. "These tests are most accurate after you have missed your second period." c. "Home pregnancy tests often give false positives and should not be trusted." d. "The test can provide accurate information when used right after ovulation."

A woman with type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? A. Describe diet changes that can improve the management of her diabetes B. inform the client that oral hypoglycemic agents are teratogenic during pregnancy C. Demonstrate self-administration of insulin D. evaluate the client's ability to do glucose monitoring

During a prenatal examination the nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for what? a. Acute hemolytic anemia b. Respiratory distress syndrome c. Protein metabolism deficiency d. Physiological hyperbilirubinemia

What is the nurse's priority assessment for a client in the fourth stage of labor? a. Degree of relaxation b. Distention of the bladder c. Extent of breast engorgement d. Presence of mother-infant bonding

During a routine prenatal visit, a client listens to the fetal heartbeat with the healthcare provider for the first time during her first trimester. The fetal heart rate is 150 beats/minute (bpm). The client looks frightened and asks whether this is normal. How should the nurse respond? a. "Normal range for fetal heart rate at 12 weeks gestation is 120 to 180 bpm." b. "Fetal average heart rate can be determined by multiplying the mother's heart rate times two." c. "A slow fetal heart rate is more concerning than a rapid heart rate." d. "A rapid fetal heart rate is necessary to meet nutritional needs."

Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 bpm and respirations of 20 breaths/min. What action should the nurse perform next? A. initiate positive pressure ventilation B. intervene after the one minute Apgar is assessed C. initiate CPR on the infant D. assess the infant's blood glucose level

On admission to the prenatal clinic, a 23-year old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be A. November 22 B. November 8 C. December 22 D. October 22

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth (EDB)? A. November 22 B. November 8 C. December 22 D. October 22

The healthcare provider prescribes terbutalne (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A. gestational diabetes B. elevated blood pressure C. urinary tract infection D. swelling in lower extremities

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks gestation. What type of emotional response should the nurse anticipate? A. grief related to her perceptions about the loss of this child B. Relief of ambivalent feelings experienced with this pregnancy C. Shock because she may not have realized that she was pregnant D. guilt because she had not followed her healthcare provider's instructions

The nurse is assessing a 3 day old infant with a cephaloheatoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? A. Yellowish tinge to the skin B. Babinski reflex present bilaterally C. pink papular rash on the face D. Moro reflex noted after a loud noise

The nurse is assessing a 3 day old infant with cephalahematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? a. yellowish tinge to skin b. babinski reflex present bilaterally c. pink papular rash on the face d. moro reflex noted after a loud noise

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of the greatest concern? A. edema, basilar rates, and an irregular pulse B. increased urinary output and tachycardia C. shortness of breath, bradycardia, and hypertension D. regular heart rate and hypertension

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs A. two weeks before menstruation B. immediately after menstruation C. immediately before menstruation D. three weeks before menstruation

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation

The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings? a. Notify the practitioner, because circumoral pallor may indicate cardiac problems b. Notify the practitioner, because both signs are indicative of increased intracranial pressure c. Take no specific action, because both signs are expected in a newborn until 2 weeks of age d. Take no specific action, because circumoral pallor is an expected finding during feedings and periods of crying

The nurse is providing discharge for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? A. reduce activity level and notify the healthcare provider B. go to bed and assume a knee-chest position C. massage the uterus and go to the emergency room d. do not worry as this is a normal occurance

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A. Avoid alcohol because it is excreted in breast milk. B. Eat a high-roughage diet to help prevent constipation. C. Increase caloric intake by approximately 500 cal/day. D. Increase fluid intake to at least 3 quarts each day.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. between the time the temperature falls and rises B. between 36 and 48 hours after the temperature rises C. when the temperature falls and remains low for 36 hours D. within 72 hours before the temperature falls

Twenty four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line in a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications C. molding, caused by pressure during labor and will disappear within 2 to 3 days D. a subdural hematoma which can result in lifelong damage

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings."

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? Select all that apply A. admission weight of 4 pounds, 15 ounces (2244 grams) B. head to heel length of 17 inches (42.5 cm) C. Frontal occipital circumference of 12.5 in (31.25 cm) D. Skin smooth with visible veins and abundant vernix E. Anterior plantar crease and smooth heel surfaces F. Full flexion of all extremities in resting supine position

a,b,c

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply) A. mood swings B. panic attacks C. tearfulness D. decreased need for sleep E. disinterest in the infant

a,c

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? Select all that apply. a. "Wash your hands before touching the newborn." b. "Send the newborn to nursery to be monitored during the night." c. "All client identification bands should remain in place until discharge." d. "Do not let anyone remove the infant from your sight while you are in the hospital." e. "Check the identification of staff, and if there is a question of validity, call the nursing station."

a,c,e

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A. Pain in the lower back that radiates to abdomen B. Contractions decreased in frequency with ambulation C. Progressive cervical dilation and effacement D. Discomfort localized in the abdomen E. Regular and rhythmic painful contractions

a,c,e

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.) A. Increased heartburn that is not relieved with doses of antacids B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C. Shoes and rings that are too tight because of peripheral edema in extremities D. Decrease in ability for the client to sleep for more than 2 hours at a time E. Chronic headache that has been lingering for a week behind the client's eyes

a,e

A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is given a dose of terbutaline 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? a. maternal blood pressure and respirations b. maternal and fetal heart rates c. hourly urine output d. deep tendon reflexes

A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg SQ. Which assessment is the highest priority for the nurse to monitor during the adminstration of this drug? A. maternal blood pressure and respirations B. maternal and fetal heart rates C. hourly urinary output D. deep tendon reflexes

A 30 year old gravida, 2 para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? A. maternal blood pressure and respirations B. maternal and fetal heart rates C. hourly urinary output D. deep tendon reflexes

A client at 39 weeks' gestation arrives in the birthing suite reporting that she is having regular contractions. A vaginal examination reveals that the presentation is a double-footling breech. The primary healthcare provider decides to proceed to a cesarean birth under regional anesthesia. Which intervention is important in preventing postoperative maternal complications? a. Providing scrupulous skin care b. Maintaining adequate hydration c. Monitoring the vital signs frequently d. Teaching the client how to use an incentive spirometer

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? a. Ask the client if she takes a daily calcium tablet b. Extend the leg and dorsiflex the foot c. Lower the leg off the side of the bed d. Elevate the leg above the heart

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. ask if she takes a daily calcium tablet B. extend the leg and dorsiflex the foot C. lower the leg off the side of the bed D. elevate the leg above the heart

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to the infant. The nurse's response should be based on what information? A. males inherit the disorder with a greater frequency than females B. each pregnancy carries a 50% chance of inheriting the disorder C. the disorder occurs in 25% of pregnancies D. all children will be carriers of the disorder

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide? A. Avoid using the breast pump. B. Breastfeed the infant every 2 hours. C. Reduce fluid intake for 24 hours. D. Skip feedings to let the sore breasts rest.

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. supplementary iron is more efficiently utilized during pregnancy B. it is difficult to consume 18 mg of additional iron by diet alone. C. iron absorption is decreased in the GI tract during pregnancy D. iron is needed to prevent megaloblastic anemia in the last trimester

A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse have available for signs of potential toxicity? A. oxytocin (pitocin) B. calcium gluconate C. terbutaline (Brethine) D. naloxone (narcan)

A couple interested in delaying the start of a family discuss the various methods of family planning. Together they decide to use the basal body temperature method. The nurse explains that the fertile period surrounding ovulation lasts from when to when? a. 12 hours before to 24 hours after ovulation b. 72 hours before to 24 hours after ovulation c. 72 to 80 hours before to 72 hours after ovulation d. 24 to 48 hours before to 48 hours after ovulation

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? A. "Your current dose of insulin should be maintained throughout your pregnancy." B. "Maintain blood sugar levels in a constant range within normal limits during pregnancy." C. "The course and outcome of your pregnancy is not an achievable goal with diabetes." D. "Expect an increase in insulin dosages by 5 units/wk during the first trimester."

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? a. length of labor and method of delivery b. infants condition at birth and treatment received c. feeding method chosen by the parents d. history of drugs given to the mother during labor

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? A. length of labor and method of delivery B. infant's condition at birth and treatment received C. feeding method chosen by the parents D. history of drugs given to the mother during labor

A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? A. the length of labor and method of delivery B. the infant's condition at birth and treatment received C. the feeding method chosen by the parents D. the history of drugs given to the mother during labor

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate? A. "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." B. "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C. "Offer the baby extra bottled milk after her feeding and see if she still seems hungry." D. "If you're concerned, you might consider bottle feeding so that you can monitor intake."

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation will the nurse provide? A. "weigh the baby daily, and if she is gaining weight, she is eating enough." B. "your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times/day." C. "Offer the baby extra bottle milk after her feeding and see if she is still hungry." D. "If you're concerned, you might consider bottle feeding so that you can monitor her intake."

A nurse is teaching a class regarding childbearing and contraceptive options. The nurse explains that fertilization of the ovum by the sperm occurs during a very specific time frame. Which statement best describes when fertilization occurs? a. As the ovum leaves the ovary b. When one sperm penetrates the wall of the ovum c. When the ovum reaches the endometrium of the uterus d. As one sperm prevents the ovum from moving along the tube

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Tiny white papules on the nose or chin D. Red patches on the cheeks and trunk

A primigravida in her first trimester visits the prenatal clinic for the first time. Which statement illustrates a psychologic reaction to pregnancy that usually occurs in the first trimester? a. "I know I'm going to be a terrible mother—I'll forget the baby when I go out." b. "I'm excited about the baby, but I'm not sure that I'm ready to be a mother." c. "I know I'm going to have a girl. I dreamed that she would be a doctor or a lawyer and be very successful." d. "I'm so excited about this baby, but I'm so afraid of losing control during labor. I know I'll be a terrible patient."

A primigravida in her seventh week of gestation asks the nurse when she can expect to feel her baby move. The nurse replies that quickening usually occurs in which week? a. 24th week b. 20th week c. 16th week d. 12th week

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted? A. If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C. If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D. If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.

An infant has had surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant? a. Frequent crying b. Bulging fontanels c. Change in vital signs d. Difficulty with feeding

During a prenatal visit a client who is at 36 weeks' gestation states that she is having uncomfortable, irregular contractions. How should the nurse respond? a. "Lie down until they stop." b. "Walk around until they subside." c. "Time the contractions for 30 minutes." d. "Take two extra-strength aspirin if the discomfort persists."

During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother? A. Lower Apgar score recorded at delivery B. Lower initial weight documented at birth C. Higher oxygen use to stimulate breathing D. Higher prevalence of congenital anomalies

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores B. lower birth weights C. respiratory distress D. a higher rate of congenital anomalies

During her first prenatal visit a client tells the nurse that she needed an exchange transfusion when she was born because of Rh incompatibility. She asks the nurse whether her baby will need one also. How should the nurse respond? a. "Your baby has a 50% chance of being affected." b. "You should have no problem because you're Rh positive." c. "You'll be given RhoGAM, which will prevent the development of antibodies." d. "Your baby's cord blood will be tested to determine whether there's going to be a problem."

During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond? a. "You may use oral contraceptives—they're almost completely effective in preventing pregnancy." b. "You should use foam with a condom to prevent pregnancy—this is the safest method for women with your illnesses." c. "You'll find that the intrauterine device is best for you, because it prevents a fertilized ovum from implanting in the uterus." d. "You have little to worry about regarding becoming pregnant in the near future, because women with your illnesses usually become infertile."

The newborn's total body response to noise or movement is often distressing to the parents. What should the nurse explain about this response? a. This automatic response probably signifies hunger. b. This reflexive response is an expected part of development. c. It is an involuntary response that will remain for the first year of life. d. It is a voluntary response that indicates insecurity in a new environment.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing? A. Taking-in phase B. Postpartum blues C. Attachment difficulty D. Letting-go phase

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distending bladder could be traumatized during labor, as well as prolong the progress of labor C. urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. frequent voiding minimizes the need for catheterization which increases the chance of bladder infection

The nurse identifies crepitus when examining the chest of the newborn who was delivered vaginally. Which further assessment should the nurse perform? A. elicit a positive scarf sign on the affected side B. observe for an asymmetrical Moro (startle) reflex C. Watch for swelling of fingers on the affected side D. Note paralysis of affected extremity and muscles

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? A) Ask the mother why she won't look at the infant. B) Observe the mother for other attachment behaviors. C) Examine the newborn's eyes for the ability to focus. D) Recognize this as a common reaction in new mothers.

The nurse should explain to a 30 year old gravid client that alpha fetoprotein testing is recommended for which purpose? A. detect cardiovascular disorders B. screen for neural tube defects C. monitor for placental functioning D. assess for maternal pre-eclampsia

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body.

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. she eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body

While performing a newborn assessment after a vaginal birth, a student nurse observes a swelling on one side of the top of the head that does not cross the suture line. The student nurse has identified what clinical manifestation? a. A bulging fontanel b. A cephalhematoma c. Caput succedaneum d. Normal molding pattern

Why should the nurse limit food and oral fluids as a laboring client approaches the second stage of labor? a. The mechanical and chemical digestive processes require energy that is needed for labor. b. Undigested food and fluid may cause nausea and vomiting and limit the choice of anesthesia. c. The gastric phase of digestion stimulates the release of hydrochloric acid and may cause dyspepsia. d. Food and fluid will further aggravate gastric peristalsis, which is already increased because of the stress of labor.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.) A) Provide oxygen via face mask B) Reposition the client. C) Call the healthcare provider. D). Increase IV fluid.

b,a,d,c

A 23 year old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? a. refer the client to a social worker to arrange for home care b. recommend perinatal care from an obstetrician, not a nurse-midwife c. teach the client why keeping prenatal care appointments is important d. advise the client that neonatal intensive care may be needed

A 23 year old client who is receiving Medicaid is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? A. refer the client to a social worker to arrange for home care B. recommend prenatal care from an obstetrician, not a nurse midwife C. teach the client why keeping prenatal care appointments is important D. Advise the client that neonatal intensive care may be needed

A 24 hour old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. Which action should the nurse implement? a. notify the healthcare provider b. move the newborn to an isolation nursery c. document the finding in the infant's record d. obtain a culture of the vesicles

A 24-hour old newborn has a pink papular rash with vesicles superimposed on the thorax, back and abdomen. What action should the nurse implement? A. notify the healthcare provider B. move the newborn to an isolation nursery C. document the finding in the infant's record D. obtain a culture of the vesicles

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record? A. Gravida 1, para 0 B. Gravida 1, para 1 C. Gravida 2, para 0 D. Gravida 2, para 1

A 26 year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? a. drowsiness and bradycardia b. depressed reflexes and increased respirations c. tachycardia and a feeling of nervousness d. a flushed, warm feeling and a dry mouth

A 26-year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg SQ to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? A. drowsiness and bradycardia B. depressed reflexes and increased respirations C. tachycardia and a feeling of nervousness D. a flushed, warm feeling and a dry mouth

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A. Drowsiness and paroxysmal bradycardia B. Depressed reflexes and increased respirations C. Tachycardia and a feeling of nervousness D. A flushed warm feeling and dry mouth

A 38-week primagravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings B. Reduce salt in her diet C. Move about every hour D. Avoid constrictive clothing

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in the diet. C. Move about every hour. D. Avoid constrictive clothing.

A 4 week old premature infant has been receiving epoetin alfa (Epogen) for the last 3 weeks. Which assessment finding indicates to the nurse that the drug is effective? A. slowly increasing urinary output over the last week B. respiratory rate changes from the 40s to the 60s. C. changes in apical heart rate from the 180s to the 140s D. change in indirect bilirubin from 12 mg/dl to 8 mg/dl

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now, and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick and high. Based on this data, which intervention should the nurse implement first? A. provide oral hydration B. have a complete blood count (CBC) drawn C. obtain a specimen for urine analysis D. place the client on strict bedrest

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? a. Provide oral hydration b. Have a complete blood count (CBC) drawn c. Obtain a specimen for urine analysis d. Place the client on strict bedrest

A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment is most indicative of an impending convulsion? A. 3+ deep tendon reflexes B. periorbital edema C. epigastric pain D. decreased urine output

A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? A. 4+ reflexes B. urinary output of 50 mL per hour C. a decrease in respiratory rate from 24 to 16 D. a decreased body temperature

A client gives birth to an 8-lb (3529-g) baby. Ten minutes after the birth, the placenta has not yet separated. What is the nurse's priority action at this time? a. Applying fundal pressure b. Administering a second dose of oxytocin c. Continuing to assess the client for signs of separation d. Preparing a consent form for manual removal of the placenta

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response? A. Telling the client and her partner that the labor process is often unpredictable B. Informing the client that this means she will give birth sooner than expected C. Asking the client and her partner if they would like the nurse to stay in the room D. Affirming that the fetal heart rate is remaining within normal limits

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? A. heart rate of 100 bpm B. variable fetal heart rate C. onset of uterine contractions D. burning on urination

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take? A. Instruct the client to go to the emergency room. B. Recommend vaginal douching. C. Explain this is a normal finding. D. Determine if ovulation has occurred.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pad are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? a. cleanse the perineum b. obtain a blood pressure c. palpate the firmness of the fundus d. inspect the perineum for lacerations

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6 inch diameter pool of blood. Which action should the nurse implement next? A. cleanse the perineum B. obtain a blood pressure C. palpate the firmness of the fundus D. inspect the perineum for lacerations.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort related to nausea and abdominal distention C. Impaired bowel motility related to pain medication and immobility D. Fatigue related to cesarean delivery and physical care demands of infant

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? A) Gravidity and parity. B) Time and amount of last oral intake. C) Date of last normal menstrual period. D) Frequency and intensity of contractions.

A client with no prenatal care arrives at the labor unit screaming, "the baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain? A. gravidity and parity B. time and amount of last oral intake C. date of last normal menstrual period D. frequency and intensity of contractions

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that that woman's fallopian tubes are patient? A. back pain B. abdominal pain C. shoulder pain D. leg cramps

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? a. back pain b. abdominal pain c. shoulder pain d. leg cramps

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B. Wash off the yellow exudate on the glans once every day to prevent infection. C. Place petroleum ointment around the glans with each diaper change and cleansing. D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A. Wear a cotton bra with nonbinding support. B. Increase nursing time gradually over several days. C. Ensure that the baby is positioned correctly for latching on. D. Manually express a small amount of milk before nursing.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? A. wear a cotton bra B. increase nursing time gradually C. correctly place the infant on the breast D. manually express a small amount of milk before nursing

A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help expel the placenta? a. Put pressure on the fundus b. Ask the mother to bear down c. Have the mother breast-feed the newborn d. Place gentle continuous tension on the cord

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head" Which response by the nurse is best? A. "This is not an unusual shaped head, especially for a first baby." B. "It may look funny to you, but newborn babies are often born with heads like your baby's." C. "That is normal, the head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the baby's head had to adjust to the birth canal."

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A. "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the head had to adjust to the birth canal."

A new mother who is learning about infant feedings asks the nurse how anyone who is breast-feeding gets anything done with a baby feeding on demand. What is the best response by the nurse? a. "Most mothers find that feeding whenever the baby cries works out fine." b. "Perhaps a schedule would be better because the baby is already accustomed to the hospital routine." c. "Babies on demand feedings eventually set a schedule, so there should be time for you to do other things." d. "Most breast-feeding mothers find that their babies do better on demand because the amount of milk ingested varies from feeding to feeding."

A newborn infant is brought to the nursery from the bathing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? A. notify the pediatrician B. suction the infant's nares, then the oral cavity C. check the infant's oxygen saturation rate D. position the infant on the right side.

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is A. shortness of breath B. joint pain C. a persistent cold D. organomegaly

A nurse in the fertility clinic works with couples who have been trying to become pregnant for more than 1 year. How can the nurse help ease the feeling of isolation that infertile couples often experience? a. Teach them about infertility and its treatment. b. Identify activities that are interesting and satisfying. c. Explore ways to promote communication with family and friends. d. Explain to them that men and women cope differently with stressful situations.

A nurse is caring for a client with type 1 diabetes on her first postpartum day. While planning care for this client, what changes in insulin requirements does the nurse anticipate? a. Slowly decrease b. Quickly increase c. Suddenly decrease d. Usually remain unchanged

At 14 weeks gestation, a client arrives at the emergency center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 bpm, and a blood pressure of 86/48. Which action should the nurse implement next? A. check the hematocrit results B. administer pain medication C. increase the rate of IV fluids D. monitor client for contractions

At 14 weeks gestation, a client arrives to the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates and IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 bpm, and a blood pressure of 86/48. Which condition should the nurse implement next? a. check the hematocrit levels b. administer pain medications c. increase the rate of IV fluids d. monitor client for contractions

Pregnant women with cardiac problems must be assessed more frequently than is typical. Which physiologic adaptation does the nurse suspect is the result of early decompensation? a. Hemoptysis b. Tachycardia c. Increasing fatigue d. Generalized edema

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply baby lotion after the baby's daily bath.

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A. Turn the client to her side. B. Begin oxygen by nasal cannula at 2 L/min. C. Place the client in a slight Trendelenburg position. D. Assess for cervical dilation.

The four essential components of labor are passenger, powers, passageway, and position. Passageway refers to the bony pelvis. Which type of pelvis is considered the most favorable for a vaginal delivery? a. Android b. Anthropoid c. Gynecoid d. Platypelloid

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A. insert an internal fetal monitor B. assess for cervical changes q1h C. monitor for bleeding from IV sites D. perform Leopold's maneuvers

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A. Administer oxygen by facemask. B. Notify the health care provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate.

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? A. administer oxygen by face mask B. notify the healthcare provider of the client's symptoms C. have the client breathe into her cupped hands D. check the client's blood pressure and fetal heart rate

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? A. two vessels: one artery and one vein B. two vessels: two arteries and no veins C. three vessels: two arteries and one vein D. three vessels: Two veins and one artery

The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D. February 6 to 7

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be A. January 14-15 B. January 22-23 C. January 30-31 D. February 6-7

The nurse is preparing a client in active labor for epidural anesthesia. Which prescribed intervention should the nurse initiate before the anesthesiologist initiates the epidural? a. Application of oxygen at 5 L/min with a face mask b. Ensuring that naloxone is available on the unit c. Administering a 500-mL bolus of lactated Ringer solution intravenously d. Preparing an intravenous infusion of oxytocin (Pitocin) to augment the client's labor

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A. Maternal blood pressure B. Maternal temperature C. Fetal heart rate (FHR) D. White blood cell count (WBC)

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? A. begin as soon as your baby is born to establish a four-hour feeding schedule B. resting helps with milk production. Ask that your baby be fed at night in the nursery C. feed your baby every 2 to 3 hours or on demand, whichever comes first. D. do not allow your baby to nurse any longer than the prescribed number of minutes

The nurse is teaching breastfeeding to prospective parents in childbirth education class. Which instruction should the nurse include as content in the class? a. begin as soon as your baby is born to establish a four-hour feeding schedule b. resting helps with milk production, ask that your baby be fed at night in the nursery c. feed your baby every 2-3 hours or on demand, whichever comes first d. do not allow your baby to nurse any longer than the prescribed number of minutes

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? A. Herpes B. Staphylococcus C. Gonorrhea D. Syphilis

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A. 3 B. 4 C. 5 D. 8

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? A. cuddles the baby close to her B. rocks and soothes the infant in her arms C. places the infant prone in the bassinet D. wraps the baby in a warm blanket after bathing

The nurse should encourage the laboring client to begin pushing when A. there is only an anterior or posterior lip of cervix left. B. the client describes the need to have a bowel movement. C. the cervix is completely dilated D. the cervix is completely effaced

The total bilirubin level of a 36 hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? A. provide phototherapy for 30 minutes q8h B. feed the newborn sterile water hourly C. encourage the mother to breastfeed frequently D. assess the newborn's blood glucose level

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? A. Notify the health care provider or anesthesiologist. B. Continue to assess the blood pressure every 5 minutes. C. Place the client in a lateral position. D. Turn off the continuous epidural.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take? A. notify the healthcare provider or anesthesiologist immediately. B. continue to assess the blood pressure q5 minutes C. place the woman in a lateral position D. turn off the continuous epidural

What is the optimal nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? a. Document the fetal heart rate every 5 minutes. b. Call the anesthesia department to alert the staff there of an imminent birth. c. Assist the client's coach in helping her with the use of breathing techniques. d. Suggest that the client accept the as-needed (PRN) medication for pain that has been prescribed.

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7-10 days B. Meconium is the first stool and is usually yellow gold in color C. Vernix is a white, cheesy substance, predominantly located in the skin folds D. Pseudostrabismus found in newborns is treated by minor surgery.

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.

While performing Leopold maneuvers on a client who has been admitted to the birthing room, the nurse identifies a firm, round prominence over the symphysis pubis; a smooth, convex structure along her right side; irregular lumps along her left side; and a soft roundness in the fundus. What is the fetal position? a. LOP b. RSA c. ROA d. LOA

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (select all that apply) A. Litmus paper B. fetal scalp electrode C. a sterile glove D. an amniotic hook E. sterile vaginal speculum F. a Doppler

c,d,f

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (select all that apply) A. litmus paper B. fetal scalp electrode C. a sterile glove D. an amnihook E. sterile vaginal speculum F. lubricant

c,d,f

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? a. Encourage the mother to provide total care for her infant b. Provide privacy so the mother can develop a relationship with the infant c. Encourage the father to provide most of the infant's care during hospitalization d. Meet the mother's physical needs and demonstrate warmth toward the infant

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. encourage the mother to provide total care for her infant B. provide privacy so the mother can develop a relationship with the infant. C. encourage the father to provide most of the infant's care during hospitalization. D. Meet the mother's physical needs and demonstrate warmth toward the infant.

A 26-year-old woman whose sister recently had a lumpectomy for breast cancer calls the local women's health center for an appointment for a mammogram. What guidance should the nurse provide the client in preparation for the test? a. Do not eat for 6 hours before the test. b. The room will be darkened throughout the procedure. c. The first mammogram is usually performed at 50 years of age. d. During the procedure, each breast will be compressed firmly between two plates.

A 30 year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? a. "Tell the older child that he is a big boy now and should love his new sister." b. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him." c. Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn." d. Regression in behaviors in the older child is a typical reaction so he needs attention at this time."

A 30-year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter. I don't know who I'll ever manage both children when I get home." How should the nurse respond? A. "Tell the older child that he is a big boy now and should love his new sister." B. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him." C. "Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the newborn." D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this time."

A 35-year old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity? A. deep tendon reflexes 2+ B. blood pressure 140/90 C. respiratory rate 18/min D. urine output 90 mL/4 hours

A 40 week gestation primigravada client is being induced with an oxytocin (pitocin) secondary infusion and complains pain in her lower back. Which intervention should the nurse implement? A. discontinue the oxytocin (Pitocin) infusion B. place the client in a semi-Fowler's position C. inform the healthcare provider D. apply firm pressure on the sacral area.

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A. Place a wedge under the client's left side. B. Determine cervical dilation and effacement. C. Administer 10 L of oxygen via facemask. D. Increase the rate of the oxytocin (Pitocin) infusion.

A client at 32 weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue and a moist cough. Which question is most important for the nurse to ask this client? A. "Which symptom did you experience first?" B. "Are you eating large amounts of salty foods?" C. "Have you visited a foreign country recently?" D. "Do you have a history of rheumatic fever?"

A client is admitted to the birthing room in active labor. The nurse determines that the fetus is in the left occiput posterior (LOP) position. At which point can the fetal heart be heard? a. a b. b c. c d. d

A client seeking advice regarding contraception asks a nurse to explain how an intrauterine device (IUD) prevents pregnancy. How should the nurse respond? a. "It covers the entrance to the cervical os." b. "The openings to the fallopian tubes are blocked." c. "The sperm are kept from reaching the vagina." d. "It produces a spermicidal intrauterine environment."

A client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet? a. Fat-soluble vitamins b. Dietary fiber and oat bran c. Low-fat foods with essential fatty acids d. Vitamins C and E

A client who is in the second trimester tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? A. "Herbs are a cornerstone of good health to include in your treatment." B. "Touch is also therapeutic in relieving discomfort and anxiety." C. "Your healthcare provider should direct treatment options for herbal therapy." D. "It is important that you want to take part in your care."

A client with severe preeclampsia develops eclampsia. After the seizure, the client has a temperature of 102° F (38.9° C). What does the nurse suspect as the cause of the elevated temperature? a. Excessive muscular activity b. Development of a systemic infection c. Dehydration caused by rapid fluid loss d. Irregularity in the cerebral thermal center

A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A. Exercise regimen of both partners includes running 4 miles each morning B. history of having sexual intercourse 2-3x/wk. C. The woman's menstrual period occurs every 35 days D. They use lubricants with each sexual encounter to decrease friction

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide? A. Most infants of HIV-positive women will continue to test positive for HIV antibodies. B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C. Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-negative. D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot". Which explanation should the nurse give to this anxious client? A. "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." B. "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot. C. "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair."

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? a. "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." b. "That's just an old wives tail so don't worry, you can't harm your baby's head by touching the soft spot." c. "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." d. "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair."

A newborn is circumcised prior to discharge from the hospital. What should the immediate postoperative care include? a. Keeping the infant NPO for 4 hours to prevent vomiting b. Encouraging the intake of alkaline fluids to reduce urine acidity c. Changing the dressing using dry, sterile gauze to maintain cleanliness d. Encouraging the mother to cuddle her baby to provide emotional support

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. How should the nurse explain the purpose of PKU testing to this mother? a. It detects thyroid deficiency b. It reveals possible brain damage c. It identifies chromosomal damage d. It is used to measure protein metabolism

A nurse at the fertility clinic is counseling a couple about the tests that will be necessary in order to determine the cause of their infertility. Which test will most likely be used to evaluate the woman's organs of reproduction? a. Biopsy b. Cystogram c. Culdoscopy d. Hysterosalpingogram

A pregnant client has a positive group B Streptococcus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan? a. "Go straight to the outpatient area of the maternity unit for a nonstress test." b. "You'll need to schedule visits twice a week with your healthcare provider until you deliver." c. "Your baby will have to spend at least 3 days in the neonatal intensive care unit because of this infection." d. "This information will be in your prenatal record; however, please remind your labor and delivery nurse of this finding."

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in the client's record? A. 31203 B. 41203 C. 21212 D. 31103

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record? A) 3-1-2-0-3. B) 4-1-2-0-3. C) 2-1-2-1-2. D) 3-1-1-0-3.

A pregnant woman reports nausea and vomiting during the first trimester of pregnancy. The nurse explains that an increase in which hormone is the precipitating cause of the nausea and vomiting? a. Estrogen b. Progesterone c. Luteinizing hormone d. Chorionic gonadotropin

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? A. cervical dilation of 5 cm with 90% effacement B. WBC of 12,000/mm3 C. hemoglobin of 12 mg/dl and hematocrit of 38%. D. a platelet count of 67,000/mm3

A woman who had a miscarriage 6 months ago became pregnant. Which instruction is most important for the nurse to provide this client? A. Elevate lower legs while resting B. increase caloric intake by 200-300 calories per day C. increase water intake to 8 full glasses per day D. take prescribed multivitamin and mineral supplements

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important is most important for the nurse to provide this client? a. Elevate lower legs while resting b. Increase caloric intake by 200 to 300 calories per day c. Increase water intake to 8 full glasses per day d. Take prescribed multivitamin and mineral supplements

After each feeding, a 3-day old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac Soy Isomil Formula, a soy protein isolate based on infant formula. What information should the nurse provide to the mother about the newly prescribed formula? A. The new formula is a coconut milk formula used with babies with impaired fat absorption B. Enfamil Formula is a demineralized whey formula that is needed with diarrhea C. the new formula is a casein protein source that is low in pheynylalanine. D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A. Suggest that his wife seek professional counseling to deal with her symptoms. B. Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D. Reassure him that normal maternal-fetal bonding is occurring.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use thread to tie off the umbilical cord. B. Provide privacy for the woman. C. Reassure the husband and keep him calm. D. Put the newborn to the breast immediately.

An off-duty nurse finds a woman in a supermarket parking lot delivery an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. use a thread to tie off the umbilical cord. B. provide as much privacy as possible for the woman. C. reassure the husband and try to keep him calm D. put the newborn to breast.

As part of an infertility workup involving both partners, a male client is to have a semen analysis. What should the nurse include as part of his instructions? a. Obtain the specimen upon awakening. b. Use a condom to collect the semen specimen. c. Ejaculate at least 4 hours before collection to ensure a pure specimen. d. Deliver the specimen to the laboratory within 2 hours of obtaining it.

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take? A. Encourage her to pant between contractions and blow with contractions. B. Coach her to take a deep cleansing breath and then refocus. C. Instruct her to pant three times and then exhale through pursed lips. D. Have her cup both hands over her nose and mouth while breathing.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

In developing a teaching plan for expectant parents, the nurse plans to including information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2-4 months and the posterior by the end of the first week B. anterior fontanel closes at 5-7 months and the posterior by the end of the second week C. anterior fontanel closes at 8-11 months and the posterior by the end of the first month D. anterior fontanel closes at 12-18 months and the posterior by the end of the second month.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby B. Ask the client to describe why she was unsuccessful with breastfeeding her last child C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the woman to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the woman to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

One hour after giving birth to an 8 pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 bpm and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM x 1. What action should the nurse take immediately? A. give the medication as prescribed and monitor for efficacy B. encourage the client to breast feed rather than bottle feed C. have the client empty her bladder and then massage the fundus D. call the healthcare provider to question the prescription

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.

The health care provider hands a neonate to a nurse immediately after birth. Which is the most appropriate action for the nurse to take next for this newborn? a. Perform an abbreviated physical assessment b. Administer oxygen until cyanosis disappears c. Cut the umbilical cord and attach an umbilical clip d. Dry the infant and provide skin-to-skin contact with the mother

The nurse is assessing a client who is having a non-stress test (NST) at 41 weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occuring. What action should the nurse take? A. check the client for urinary bladder distension B. notify the healthcare provider of the nonreactive results C. have the mother stimulate the fetus to move D. ask the client if she has felt any fetal movement

The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? A. August 1 B. August 10 C. September 3 D. September 8

The nurse is caring for a client in the transition phase of labor. Which breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation? a. Expulsion pattern b. Slow-paced pattern c. Shallow-chest pattern d. Panting-blowing pattern

The nurse is caring for a client who has had a spontaneous abortion. The client asks why spontaneous abortions occur. The nurse responds that they are most commonly caused by what? a. Physical trauma b. Unresolved stress c. Congenital defects d. Embryonic defects

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A. Reapply the external transducer. B. Insert the intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress.

The nurse is planning preconception care for a new female client. Which information should the nurse provide to the client? A. discuss various contraceptive methods to use until pregnancy is desired B. provide written or verbal information about prenatal care C. ask the client about risk factors associated with complications of pregnancy D. encourage healthy lifestyles for families desiring pregancy

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? a. a gravida 6, para 5 who is 38 years of age and in early labor b. a 37 week primigravida who presents with 100% effacement, 3 cm cervical dilation, and a 1- station c. a gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to post dates d. a 40 week primigravida who is at 6 cm dilation and the presenting part is not engaged

The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure? A. a gravida 6, para 5 who is 38 years of age an in early labor B. a 37 week primigravida who presents at 100% effacement, 3 cm cervical dilation and a -1 station. C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to post dates D. A 40-wk primigravida who is at 6 cm dilation and the presenting part is not engaged

The nurse is providing preoperative teaching to a client who has scheduled a vasectomy. What information is essential for the nurse to explain to the client? a. Recanalization of the vas deferens is impossible. b. Unprotected coitus is safe within 1 week to 10 days. c. Some impotency is to be expected for several weeks after the procedure. d. At least 15 ejaculations to clear the tract of sperm must occur before the semen is checked.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? A. monitor urinary output via an indwelling catheter B. assess the abdominal dressings for drainage C. give the Ringer's lactated infusion at 125 ml/hr. D. check the firmness of the uterus every 15 minutes

What is a priority intervention for the infant undergoing phototherapy? a. Covering the infant's face with a soft mask b. Administering glucose water between breast or bottle feedings c. Keeping the infant in the supine position with the genitals covered d. Exposing as much skin as possible by turning the infant every 2 hours

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation

When assessing a client who is 12 weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? a. at 16 weeks gestation b. at 20 weeks gestation c. at 24 weeks gestation d. at 30 weeks gestation

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. at 16 weeks gestation B. at 20 weeks gestation C. at 24 weeks gestation D. at 30 weeks gestation

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? A. blood glucose level of 45 mg/dl B. blood pressure of 82/45 C. non-bulging anterior fontanel D. central cyanosis when crying

Which interventions should be included in the plan of care for a client with class I cardiac disease during the last weeks of pregnancy? a. Administering penicillin, promoting periods of rest, and daily testing of urine for protein b. Maintaining bed rest, administering oxygen and penicillin, and monitoring for cardiac decompensation c. Instituting seizure precautions and instructing the client to report dyspnea, coughing, palpitations, and increased fatigue d. Advising the client to limit stress, promoting rest after meals, and educating the client about the analgesia and anesthesia used during labor

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succadeaneum. Which additional information should the nurse provide this new mother? A. the infant should be positioned to reduce the swelling B. the swelling is a subperiosteal collection of blood C. the pediatrician will aspirate the blood if it gets larger D. the scalp edema will subside in a few days after birth.

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? a. the infant should be positioned to reduce the swelling b. the swelling is a subperiosteal collection of blood c. the pediatrician will aspirate the blood if it gets larger d. the scalp edema will subside in a few days after birth

Within minutes of giving birth to a healthy infant, the client displays symptoms of respiratory distress. An amniotic fluid embolism is suspected. In addition to respiratory distress, for what other complication should the nurse assess the client? a. Hypertension b. Uterine atony c. Thrombophlebitis d. Uncontrolled bleeding

A pregnant woman tells the nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse which foods contain a significant amount of folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply. a. Lean ground beef b. Milk and cheese c. Chicken breast meat d. Black and pinto beans e. Enriched bread and pasta

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