OB HESI: ULTIMATE QUESTION PACK

Teaching how to perform kick counts. Instruction to include?

- 10 kicks not felt, drink orange juice and count again

40 weeks gestation and spontaneous rupture of membranes that is meconium stained. What additional finding should the nurse report?

- FHR 100-110

There is a question that has to be put in order:

- Isolate baby - Move mom to private room - Collect U/A - Start IV

How do we lower the bilirubin levels if not severe?

- Monitor infant to prevent further complications - Breast milk provides calories & enhances GI motility, which will assist the bowel in eliminating bilirubin

Circumcision

- Monitor the first void after -Yellow film indicates healing unless other signs of infection are also present such as fever, redness - Yellow, even crusty, is okay be sure to teach mom so she is not concerned

Select all that apply: Iron Intake

- Take at bedtime - Turns stool dark (Take with vitamin C (OJ))

Treating mastitis: select all that apply

- Use bras - Take antibiotic - warm compress

Non breastfeeding mom has breast engorgement

- Use support bra - No stimulation of nipples

Woman with gestational diabetes, she wants to fast for holiday

- Work with her HCP to modify her insulin regimen*** (Anytime there is a religious question, do whatever you can to protect their beliefs and preferences)

Patient receiving Pitocin is experiencing tetanic contractions with variable FHR. What action should the nurse implement?

- turn off the Pitocin drip

What is the reason to do an ultrasound on a mother at 20 weeks gestation

- ultrasound for gestation and fetal growth

A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide?

---

The newborn nursery admission protocol includes a prescription for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer?

0.3

The nurse is providing anticipatory guidance for an African-American client who is at 24-weeks gestation. Which prenatal lab assessment, prescribed at 28-weeks, should the nurse include?

1 hr glucose

After delivery patient asks the nurse when she can leave to go home. Information most important to provide? A) When there is no significant vaginal bleeding B) When ambulating to void does not cause dizziness C) After the vitamin K Injection is given to the baby D) After the baby no longer demonstrates acrocyanosis

1) When there is no significant vaginal bleeding

Dose caculation

1. Sulfate Magnesium 2. Oxytocin

Question: Chorionic villi sampling when can it be done

10 weeks and no later than 12 weeks

When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the HCP?

101.2 F oral temp**

Math problem: Pitocin 4 mU/min. 1000 mL/2 mU. in mL/hr

12 mL/hr

A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only)

13

Increased calories per trimester

1st: none, DO NOT CHANGE 2nd and 3rd- extra 300 k cals/day if normal BMI

Infant formula calories

20 calories/oz A baby will need 50 calories/lbs

Estimate the date of delivery for Nagele rules : 15 February first day last menstruation

22 November

Magnesium Sulfate in D5W 500 mL. 20 g Mag Sulfate at 1 g/hr. How many mL/hr?

25 **

When do you give Rhogam and why?

28 weeks and postpartum. You give bc you want to prevent antibodies from forming against the Rh+ baby

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?

30 weeks gestation

Urinary output must be monitored when administering Magnesium sulfate & should be at least 30 ml/hr. What is the therapeutic level of mag sulfate?

4.8 - 9.6 for a PIH client What does it help prevent? Seizures What indicates toxic levels? (3) - Respiratory rate < 12 - Absent DTRs - Urine output < 100 ml/4 hours

Question: Patient with eclampsia, when does risk for seizure decrease

48 hours postpartum

What is a normal bilirubin at 1 day old?

6 - 12 after day 1 of life

Question: Signs of a ruptured tubal pregnancy occur when

6 weeks into pregnancy this is when the fallopian tube is no longer able to get any larger

Protein needs during pregnancy

60g (14g over normal)

When does the head return to its normal shape?

7-10 days

A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only)

75

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

A decrease in respiratory rate from 24 to 16 (Respiratory rate BELOW 12 indiates toxicity)

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 a pregnancy. Which response is best?

A home pregnancy test can be used right after your first missed period. (Home urine tests are based on chemical detection of HCG, which begins to increase 6-8 days after conception; best detected 2 weeks gestation or immediately after first missed period)

The charge nurse working on a postpartum unit is making assignments for a staff consisting of a nurse, practical nurse and 2 unlicensed assistive personnel. which client should the charge nurse assign to the practical nurse?

A multagraida who delivered during c section 20 min ago and needs her vital signs taken.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? A) Administer oxygen via face mask. B) Place the mother in a supine position. C) Increase the rate of the oxytocin (Pitocin) intravenous infusion. D) Document the findings and continue to monitor the fetal patterns.

A) Administer oxygen via face mask.

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 to 150 beats/minute. What action should the nurse implement next? A) Complete a sterile vaginal exam B) Take maternal temperature every 2 hours C) Prepare for immediate C-Section D) Obtain sterile suction equipment

A) Complete a sterile vaginal exam Should be done to assess for presence of prolapsed cord

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 greatest concern? A) Edema, basilar rales, and irregular pulses B) increased UOP & tachycardia C) SOB, bradycardia, and HTN D) Regular heart rate, HTN

A) Edema, basilar rales, and irregular pulses Indicates cardiac decompensation & requires immediate intervention

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) Mood Swings C) Tearfulness Common emotion response due to rapid decrease in placental hormones

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? A) Notify the health care provider (HCP). B) Continue monitoring the fetal heart rate. C) Encourage the client to continue pushing with each contraction. D) Instruct the client's coach to continue to encourage breathing techniques.

A) Notify the health care provider (HCP).

Postpartum patient has a spinal headache 24 hours after delivery. Prior to anesthesiologist's arrival what action is best for the nurse to perform? A) Place procedure equipment at bedside B) Apply an abdominal binder C) Cleans the spinal injection site D) Insert indwelling foley catheter

A) Place procedure equipment at bedside

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? A) Tachypnea and retractions B) Acrocyanosis and grunting C) Hypotension and bradycardia D) Presence of a barrel chest and acrocyanosis

A) Tachypnea and retractions

A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? A) The client's obstetric status is optimal for receiving the vaccine. B)The client's immune system is highly responsive during the postpartum period. C) The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. D) The client's insurance company will pay for the shot if it is given during the immediate postpartum period.

A) The client's obstetric status is optimal for receiving the vaccine.

The nurse is teaching a postpartum client about breastfeeding. Which instruction should the nurse include? A) The diet should include additional fluids. B) Prenatal vitamins should be discontinued. C) Soap should be used to cleanse the breasts. D) Birth control measures are unnecessary while breast-feeding.

A) The diet should include additional fluids.

A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? A) The woman should not become pregnant for at least 4 weeks. B) The woman should pump and dump her breast milk for 1 week. C) The mother must wear a surgical mask when she cares for the baby. D) Passive antibodies transported across the placenta will protect the baby.

A) The woman should not become pregnant for at least 4 weeks.

Patient 20 weeks gestation has vaginal warts (HPV). What is the best information for the nurse to provide? A) Treatment options, while limited due to pregnancy, are available B) Penicillin G C) Acyclovir (Zovirax) D) Termination of pregnancy should be considered

A) Treatment options, while limited due to pregnancy, are available

A client at 33-weeks gestation is admitted with a moderate amount of vaginal bleeding & no contractions are noted on the external monitor. Which intervention? A) Weigh pads B) Weight daily C) Measure I&O D) Ambulate 15 mins QID

A) Weigh pads

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. A) Wear a supportive bra. B) Rest during the acute phase. C) Maintain a fluid intake of at least 3000 mL. D) Continue to breast-feed if the breasts are not too sore. E) Take the prescribed antibiotics until the soreness subsides. F) Avoid decompression of the breasts by breast-feeding or breast pump.

A, B, C, D

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? Select all that apply. A) "I should wear a bra that provides support." B) "Drinking alcohol can affect my milk supply." C) "The use of caffeine can decrease my milk supply." D) "I will start my estrogen birth control pills again as soon as I get home." E) "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." F) "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

A, B, C, F

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.)

A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts.

The nurse has performed a nonstress test on pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? A. Normal B. Abnormal C. The need for further evaluation D. That findings were difficult to interpret

A. Normal

The amniotic membranes of a client in active labor spontaneously rupture. The fluid is greenish brown with a foul odor. What action is a priority for the nurse? A) Evaluate the labor pattern. B) Administer oxygen. C) Place the client into the knee-chest position. D) Apply internal fetal heart monitor and note the time of membrane rupture

ANS: D Rationale:In the presence of greenish brown amniotic fluid, the fetal heart rate should be monitored continuously using an internal fetal heart rate monitor, and the time of membrane rupture should be noted since birth should occur within 24 hours of the rupture of membranes.

A primigravida in labor has complete cervical dilatation. Contractions are occurring every 1.5 to 2 minutes lasting 60 to 90 seconds. Upon examination, the nurse determines that birth is imminent because what has occurred? A) An increase in bloody show B) Perineum is bulging. C) Perineum is flattened. D) Crowning

ANS: D) CROWNING

Vaginal examinations reveal that a laboring client cervix is dilated 2cm, 70% effaced, with presenting part at -2 station. The client tells the nurse " I need my epidural now! This hurts!" The nurse response to the client should be based on which information.

Administering an epidural at this point would slow the labor process.

Best birth control for a breastfeeding mom

Answer: condom with spermicide gel. ***Nothing with hormones in it NOT the combined pill bc of the estrogen NOT TRUE: she does not need birth control bc she is breastfeeding

When do the anterior and posterior fontanels close?

Anterior closes at 12-18 months and the posterior closes by the end of second month

What does a child in respiratory distress look like?

Apneic spells & grunting with prematurity or sepsis

During a prenatal visit, a client at 30-weeks gestation reports persistent heartburn during the past two weeks. The nurse notes the client has 3+ bilateral, pitting, pedal edema. Which action should the nurse implement?

Ask if blurred vision and headache have occurred.

A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on.

The nurse notes that a newborn at 24hrs of age has a large cephalhematoma. Which intervention has the highest priority?

Assess for jaundice q 8 hours**

The fetal heart rate of a client in active labor shows variable decelerations. The cervix is 7cm dilated and the membranes are intact. What intervention should the nurse implement first?

Assist client with turning to the left side.

A three hour old newborn of a gestational diabetic mother who is asymptomatic and successful breastfed after birth, heel stick glucose level is 36 mg/dL. Which intervention should the nurse do first?

Assist the mother to breastfeed the infant

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? A) "I will watch for the evidence of the passage of tissue." B) "I will maintain strict bed rest throughout the remainder of the pregnancy." C) "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." D) "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."

B) "I will maintain strict bed rest throughout the remainder of the pregnancy."

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? A) Length of 19 inches B) Abnormal palmar creases C) Birth weight of 6 lb, 14 oz 4. D) Head circumference appropriate for gestational age

B) Abnormal palmar creases

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? A) Identify the types of accelerations. B) Assess the baseline fetal heart rate. C) Determine the intensity of the contractions. D) Determine the frequency of the contractions.

B) Assess the baseline fetal heart rate.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? A) Apply antibiotic ointment to the perineum daily. B) Change the peripad at each voiding. C) Void at least every two hours. D) Spray the perineum with a povidone-iodine solution after toileting.

B) Change the peripad at each voiding.

The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? A) Turn on the apnea and cardiorespiratory monitors. B) Connect the resuscitation bag to the oxygen outlet. C) Set up the intravenous line with 5% dextrose in water. D) Set the radiant warmer control temperature at 36.50 C (97.6° F).

B) Connect the resuscitation bag to the oxygen outlet.

Mother who is lactoovovegetarian plans to breastfeed. Information to provide before discharge? A) Avoid using lanolin-based nipple cream or ointment B) Continue prenatal vitamins with B12 while breastfeeding C) Offer iron-fortified supplemental formula daily D) Weigh the baby weekly to evaluate the growth of the newborn

B) Continue prenatal vitamins with B12 while breastfeeding

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? A) Feed the newborn less frequently. B) Continue to breast-feed every 2 to 4 hours. C) Switch to bottle-feeding the infant for 2 weeks. D) Stop breast-feeding and switch to bottle-feeding Permanently.

B) Continue to breast-feed every 2 to 4 hours.

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? A) Ask 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 leg above the heart

B) Extend the leg and dorsiflex the foot

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? A) Hemoglobin of 11 g/dL B) Fetal heart rate of 180 beats/minute C) Maternal pulse rate of 85 beats/minute D) White blood cell count of 12,000 cells/mm3

B) Fetal heart rate of 180 beats/minute

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? A) Developmental delays because of excessive size B) Maintaining safety because of low blood glucose levels C) Choking because of impaired suck and swallow reflexes D) Elevated body temperature because of excess fat and glycogen

B) Maintaining safety because of low blood glucose levels

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? A) Elevate the client's legs. B) Massage the fundus until it is firm. C) Ask the client to turn on her left side. D) Push on the uterus to assist in expressing clots.

B) Massage the fundus until it is firm.

After delivery patient presents with profuse hemorrhage after IV Pitocin is infused. Action to implement/what to the provider? A) Total amount of Pitocin infused B) Maternal BP C) Maternal apical pulse rate D) Time Pitocin infusion completed

B) Maternal BP

A client's membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. What does the nurse suspect is the cause of this change? A) Fetal acidosis B) Prolapsed cord C) Head compression D) Uteroplacental insufficiency

B) Prolapsed cord This variable pattern with bradycardia is an ominous sign; it is indicative of cord compression, which can result in fetal hypoxia. Immediate intervention is required. Fetal acidosis occurs with uteroplacental insufficiency, not in response to a prolapsed cord. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia are associated with uteroplacental insufficiency, not a prolapsed cord.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? A) Ambulation B) Rest between contractions C) Change positions frequently D) Consume oral food and fluids

B) Rest between contractions

After breastfeeding for 10 minutes on each breast, baby spits up. Action to implement first? A) Wipe away spit-up and assist with diaper change B) Turn newborn to the side & bulb suction mouth & nares C) Sit the newborn up and burp by rubbing or patting upper back D) Place newborn in position with head lower than feet

B) Turn newborn to the side & bulb suction mouth & nares

During the postpartum period, a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? A) Liver and raisins B) Cheese and broccoli C) Eggs and lean meats D) Whole-wheat bread and cereals

B) cheese and broccoli - need calcium for stopping leg cramps

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? A. Notify the health care provider. B. Discontinue the infusion of oxytocin (Pitocin). C. Place oxygen on at 8 to 10 L/minute via face mask. D. Contact the client's primary support person(s) if not currently present.

B. Discontinue the infusion of oxytocin (Pitocin).

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? A. Gently push the cord into the vagina. B. Place the client in Trendelenburg's position. C. Find the closest telephone and page the health care provider stat. D. Call the delivery room to notify the staff that the client will be transported immediately.

B. Place the client in Trendelenburg's position.

A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform?

Babinski's reflex.

The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?

Betamethasone (Celestone) 12 mg deep IM.

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?

Between the time the temperature falls and rises

The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?

Blood pressure 149/90.

The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this finding?

Both the lower uterine segment and the fundus must be massaged. (Has clots that need to be expelled)

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? A) "I should stay on the diabetic diet." B) "I should perform glucose monitoring at home." C) "I should avoid exercise because of the negative effects on insulin production." D) "I should be aware of any infections and report signs of infection immediately to my health care provider."

C) "I should avoid exercise because of the negative effects on insulin production."

Baby born with congenital heart defect. Which assessment finding warrants immediate intervention? A) Sweating during feedings B) Weak peripheral pulse C) Bluish tinge to tongue D) Increased RR

C) Bluish tinge to tongue

A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity? A) Oxygen B) Naloxone C) Calcium gluconate D) Suction equipment

C) Calcium gluconate The antagonist of magnesium sulfate is calcium gluconate. Oxygen is ineffective if the action of magnesium is not reversed. Naloxone is unnecessary; it is an opioid antagonist. Suction equipment may be necessary if the client has excessive secretions after a seizure. The priority intervention is trying to prevent a seizure.

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? A) The contractions are regular. B) Membranes have ruptured C) Cervix is completely dilated D) The client begins to expel clear vaginal fluid.

C) Cervix is completely dilated

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A) Warming the crib pad B) Closing the doors to the room C) Drying the infant with a warm blanket D) Turning on the overhead radiant warmer

C) Drying the infant with a warm blanket

A 36-year-old woman comes to the emergency department complaining of severe abdominal cramping and heavy bleeding. She informs the nurse that she is 10 weeks pregnant. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of miscarriage is the client experiencing? A) Missed B) Complete C) Inevitable D) Threatened

C) Inevitable Miscarriage is inevitable because the cervical os has opened, heavy bleeding is occurring, and tissue is present with the bleeding. In a missed miscarriage, the fetus has died but the products of conception are retained in utero for as long as several weeks. There may be no bleeding or cramping, and the os is closed. In a complete miscarriage all fetal tissue has already passed and the cervix is closed; there may be slight bleeding. Symptoms of a threatened miscarriage include spotting and a closed cervical os. There may be mild cramping.

Patient scheduled for cesarean for 0600 tells the nurse that she drank some coffee at 0400 to avoid getting a headache. What action does the nurse take next? A) Ensure preop lab results are available B) Start IV LR as prescribed C) Inform anesthesiologist D) Contact client obstetrician

C) Inform anesthesiologist**

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? A) Record the findings B) Massage the fundus. C) Notify the health care provider (HCP). D) Place the client in Trendelenburg's position.

C) Notify the health care provider (HCP).

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 CBC drawn C) Obtain specimens for urinalysis D) Place the client on strict bedrest

C) Obtain specimens for urinalysis Obtained first because preterm clients with uterine irritability & contractions are often suffering from UTI and this should be ruled out first.

One hour after delivery the nurse is unable to palpate the fundus. Large amount of lochia on pad. Massage umbilicus and get vitals. What intervention does the nurse implement next? A) Document # of pad changes in the last hour B) Increase rate of oxytocin infusion C) Palpate suprapubic area for bladder distention D) Provide bedpan to void if unable to ambulate

C) Palpate suprapubic area for bladder distention

Mom is Rh- suffers abdominal trauma in a motor vehicle accident. Which assessment finding is most important to report to the healthcare provider? A) Fetal HR of 162 B) Trace of protein in urine C) Positive fetal Hemoglobin test D) Mild contractions q 10 minutes

C) Positive fetal Hemoglobin test

The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? A) Fatigue B) Drowsiness C) Uterine hyperstimulation D) Early decelerations of FHR

C) Uterine hyperstimulation

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? A. Strict bed rest is required after the procedure. B. Hospitalization is necessary for 24 hours after the procedure. C. An informed consent needs to be signed before the procedure. D. A fever is expected after the procedure because of the trauma to the abdomen.

C. An informed consent needs to be signed before the procedure.

Which assessment finding following an amniotomy should be conducted first? A. Cervical dilation B. Bladder distention C. Fetal heart rate pattern D. Maternal blood pressure

C. Fetal heart rate pattern

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? A. Monitor fetal heart rate continuously. B. Monitor maternal vital signs frequently. C. Perform a vaginal examination every shift. D. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.

C. Perform a vaginal examination every shift.

Question: Classification of magnesium sulfate

CNS depressant

Positive Homan's sign

Call physican

Question: megaloblastic anemia in pregnancy

Can cause neural tube defects Mother needs to be started on folic acid supplements asap

Question about hydatidiform mole

Causes extra large uterus (Hydatidiform mole is the common type of disease arising from gestational trophoblastic disease. Tons of nonviable masses of cells divide and cause uterine enlargement)

24 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 an accumulation of blood between the periosteum and skull that does not cross suture lines is known as

Cephalohematoma (Caused by forceps trauma, may last up to 8 weeks)

Patient with continuous fetal monitoring notices FHR fall and rise abruptly with "v" shaped pattern. Nurse action to take first? An oxytocin induction was started for a gravid client 6 hours ago. When assessing the FHR on the electronic fetal monitor, the nurse notes a "U-shaped" pattern... Which intervention should the nurse implement first?

Change position of patient**

A client in the first trimester of pregnancy calls the prenatal clinic to report she is nauseated and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? Select all that apply

Changes in color and consistency of stool are normal

Baby shows signs of being cold. What should the nurse do first?

Check baby's blood sugar

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

Check the differential, since the WBC is normal for this client.

Question: Pt. with pre-eclampsia is admitted after vitals are taken what is the next priority

Checking pt. reflexes

A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet?

Chicken.

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have esophageal atresia. Which symptoms is the newborn likely exhibiting?

Choking, coughing, cyanosis (3 Cs)

A client at 35 weeks gestation complains of a "pain whenever the baby moves". On assessment, nurse notes client's temperature to be 101.2 , with severe abdominal or uterine tenderness on palpation. The nurse knows these findings are indicative of what condition?

Chorioamnionitis**

32 weeks gestations with possible UTI. Action to implement?

Collect urine for culture**

A client at 28-weeks gestation calls the antepartum clinic 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 contractions or abdominal pain. Which instruction should the nurse provide?

Come to the clinic today for an ultrasound (Concerned about placenta previa)

A pregnant woman 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 the best?

Complete bedrest decreases oxygen needs and demands on heart muscles

A client at 28 weeks gestation admitted to unit following involvement in a motor vehicle collision. While stabilizing the patient, the nurse obtains fetal monitor reading. Which action should the nurse take if the fetus is tachycardic on the monitor?

Contact the healthcare provider after initiating oxygen per face mask

A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?

Contact the healthcare provider.

A newborn with a respiratory rate of 40 bpm at one minute after birth is demonstrating cyanosis of the hands and feet. What action should the nurse take?

Continue to monitor

The healthcare provider prescribes 10 units/L of oxytocin via IV drip to augment a clients labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?

Contraction duration of 100 seconds

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

Contraction pattern

A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time?

Contractions decrease with walking.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? A) "I should breast-feed every 2 to 3 hours." B) "I should change the breast pads frequently." C) "I should wash my hands well before breast-feeding." D) "I should wash my nipples daily with soap and water."

D) "I should wash my nipples daily with soap and water."

The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? A) "Your newborn needs vitamin K to develop immunity." B) "The vitamin K will protect your newborn from being jaundiced." C) "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel. " D) "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

D) "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

A 38 week primigravida is admitted to L&D after a non-reactive result on a non-stress test (NST). The nurse begins contraction stress test (CST) with oxytocin (Pitocin) infusion, Which finding is most important to report to the HCP? A) Spontaneous rupture of membranes B) FHR accelerations with fetal movement C) Absence of uterine contractions within 20 minutes D) A pattern of late fetal decelerations

D) A pattern of late fetal decelerations

A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client? A) increased blood pressure and pulse B) Reduction of pain in the perineal area C) Gradual cervical dilation as labor progresses D) Decreased frequency and duration of contractions

D) Decreased frequency and duration of contractions Terbutaline sulfate (Brethine) is a β-mimetic that acts on the smooth muscles of the uterus to reduce contractility, which in turn inhibits dilation and the frequency and duration of contractions. Although terbutaline may increase blood pressure and pulse, this is a side, not a therapeutic, effect requiring frequent assessments. Terbutaline is not an analgesic. It should stop cervical dilation rather than increase it.

A patient, G2P102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the following is the appropriate nursing intervention at this time? A) Notify the doctor to get an order for acetaminophen. B) Request an infectious disease consult from the doctor. C) Provide the woman with cool compresses. D) Encourage intake of water and other fluids.

D) Encourage intake of water and other fluids.

Patient complains of morning sickness. Nurse recommends? A) Ginkgo B) Chamomile C) Peppermint D) Ginger

D) Ginger NOT PEPPERMINT

Artificial rupture of membranes of laboring client reveals meconium stained fluid. What is priority? A) Clean perineal area to prevent infection B) Assess mother's BP to assess for signs of preeclampsia C) Assess mother's temperature to check for development of sepsis D) Have meconium aspirator available at delivery

D) Have meconium aspirator available at delivery

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply A) Avoid stimulation. B) Decrease fluid intake. C) Expose all of the newborn's skin. D) Monitor skin temperature closely. E) Reposition the newborn every 2 hours. F) Cover the newborn's eyes with eye shields or patches.

D) Monitor skin temperature closely. E) Reposition the newborn every 2 hours. F) Cover the newborn's eyes with eye shields or patches.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? A) Variability B) Accelerations C) Early decelerations D) Variable

D) Variable

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? A. Slow the intravenous flow rate. B. Place the client in a high Fowler's position. C. Continue the oxytocin (Pitocin) drip if infusing. D. Administer oxygen, 8 to 10 L/minute, via face mask.

D. Administer oxygen, 8 to 10 L/minute, via face mask.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? A. Notify the health care provider of the findings. B. Reposition the mother and check the monitor for changes in the fetal tracing. C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadedness when she is lying down. What intervention is best for the nurse to recommend to this client.

D. Elevate the head with two pillows while sleeping

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?

Describe diet changes that can improve management of her diabetes

A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first?

Determine current cervical dilation.

An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take?

Determine the infant's blood sugar level.

Question: nursing intervention for pt. with placental previa

Document amount of bleeding

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement?

Document the vital signs in the record.

Question: heartburn while pregnant

Don't take antacids with sodium

Question: Pt. receiving Lovenox for DVT, what sign is most concerning?

Dyspnea

At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per minute. What intervention is most important for the nurse to perform? a. encourage the client to empty her bladder b. determine the maternal pulse rate c. instruct the client to drink a glass a juice d. place the client in a supine position

Encourage the client to empty her bladder

Mother (Rh -) does not want Rhogam

Explain possible conflict in future if baby are RH +

A young Ashkenazi Jewish woman is planning to become pregnant and asks the nurse if she should be tested for any genetic disorders. What action should the nurse implement?

Explain the risk for carrying genes for Tay-Sachs disease**

What's the FIRST thing to do when mom has the baby with just you in the room? and then what?

FIRST push the call light, then warm,dry stimulate

The nurse, assessing a client who is 32 weeks pregnant during a routine visit, is concerned that the fetus is in the breech presentation. What did the nurse assess in the client?

Fetal heart rate above the umbilicus.

What is megaloblastic anemia caused by?

Folic acid deficiency

What can obesity cause?

GDM, macrosomia which may lead to should dystocia

Question: when newborn is small for gestational age priority nursing intervention is

Glucose test reading (Small infant: don't have fat pads yet Post mature: already used up the fat pads)

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?

Gonorrhea (Erythromycin ointment is instilled to prevent ophthalmic neonatorum, an infection caused by gonorrhea & conjunctivitis, an infection caused by chlamydia).

Newborn receiving positive pressure intubation after delivery. Which assessment finding should nurse initiate chest compressions?

HR 54

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins complaining of tingling fingers and dizziness. What action should the nurse take?

Have the client breathe into her cupped hands (or a paper bag) (related to hyperventilation and hypercapnia)

Which hormone is responsible for positive pregnancy test? Elevated in pregnancy.

HcG (Human chorionic gonadotropin)**

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips

Question: what contraindicates pitocin

Herpes infection

Question: Lepolds maneuver on a patient with placental previa expects

High floating, presenting part (Possibly related to placenta blocking birth canal & cervical os)

Newborn with 4 lb, 18 inch , what condition is of first priority:

Hypoglycemia

what's the main s/e of epidural?

Hypotension

4 postpartum clients. Who is a priority for psychosocial distress?

Immigrant that just moved with her husband, first baby, new country**

Question: Blood in urine in catheter back during c-section indicates

Incisional injury in the bladder

Question: necrotizing enterocolitis (NEC): what will the nurse expect to find as a complication

Increased amount of residual gastric volume from earlier feedings

Which action should the nurse take if an infant, who wa born yesterday weighing 7.5 lbs

Inform and assure the mother that this is normal weight loss.

Action to prevent bleeding in a neonate with 1 hr to birth :

Injection vitamin K (Phytonadione) *

A client is attending antepartum classes, asks nurse why her healthcare provider prescribed iron tablets,. The nurse's response is based on what knowledge?

It is difficult to consume 18 mg of additional iron by diet alone

A client in the last trimester of pregnancy is prescribed sulfonamide for a urinary tract infection. What risk will this medication be to the developing fetus?

Jaundice

Patient is diagnosed with eclampsia, what do you do

Keep airway at bedside (immediate goal of care when during convulsion is to maintain a patent airway. When seizures do occur, turn woman on her side to prevent aspiration)

Question: When a patient is on magnesium sulfate

Keep room dark and quiet

Naegael's rule ***

LMP + 7 days - 3 months OR add 9 months + 7 days (1 week)

After precipitous labor, continues trickling of bright red blood from vagina

Laceration of cervix

Question: Positive Contraction stress test indicates

Late decelerations of the fetal heart rate are occurring with each contraction. also uteroplacental insufficiency

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains"?

Lying prone with pillow on the abdomen

The nurse is caring for a female client, a primigravida with preeclampsia. Finding include +2 proteinuria, BP 172/112 mmHg, Facial and hand sweating, complaints of blurry vision, and a severe frontal headache. Which medication should the nurse anticipate for this client?

Magnesium sulfate

Question: greenish amniotic fluid indicates

Meconium in amniotic fluid and MD should be notified immediately

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

Monitor Blood pressure, pulse, and respirations q4h.

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. Given dose of terbutaline sulfate (Berthine) 0.25 mg SQ. Which assessment is the highest priority for the nurse to monitor during administration of this drug?

Monitoring fetal & maternal heart rates!!!

Question: likely to get placental previa

Most likely to have it is a 30y/0m G6 P5

A 38-week primigravida who works as a secretary & sits at a computer for 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 lower extremities?

Move about every hour

Newborn has white plaques in mouth

Needs medical treatment

Postpartum client receives rubella vaccine. Recommendation?

No sexual contact 28 days

The pregnant woman worried she has white discharge. Ask nurse.

Normal

A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

Offer information about ultrasonography and genotyping to determine sex assignment.

The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) 2 days ago. Which information is most important for the nurse to include in this client's teaching plan?

Oral contraceptive use for at least 1 year

Question: vaginal hematoma

Pain is severe and vagina feels full and heavy

Question: Low lying placenta in the third trimester puts mom at risk for

Painless vaginal bleeding (PLACENTA PREVIA)

Question: What is a danger sign for a mom with a history of preterm multi gestational neonatal deaths

Pelvic pressure

35 weeks gestation. Breech baby. Contractions 3-5 minutes apart and mom states "I think my water just broke". Inspection reveals umbilical cord protruding. Intervention to implement?

Place patient in the knee-chest position

A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?

Place the infant on the abdomen to protect the sac.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?

Place woman in lateral position

A postpartum who is breastfeeding arrives for her 6-week postpartum visit and reports that she is still having vaginal discharge. How should the nurse respond?

Please describe the discharge

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Pulse rate of 56 bpm

Pregnancy lithotomy position has dizziness

Put a wedge below hip

Delivery of women in the street. Baby was born with HPV / herpes. What is the first thing you should do?

Put the baby in the isolation room

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?

Put the newborn to breast (Helps contract the uterus and prevent hemorrhage)

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?

Raise the foot of the bed

A newborn's head circumference is 12 inches (30.5cm), and his chest measurement is 13 inches (33cm). The nurse notes that this infant has no molding, and was at breech presentation delivery by c section. What action should the nurse take based on these data?

Record the finding on the chart. They are within normal limits.

Question: Pt on magnesium sulfide, what baseline assessment is needed?

Respiration rate (LOC is also affected but do not need a baseline)

Mom was in a car accident and it is a trauma situation..what are you worried about?

Rh status of the mom and baby

What does a diaphragmatic hernia look like?

Scaphoid abdomen & anorexia

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?

Shoulder pain (If fallopian tubes are OPEN, pain is referred to shoulder)

What equipment do you need to have for a cervical check?

Sterile gloves, lubricant (You do NOT need a specula)

A nurse administers two serial intramuscular injections of betamethasone (Celestone) to a woman at 32 weeks gestation who has been admitted to preterm labor. The nurse knows that this medication is given in order to:

Stimulate surfactant production. Corticosteroids stimulate surfactant production; they also have been shown to reduce the incidence of intraventricular hemorrhage. Betamethasone (Celestone) does not affect the labor process, increase placental perfusion, or affect the intensity of contractions.

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

Stimulate the infant to cry.

Patient with hypertonic contraction using Oxytocin

Stop infusion

How determine estimated delivery date? (Naegael's rule)

Subtract 3 months from LMP then add seven days and change the year if needed

Supine hypotension

Supine hypotension- Anytime she has a hypotensive blood pressure: first thing you want to look for is putting a wedge under the hip or turning her on the stretcher Bc the baby is pushing on the vena cava- Preferred method: wedge

Question: mom with mitral valve stenosis, what symptom indicates cardiac difficulties

Syncope on exertion

If a mom scheduled for a C-section tells "I ate a big breakfast and had OJ", what do you do?

TELL the anesthesiologist; she is at risk for aspiration

A 26-year old, G2 P1 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 SQ to stop her labor contractions. The nurse plans to monitor which primary side effect of terbutaline sulfate?

Tachycardia & feeling of nervousness

Woman arrives with premature rupture of membranes with dilation, +2 stage of fetal head, FHR 170-180 (45 mins ago) What should nurse do?

Take mom's temp*

Abnormal finding in postpartum client after 24 hours

Temp elevated 102

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding?

The TSH is high because of the low production of T4 by the thyroid.

The nurse should encourage the laboring client to begin pushing when...

The cervix is completely dilated

What did Nurse theorist Reva Rubin describe?

The initial postpartum period as the "taking-in phase", which is characterized by maternal reliance on others to satisfy needs for comfort, rest, nourishment, and closeness

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?

There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb hair

The client will need to be catheterized before the epidural can be administered. A client who is HIV+ is receiving zidovudine during labor. Which information should the nurse provide to the client?

This treatment helps prevent transmission of the virus to the fetus.

During fundal massage, place one hand at the fundus, what is the second hand used for

To guard from prolapse; anchor fundus

Question: safest position for mom with a prolapsed cord

Trendelenburg

Question: Risk for hypotonic uterine dystocia

Twin gestation

A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a button attached to the fetal monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. Which outcome indicates a reactive NST?

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded.

A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?

Ultrasonography and nonstress test.

Question: after internal fetal heart monitor placement, MD listens to fetal heart rate for 1 full minute to monitor

Uterine cord prolapse

30 minutes postpartum, continuing to bleed. Boggy uterus. Intervention?

Uterine massage

At 34 weeks gestation, a primigravida is assessing at her bimonthly clinic visit. Which assessment finding is important for the nurse to report to the HCP?

Weight gain of 7 pounds***

Question: medication to strop pre-term labor

a beta-adrenergic (has tocolytic agents)

Question: circumoral pallor can indicate

a cardiac problem

Patient presents with bright red blood, rigid abdomen and in pain. Nurse suspects possibility?

abruptio placentae

Question: priority nursing intervention for pt admitted with abdominal pain and vaginal bleeding

administer oxygen

puerperal with SIDA received AZT during the pregnancy the newborn is received for the nurse priority

administered AZT before the 6 hours to newborn*

Question: Pt. arrives at high risk unit for delivery with abdominal pain and vaginal bleeding what does nurse do

adminster oxygen

Question: what to avoid for a pt who is breastfeeding with PKU

amino acids

Question about cytotec

answer is you are at an increased risk for abortion

Pregnant woman has an increased costal angle and diaphragm is elevated , how does the nurse document this

as a normal finding

Baby has peri-oral cyanosis

assess the oral mucosa

Postpartum after c-section, pt is nauseated and abdominal distention, what to do first

auscultate for bowel sounds

What medication to give mom to prevent RDS in fetus

betamethasone

Spinal anesthesia causes a headache so what do you to help it...

blood patch

Mom wakes up in a pool of blood and comes to emergency room. What to check first

blood pressure

Postpartum patient complains of severe pain and feeling pressure in perineal area. Nurse finds hematoma beginning to form. Which assessment finding should nurse obtain first?

blood pressure and heart rate

Masitits patient teaching

breast feeding is okay unless contraindicated b/c the abx they're on

Baby shows signs of jitteriness and other signs of hypoglycemia. What to do first

capillary glucose level

Last trimester UTI

cause preterm labor

If the uterus is firm but there is a constant trickle of blood, what could this indicate?

cervical laceration or superficial tear somewhere

Baby starts showing signs of respiratory difficulty (nasal flaring, expiratory grunt, cyanosis)

check O2 saturation levels

Baby is showing signs of mottling

check temperature

Jehovah's Witness patient hemorrhaging is in the ICU. Nurse action to take?

clarify the wishes of the client

Question: Folic acid in a patient with sickle cell is important for

compensating for a rapid turnover of red blood cells

Question: reason for increased pain in abruptio placentae

concealed hemorrhage

3 day postpartum patient. Husband calls states wife is crying, irritable. Inform the husband?

contact the clinic in 2 weeks if symptoms become worse Baby blues are normal, he needs to bring her in if it gets severe or persists for two weeks Review this bc the answer choices are tricky!!Not just be there with her.. WATCH her and symptoms

Patient comes in stating that she is in labor. Which finding confirms not in labor?

contractions decrease when walks

Patient is having labor back pain

counter pressure on lower back (sacrum)

Question: when a newborn has a meningocele priority nursing intervention is

covering sac with sterile moist gauze

Extrauterine transition

cries vigorously when stimulated

Patient breastfeeding

decrease need for insulin

Question: magnesium sulfate - how to know when you have reached therapeutic level

deep tendon reflexes +2

Question: for patient with abuse what is priority action of the nurse

develop a safety plan

Patient is taking mag sulfate and urine output is 25 mL/hr, respirations 14/min, pulse is 116/min, what should the nurse do first

discontinue mag sulfate (signs of mag tox) The finding indicate potential toxicity to magnesium sulfate and close follow up is indicated.

38 weeks gestation with a history of PIH. Pitocin started. 1 hour after Pitocin, patients gets a headache. Contractions are 1-2 minutes apart lasting 60-75 seconds. Intervention most important?

discontinue the Pitocin

Mom feels the urge to defecate during labor

do a vagina exam

Folate sources

dried roast peanuts!!! (NOT strawberries)

Baby has total bilirubin level of 12 after 24 hrs

encourage mom to breastfeed

Functions of placenta in early pregnancy

estrogen and progesterone production

In a gestational diabetic mom, what is the most important aspect for a healthy pregnancy

euglycemia**

Assessment of a normal breast after delivery

expels colostrum (3-4 days)

Parents tell nurse that baby is trying to walk. Nurse's response?

explain it is a normal stepping reflex

Question: When fetus makes a rapid decent the nurse worries about

fetal head trauma

Patient with gestational diabetes has an amniocentesis. Why is the amniocentesis being performed?

fetal lung maturity

What is the majority of pregnancy weight gain?

fetus, placenta and amniotic fluid; during the first trimester, uterus is growing and blood volume is increased

Signs of fetal alcohol syndrome

flat nose bridge

How do you measure the frequency of contractions

from the beginning of one to the beginning of the next

Question: What assessments are priority for pt with diagnosed abruptio placentae

fundal height, vital signs, skin color, urine output, FHR

Action to implement before administering Hep B vaccine?

get consent signed

What does nurse do prior to administering RhoGAM injection

get second nurse to confirm med and patient

Mom is prescribed Hemabate

give antiemetic before hemabate due to s/e (also cause diarrhea so give antidiarrheal)

What do you for the baby delivered vaginally by a mom w/ HIV?

give azithromycin

Mothers Hemoglobin A1C

give her a consultation to a nutritionist

Baby progressing in extrauterine life would show what signs

good vigorous cry with stimulation

Baby shows cyanosis in hands and feet and has elevated respirations

gradually warm the baby

Cyanotic 3 hour old infant temperature 96.5, 40 breaths/min, 165 beats/minute. Intervention best to implement?

gradually warm under heat source

what should you do if a mom is gaining more than a pound a week?

have them do a food diary

What is the best method to get hemoglobin and hematocrit on baby

heel stick

Question: signs of hypoglycemia in newborn

high-pitched cry, jitteriness, and irregular respirations

Pregnant patient, with contractions that are 5 min apart, goes to the bathroom and you hear a baby crying. What is the best action for the nurse to do?

hit the call light to call for help

Question: risk factor for abruptio placentae

hypertension

Question: Type 1 diabetes in pregnancy puts mom at risk for

hypertensive states

The mother of a breastfeeding 24 hr old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is "doing it right." She tells the nurse, "I just know my daughter is not getting enough to eat." What response would be best for the nurse to make?

if baby's urine is straw colored, baby is ok**

Before surgery mom is given an anticholinergic/atropine with anesthesia. What is the therapeutic response of the anticholinergic

increase pulse and decrease oral secretions

Mom is at 20 week gestation and has gained 20 lbs, what is of most concern out of the data of mom

increased weight gain

Question: magnesium sulfate and the importance of deep tendon reflexes

indicates respiratory depression (If decreased DTR, it means CNS is too depressed, and it can lead to decreased breathing reflexes)

Mom comes out of room screaming that her baby is missing. What do you do

initiate a lockdown

Multigravida asks for more pain meds. Just received pain meds, Stadol 2 mg, 30 minutes ago. Action to implement?

instruct to deep breathe

Education most important for nurse to implement to teenage pregnant patient?

iron deficiency anemia; good nutrition***

Question: red tinged mucus in the diaper of a female new born

is normal reaction to mothers hormones

Mom asks why her baby is being screened for T4 and TSH levels

it is state protocol to monitor for metabolic abnormalities

IDDM insulin needs

less insulin needed in the first trimester

frequent pregnancies at risk for...

malnutrition b/c you do not have time to build vitamins & mineral back up

28 weeks gestation with twins. Fundal height 27 cm. fundal height measured 28 cm 3 weeks ago. What does the nurse conclude from this?

may indicate IUGR

Patient delivered baby 24 hours ago and complains of urinating every hour or so. She asks the nurse "is that ok?" Nurse's action?

measure next voiding & palpate bladder**

Question: when newborn has necrotizing enterocolitis (NEC) it is important to

measure the abdominal girth frequently

Question: Primigravida in labor, priority nursing assessment is to

monitor FHR

3 day old baby. Feeds every 2 hours. Nurse notes white curd patches on oral mucus membranes. Action to implement?

needs medicine

3 months pregnant, thin watery secretions

normal lochia

Nurse identifies localized swelling that does not cross the suture line of parietal bone. Action to implement?

notify pediatrician of cephalhematoma

Patient has been breastfeeding for 15 months and 6 weeks pregnant now, what is major assessment

nutritional intake

30 year old primigravida delivers 9 pound vaginally after 30 hour labor. Priority nursing action?

observe for signs of hemorrhage

Mom comes to labor and delivery unit screaming "the baby is coming", what to do first

observe the perineum

Using the ballard gestational age assessment tool, the nurse determine than a 15 hours infant has a gestational age is 42 weeks , based on this finding which intervention is important for the nurse to implement?

obtain a capillary blood glucose*

38 weeks gestation, tachycardia, tremulous, hypertensive. Assessment action most important?

obtain a drug screen

Large for gestational age infant. Action to implement first? -

obtain blood glucose

A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?

obtain written consent for an emergency cesarean section.

After delivery of a 10 pound baby 2 hours ago, the fundus is above and to the right of the umbilicus. She voids 250 mL in a bed pan, Action to implement?

palpate suprapubic region for distention

Patients uterus is above the umbilicus and to the right during postpartum, what do you do first

palpate the bladder for distention

Question: what to assess before administration of magnesium sulfate

patellar reflexes and urinary output

Discussing involution. Patient understands effect of breastfeeding when states?

period may be delayed

Mom has mitral stenosis, what symptom is common with this diagnosis

persistent cough

Doctor hands baby to nurse immediately after delivery. Which action is most important to implement?

place under warmer

A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse's assessment reveals approximately 30 ml of bright red vaginal bleeding, FHR of 130 to 140 beats/min, no contraction, and no complaints of pain. What is the most likely case of this client's bleeding?

placenta previa

Newborn with apnea and the FC 100 x min treatment stimulation, no response

positive ventilation with oxygen *

Postpartum with bathroom privileges, what possible condition would the nurse place the patient on temporary bed rest for

possible thrombus in the leg if positive Homan's sign is present

Question: multiple UTI's can cause what

preterm birth

Why do you not give solid foods during labor?

prevent aspiration; also give antacids before CS

Woman in labor and they look at vagina and see cord

put woman in Trendelenburg position

Temperature of < 100.4

report b/c infection

Primipara 42 weeks gestation. Pitocin started then stopped. O2 applied. Contractions 5 minutes apart for 20 seconds. Intervention to implement?

restart Pitocin per protocol

Question: giving o2 to a infant can cause what

retinopathy of prematurity

Woman had cleft lip, dads uncle had cleft lip

send them for genetic testing

Mom has post partial hemorrhage. What is most likely the cause

she is a multigravida

Pregnant woman has a diaphragm

she needs to have it refitted for another diaphragm

Question: Creatinine

should be between 0.4-0.9. if higher indicates kidney problems

Pt is administered with anesthesia, what is the highest priority

side rails up and call bell in reach

Pt is induced for labor contractions begin occurring 1 ½ to 2 min apart with no resting in between contractions, what to do first

stop Pitocin infusion

Patient is showing signs of mag toxicity (nausea, feeling of warmth, flushing)

stop infusion

Magnesium sulfate infusion begins. Patient develops slurred speech and decreased reflexes. What nurse action to implement?

stop the infusion***

Primigravida asks nurse about exercise during pregnancy. What recommendation?

stretching

Question: PKU test will not be done until

the baby has enough milk for the test to be accurate (24 hours) **

Question: Positive CST result means

the function of the placenta has diminished you need to tell the HCP is happening

Question: risk when undergoing IVF

tubal pregnancy

Patient received prostaglandin gel vaginally to induce labor. 30 minutes after insertion of gel, patient complains of vaginal warmth. What action should nurse implement first?

turn patient to a side lying position

Beractant given for RDS in preemie. Assessment finding indicates condition is improving?

urinary output increased

Diaper change

use water

Question: when pregnant with twins mom is at higher risk for hemorrhage due to

uterine atony

Mom has been on mag sulfate and is now postpartum, what is she at increased risk for

uterine atony (hemorrhage)

Question: S/S of threatened abortion

vaginal spotting, abdominal cramping, closed cervix

What should you watch for in vegetarians?

vitamin b deficiency

Question: sign of preeclampsia other than high blood pressure

weight gain of 6 pounds in 1 month

What do you need to know before getting an order for an epidural?

what stage of labor she is in...you would want it to be in the active phase

Mom is having third baby at home, her two previous babies were rH negative, does she have to come get a direct coombs test done on baby

yes

Contraction stress test is considered positive when the baby has late decelerations

you need to tell the HCP is happening