Parent Child Final Exam

69. A client in labor is talkative and happy. How many centimeters dilated would a maternity nurse suspect that the client is at this time? 1. 2 cm. 2. 4 cm. 3. 8 cm. 4. 10 cm.

1. 2 cm

123. A full-term, 36-hour-old neonate's bilirubin level is 13 mg/dL. Which of the following signs and symptoms would the nurse expect to see? Select all that apply. 1. Lethargy. 2. Jaundice. 3. Polyphagia. 4. Diarrhea. 5. Excessive yawning.

1, 2,

14. Pg. 93 Which are the most serious complications for a child with Kawasaki disease (KD)? Select all that apply. 1. Coronary thrombosis 2. Coronary stenosis 3. Coronary artery aneurysm 4. Hypocoagulability 5. Decreased sedimentation rate 6. Hypoplastic left heart syndrome

1, 2, 3

35. The childbirth education nurse is evaluating the learning of four women, 38 to40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucus plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1, 2, 4

3. Pg. 92 Tetralogy of Fallot (TOF) involves witch defects? Select all that apply. 1. Ventricular septal defect (VSD) 2. Right ventricular hypertrophy 3. Left ventricular hypertrophy 4. Pulmonic stenosis (PS) 5. Pulmonic atresia 6. Overriding aorta 7. Patent ductus arteriosus (PDA)

1, 2, 4, 6

76. Which of the following actions would the nurse expect to perform immediately before a woman is to have regal anesthesia? Select all that apply. 1. Assess fetal heart rate. 2. Infuse 1,000 mL of Ringer's lactate. 3. Place the woman in the Trendelenburg position. 4. Monitor blood pressure every 5 minutes for 15 minutes. 5. Have the woman empty her bladder.

1, 2, 5

94. The nurse in the obstetrician's office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor (PTL)? Select all that apply. 1. 38-year-old in an abusive relationship. 2. 34-year-old whose first child was born at 32 weeks' gestation. 3. 30-year-old whose baby has a two-vessel cord. 4. 26-year-old with a history of long menstrual periods. 5. 22-year-old who smokes 2 packs of cigarettes every day.

1, 2, 5

61. A nurse who is caring for a pregnant type I diabetic should carefully monitor the client for which of the following? Select all that apply. 1. Urinary tract infection. 2. Multiple gestation. 3. Metabolic acidosis. 4. Pathological hypotension. 5. Hypolipidemia.

1, 3

67. A client is in the third stage of labor. Which of the following assessments should the nurse make/observe for? Select all that apply. 1. Lengthening of the umbilical cord. 2. Fetal heart assessment after each contraction. 3. Uterus rising in the abdomen and feeling globular. 4. Rapid cervical dilation to ten centimeters. 5. Maternal complaints of intense rectal pressure.

1, 3

84. The nurse is caring for four women who are in labor. The nurse is aware that he or she will likely prepare which of the women for cesarean delivery? Select all that apply. 1. Fetus is in the left sacral posterior position. 2. Placenta is attached to the posterior portion of the uterine wall. 3. Fetus has been diagnosed with meningomyelocele. 4. Client is hepatitis B surface antigen positive. 5. The lecithin/sphingomyelin ratio in the amniotic fluid is 1.5:1

1, 3

91. In response to a patient's request, the nurse asks the patient's primary healthcare provider for medication to relieve the pain of labor. The healthcare provider ordered self-administered inhaled nitrous oxide (N2O) in a N2O 50% / O2 50% mixture for the client. Which of the following common side effects should the nurse carefully monitor the client for? Select all that apply. 1. Nausea. 2. Hypotension. 3. Dehydration. 4. Light-headedness 5. Late fetal heart decelerations.

1, 4

22. A pregnant client's primary healthcare provider has ordered a 75-gram oral glucose tolerance test (OGTT) to screen the client for gestational diabetes. The nurse is providing preprocedure counseling to the client. Which of the following must the client do? Select all that apply. 1. Fast for 8 to 16 hours prior to the test. 2. Bring a first void during specimen to the laboratory for testing. 3. Consume a solid sugar cube immediately upon awakening. 4. Drink 16 ounces of water 1 hour prior to the test. 5. Smoke no cigarettes the day of the test.

1, 5

19. Pg. 70 Which statement by the parent of a child using an albuterol inhaler leads the nurse to believe that further education is needed on how to administer the medication? 1. "I should administer two quick puffs of the albuterol inhaler using a spacer." 2. "I should always use a spacer when administering the albuterol inhaler." 3. "I should be sure that my child is in an upright position when administering the inhaler." 4. "I should always shake the inhaler before administering a dose."

1. "I should administer two quick puffs of the albuterol inhaler using a spacer."

3. Pg. 68 The parent of a 4-month-old with cystic fibrosis (CF) asks the nurse what time to begin the child's first chest physiotherapy (CT) each day. Which is the nurse's best response? 1. "Thirty minutes before feeding the child breakfast." 2. "After deep-suctioning the child each morning." 3. "Thirty minutes after feeding the child breakfast." 4. "Only when the child has congestion or coughing."

1. "Thirty minutes before feeding the child breakfast."

58. Which should the nurse do for a 7-year-old living in a rural area who is missing school shots and who has sustained a puncture wound? 1. Administer TdaP vaccine. 2. Start the child on an antibiotic. 3. Clean the wound with hydrogen peroxide. 4. Send the child to the emergency department.

1. Administer TdaP vaccine

78. The nurse in the obstetrician's office is caring for four 25-week-gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor? 1. African American, 15 years old, with newly diagnosed gestational diabetes. 2. Asian American, 23 years old, with five-year-old twins who were born at term. 3. Jewish, 25 years old, working as a certified public accountant. 4. Mormon, 33 years old, who recently moved into a new apartment.

1. African American, 15 years old, with newly diagnosed gestational diabetes

82. A nurse is discussing diet with a pregnant woman. Which of the following foods should the nurse advise the client to avoid consuming during her pregnancy? 1. Bologna. 2. Cantaloupe. 3. Asparagus. 4. Popcorn.

1. Bologna

62. A client who has been diagnosed with severe pre-eclampsia is being administered magnesium sulfate via IV pump. Which of the following medications must the nurse have immediately available in the client's room? 1. Calcium gluconate. 2. Morphine sulfate. 3. Naloxone (Narcan). 4. Meperidine (Demerol).

1. Calcium gluconate

84. A client is receiving terbutaline (Brethine) IV for preterm labor. Which of the following maternal findings would warrant stopping the infusion? 1. Cardiac arrhythmias. 2. Respiratory rate of 24 rpm. 3. Blood pressure 90/60. 4. Hypocalcemia.

1. Cardiac arrhythmias

88. A primipara, postpartum one day from a vaginal delivery, received magnesium sulfate in labor for severe pre-eclampsia. Which of the following healthcare referrals should the nurse recommend be made for the patient? Referral to: 1. Cardiologist. 2. Gastroenterologist. 3. Hepatologist. 4. Immunologist.

1. Cardiologist

24. Which of the following long-term goals is appropriate for a client, 10 weeks' gestation, who is diagnosed with gestational trophoblastic disease (hydatidiform mole)? 1. Client will be cancer-free 1 year from diagnosis. 2. Client will deliver her baby at full term without complications. 3. Client will be pain-free 3 months after diagnosis. 4. Client will have normal hemoglobin and hematocrit at delivery.

1. Client will be cancer-free 1 year from diagnosis

75. A nurse is assisting an anesthesiologist who is inserting an epidural catheter. Which of the following positions should the nurse assist the woman into? 1. Fetal position. 2. Lithotomy position. 3. Trendelenburg position. 4. Lateral recumbent position.

1. Fetal position

95. The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time? 1. Complains of severe back pain. 2. Rapid descent and effacement. 3. Irregular and hypotonic contractions. 4. Rectal pressure with bloody show.

1. Complains of severe back pain

7. A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights on for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.

1. Cover the baby's eyes with eye pads

75. A nurse who is providing nutrition counseling to a new gravid client advises the woman that a serving of meat is approximately equal in size to which of the following items? 1. Deck of cards. 2. Paperback book. 3. Clenched fist. 4. Large tomato.

1. Deck of cards

85. A nurse is about to inject RhoGAM into an Rh-negative mother. Which of the following is the preferred site for the injection? 1. Deltoid. 2. Dorsogluteal. 3. Vastus lateralis. 4. Ventrogluteal.

1. Deltoid

13. On examination of a full-term primipara, a labor nurse notes: active labor, right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the following should the nurse report to the physician? 1. Descent is progressing well. 2. Fetal head is not yet engaged. 3. Vaginal delivery is imminent. 4. External rotation is complete.

1. Descent is progressing well

79. A biophysical profile (BPP) has been performed on a full-term client with severe pre-eclampsia. Which of the following interpretations should the nurse make regarding the BPP results of 4? 1. Fetal well-being is compromised. 2. Client's blood pressure is returning to normal. 3. Client is at high risk for seizure. 4. Fetus' amniotic sac is about to rupture.

1. Fetal well-being is compromised.

24. A nurse is performing a postpartum assessment on a client on postpartum day one. The nurse notes the following four signs/symptoms. The nurse should report which of the signs/symptoms to the client's healthcare practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids

1. Foul-smelling lochia

87. A mother is experiencing nausea and vomiting every afternoon. The ingestion of which of the following spices has been shown to be a safe complementary therapy for this complaint? 1. Ginger. 2. Sage. 3. Cloves. 4. Nutmeg.

1. Ginger

51. A client, who had no prenatal care, delivers a 10 lb 10 oz-baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum check up? 1. Glucose tolerance test. 2. Indirect Coombs' test. 3. Blood urea nitrogen (BUN). 4. Complete blood count (CBC).

1. Glucose tolerance test.

9. A gravid client with 4+ proteinuria and 4+ reflexes is admitted to the hospital. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

1. Grand mal seizure

60. A client has just done a fetal kick count assessment. She noted 6 movements during the past hour. If taught correctly, what should her next action be? 1. Nothing, because further action is not warranted. 2. Call the doctor to set up a non stress test. 3. Redo the test during the next half hour. 4. Drink a glass of orange juice and redo the test.

1. Nothing, because further action is not warranted.

97. A client who is 8 weeks' gestation has been diagnosed with a hydatidiform mole (gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symptoms would the nurse expect to see? 1. Hyperemesis and hypertension. 2. Diarrhea and hyperthermia. 3. Polycythemia. 4. Polydipsia.

1. Hyperemesis and hypertension

16. Pg. 93 The nurse is caring for a child with Kawasaki disease (KD). A student nurse who is on the unit asks if there are medications to treat this disease. The nurse's response to the student nurse is: 1. Immunoglobulin G and aspirin 2. Immunoglobulin G and ACE inhibitors 3. Immunoglobulin E and heparin 4. Immunoglobulin E and ibuprofen (Motrin)

1. Immunoglobulin G and aspirin

25. The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the health care practitioner. 4. Place the client on her left side and apply oxygen by face mask.

1. Inform the mother that the rate is normal

47. The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication? 1. Inhibit the mother's active immune response. 2. Aggressively destroy the Rh antibodies produced by the mother. 3. Prevent fetal cells from migrating throughout the mother's circulation. 4. Change the maternal blood type to Rh positive.

1. Inhibit the mother's active immune response

10. The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary health care provider to order a milk suppressant.

1. Intermittently apply ice packs to her axillae and breasts

87. A baby is entering the pelvis in the vertex presentation and in the extended attitude. The nurse determines that which of the following positions is consistent with this situation? 1. Left mentum anterior (LMA). 2. Left sacral posterior (LSP). 3. Right scapular transverse (RScT). 4. Right occiput posterior (ROP).

1. Left mentum anterior (LMA)

85. A client is on magnesium sulfate via IV pump for severe pre-eclampisa. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. Serial grip strengths

81. The laboratory reported the L/S ratio from an amniocentesis as 1:1. How should the nurse interpret the result? 1. The baby is premature. 2. The mother is at hight risk for hemorrhage. 3. The infant has kernicterus. 4. The mother is at hight risk for eclampisa

1. The baby is premature.

98. The nursing management of a neonate with physiological jaundice should be directed toward which client care goal? 1. The baby shows no signs of kernicterus. 2. The baby does not develop erythroblastosis fetalis. 3. The baby has a bilirubin of 16 mg/dL on the day of discharge. 4. The baby spends at least 20 hours per day under phototherapy.

1. The baby show no signs of kernicterus

52. Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for tachypnea? 1. The baby whose mother cultured positive for group B strep during her third trimester. 2. The baby whose mother has cerebral palsy. 3. The baby whose mother was hospitalized for 3 months with complete placenta previa. 4. The baby whose mother previously had a stillbirth.

1. The baby whose mother cultured positive for group B strep during her third trimester

53. Four 38-week-gestation gravidas have just delivered. Which of the babies should be monitored closely by the nurse for respiratory distress? 1. The baby whose mother has diabetes mellitus. 2. The baby whose mother has lung cancer. 3. The baby whose mother has mitral valve prolapse. 4. The baby whose mother has asthma.

1. The baby whose mother has diabetes mellitus

64. The nurse caring for a type I diabetic client who wishes to become pregnant notes that the client's glycohemoglobin, or glycosylated hemoglobin (HgbA1C), result was 7% today and the fasting blood glucose result was 100 mg/dL. Which of the following interpretations by the nurse is correct in relation to these data? 1. The client has been hyperglycemic for the past 3 months and is hyperglycemic today. 2. The client has been normoglycemic for the past 3 months and is normoglycemic today. 3. The client has been hyperglycemic for the past 3 months and is normoglycemic today. 4. The client has been normoglycemic for the past 3 months and is hyperglycemic today.

1. The client has been hyperglycemic for the past 3 months and is hyperglycemic today

32. A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every fifth suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1. The mother's nipples are soft to the touch

28. While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

1. The relationship between the decelerations and the labor contractions

16. A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid volume deficit. Which of the following client care outcomes should be included in the nursing care plan? During the next 24 hour period, the baby will: 1. Urinate at least 6 times. 2. Breastfeed 2 to 4 times. 3. Lose less than 12% of the baby's birth weight. 4. Have an apical heart rate of 160 to 170 bpm.

1. Urinate at least 6 times

72. A nurse concludes that a woman is in the latent phase of labor. Which of the following signs/symptoms would lead a nurse to that conclusion? 1. The woman talks and laughs during contractions. 2. The woman complains about severe back labor. 3. The woman performs effleurage during a contraction. 4. The woman asks to go to the bathroom to defecate.

1. The woman talks and laughs during contractions

31. On the third postpartum day a client tells the nurse that she feels sad and that she cries easily. The nurse should explain about which of the following? 1. These feelings are normal and should diminish when the baby is a week or so old. 2. The physician will Kelly order an antidepressant for the client to take at home. 3. If the client focuses on the fact that she has a healthy baby, the feelings will cease. 4. When the client is home with her family and friends, her sad feelings will disappear.

1. These feelings are normal and should diminish when the baby is a week or so old

89. The nurse is performing a vaginal examination on a client in labor. The client is found to be 5 cm dilated, 90% effaced, and station -2. Which of the following has the nurse palpated? 1. Thin cervix. 2. Bulging fetal membranes. 3. Head at the pelvic outlet. 4. Closed cervix.

1. Thin cervix

26. A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

1. Urine output 200 mL for last 8 hours

69. The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods? 1. Tofu, legumes, broccoli. 2. Corn, yams, green beans. 3. Potatoes, parsnips, turnips. 4. Cheese, yogurt, fish.

1. Tofu, legumes, broccoli

3. A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hypertension and oligohydramnios. She is contracting q 3 min x 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician.

1. Turn off the oxytocin infusion

74. A pregnant client is lactose intolerant. Which of the following foods could this woman consume to meet her calcium needs? 1. Turnip greens. 2. Green beans. 3. Cantaloupe. 4. Nectarines.

1. Turnip greens

77. A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. Uterine atony

52. A type 1 diabetic gravida has developed polyhydramnios. The client should be taught to report which of the following? 1. Uterine contractions. 2. Reduced urinary output. 3. Marked fatigue. 4. Puerperal rash.

1. Uterine contractions

5. A 32-week-gestation client was last seen in the prenatal clinic at 28 weeks' gestation. Which of the following changes should the nurse bring to the attention of the certified nurse midwife? 1. Weight change from 128 pounds to 138 pounds. 2. Pulse rate change from 88 bpm to 92 bpm. 3. Blood pressure change from 120/80 to 118/78. 4. Respiratory rate change from 16 rpm to 20 rpm.

1. Weight change from 128 pounds to 38 pounds

34. A neonate is in the neonatal intensive care unit. The baby is 28 weeks' gestation and weighs 1,000 grams. Which of the following is correct in relation to this baby's growth? 1. Weight is appropriate for gestational age. 2. Weight is below average for gestational age. 3. Baby experienced intrauterine growth restriction. 4. Baby experienced congenital growth hypertrophy.

1. Weight is appropriate for gestational age

4. The nurse is evaluating the effectiveness of bedrest for a client with mild pre-eclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2+ proteinuria. 3. Decrease in plasma protein. 4. 3+ patellar reflexes.

1. Weight loss

How is Naegele's Rule calculated?

1st day of LMP, minus 3 months, plus 7 days

25. Pg. 71 Which would be an early sign of respiratory distress in a 2-month-old? 1. Breathing shallowly 2. Tachypnea 3. Tachycardia 4. Bradycardia

2. Tachypnea

26. Which of the following findings would the nurse expect to see when assessing a first-trimester gravida suspected of having gestational trophoblastic disease (hydatidiform mole) that the nurse would not expect to see when assessing a first-trimester gravida with a normal pregnancy? Select all that apply. 1. Hematocrit 39%. 2. Grape-like clusters passed from the vagina. 3. Markedly elevated blood pressure. 4. White blood cell count 8,000. 5. Hypertrophied breast tissue.

2, 3

62. Pg. 143 Which is true of a Wilms tumor? Select all that apply. 1. It is also referred to as neuroblastoma. 2. It can occur at any age but is seen most often between he ages of 2 and 5 years. 3. It can occur on its own or can be associated with many congenital anomalies. 4. It is associated with a poor prognosis.

2, 3

31. The nurse assesses a newborn as follows: Heart rate: 70 Respirations: weak and irregular Tone: flaccid Color: pale Baby grimaces when a pediatrician attempts to insert an endotracheal tube What should the nurse calculate the baby's Apgar score to be? ____________

3

33. A woman with a diagnosis of ectopic pregnancy is to receive medical intervention rather than a surgical interruption. Which of the following intramuscular medications would the nurse expect to administer? 1. Decadron (dexamethasone). 2. Amethopterin (methotrexate). 3. Pergonal (menotropin). 4. Prometrium (progesterone).

2. Amethopterin (methotrexate)

77. Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following side effects? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations.

2. Drop in blood pressure

81. A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

2. Encourage the woman to breastfeed frequently

60. A woman is in the second stage of labor with a strong urge to push. Which of the following actions by the nurse is appropriate at this time? 1. Assess the fetal heart rate between contractions every 60 minutes. 2. Encourage the woman to grunt during contractions. 3. Assess the pulse and respirations of the mother every 5 minutes. 4. Position the woman on her back with her knees on her chest.

2. Encourage the woman to grunt during contractions

84. The nurse is caring for a prenatal client who states she is prone to developing anemia. Which of the following foods should the nurse advise the gravida is the best source of iron? 1. Raisins. 2. Hamburger. 3. Broccoli. 4. Molasses.

2. Hamburger

14. A newborn nursery nurse notes that a 36-hour-old baby's body is jaundiced. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2. Have the mother feed the baby frequently

41. A mother, G6 P6006, is 15 minutes postpartum. Her baby weighed 4595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

2. Hemorrhage

34. The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min x 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2. Her cervix has dilated from 2 to 4 cm

23. Pg. 94 What associated manifestation might the nurse occasionally find in. child diagnosed with Wilms tumor? 1. Atrial fibrilation 2. Hypertension 3. Endocarditis 4. Hyperlipidemia

2. Hypertension

24. An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following? 1. Jaundice. 2. Jitters. 3. Erythema toxicum. 4. Subconjunctival hemorrhages.

2. Jitters

10. During a vaginal examination, the nurse palpates fetal buttocks that are facing the left posterior and are 1 cm above the ischial spines. Which of the following is consistent with this assessment? 1. LOA -1 station. 2. LSP -1 station. 3. LMP +1 station. 4. LSA +1 station.

2. LSP -1 station

90. A physician has notified the labor and delivery suite that four clients will be admitted to the unit. The client with which of the following clinal findings would be a candidate for an external version? 1. +3 station. 2. Left sacral posterior position. 3. Flexed attitude. 4. Rupture of membranes for 24 hours.

2. Left sacral posterior position

80. A Chinese immigrant is being seen in the prenatal clinic. When providing nutrition counseling, which of the following factors should the nurse keep in mind? 1. Many Chinese eat very little protein. 2. Many Chinese believe pregnant women should eat cold foods. 3. Many Chinese are prone to anemia. 4. Many Chinese believe strawberries can cause birth defects.

2. Many Chinese believe pregnant women should eat cold foods

22. In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2. Performing effleurage

49. A client, G1 P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary healthcare provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2. Massage the woman's fundus

80. A lecithin/sphingomyelin (L/S) ratio has been ordered by a pregnant woman's obstetrician. Which of the following data will the nurse learn from this test? 1. Coagulability of maternal blood. 2. Maturation of the fetal lungs. 3. Potential for fetal development of erythroblastosis fettles. 4. Potential for maternal development of gestational diabetes.

2. Maturation of the fetal lungs.

92. Between contractions, a client in the active phase of labor states, "Not only do these contractions really hurt me, but what are they doing to my baby? I am so scared and I can't stop thinking about how my baby might be hurting, too." The patient requests medication to reduce her pain. It would be most appropriate for the nurse to suggest the client's primary healthcare provider to order which of the following labor pain-relieving methods? 1. Epidural. 2. Nitrous oxide. 3. Narcotic analgesic. 4. Spinal.

2. Nitrous oxide

5. The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

2. Notify the obstetrician

73. A G1 P0, 8 cm dilated, is to receive pain medication. The healthcare practitioner has decided to order an opiate analgesic with a medication that reduces some of the side effects of the analgesic. Which of the following medications would the nurse expect to be ordered in conjunction with the analgesic medication? 1. Seconal (secobarbital). 2. Phenergan (promethazine). 3. Benadryl (diphenhydramine). 4. Tylenol (acetaminophen).

2. Phenergan (promethazine)

78. A client, G2 P1001, 5 cm dilated and 40% effaced, has just received an epidural. Which of the following actions is important for the nurse to take at this time? 1. Assess the woman's temperature. 2. Place a wedge under the woman's side. 3. Place a blanket roll under the woman's feet. 4. Assess the woman's pedal pulses.

2. Place a wedge under the woman's side

6. A 24-week-gravid client is being seen in the prenatal clinic. She states, "I have had a terrible headache for the past 2 days." Which of the following is the most appropriate action for the nurse to perform next? 1. Inquire whether or not the client has allergies. 2. Take the woman's blood pressure. 3. Asses the woman's fundal height. 4. Ask the woman about stressors at work.

2. Take the woman's blood pressure

32. A neonate is in the neonatal intensive care nursery with a diagnosis of large-for gestational age. The baby was born at 38 weeks' gestation and weighed 3,500 grams. Based on this information, which of the following responses is correct? 1. The diagnosis is accurate because the baby's weight is too high for a diagnosis of appropriate for gestational age. 2. The diagnosis is inaccurate because the baby's weight would need to be higher than 3,500 grams. 3. The diagnosis is inaccurate because the baby's weight needs to be lower than 3,500 grams. 4. The diagnosis is inaccurate because full-term babies are never large-for gestational age.

2. The diagnosis is inaccurate because the baby's weight needs to be higher than 3,500 grams

48. An ultrasound report states, "The fetal head has entered the pelvic inlet." How should the nurse interpret this statement? 1. The fetus is full term. 2. The fetal head has entered the true pelvis. 3. The fetal lie is horizontal. 4. The fetus is in an extended attitude.

2. The fetal head has entered the true pelvis

87. At 28 weeks' gestation, an Rh-negative woman receives RhoGAM. Which of the following would indicate that the medication is effective? 1. The baby's Rh status changes to Rh-negative. 2. The mother produces no Rh antibodies. 3. The baby produces no Rh antibodies. 4. The mother's Rh status changes to Rh-positive.

2. The mother produces no Rh antibodies

64. A pregnant woman informs the nurse that her last normal menstrual period was on September 20, 2015. Using Nagele rule, the nurse calculates the client's estimated date of delivery as: 1. May 30, 2016 2. June 20, 2016 3. June 27, 2016 4. July 3, 2016

3. June 27, 2016

42. A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2. The nurse stabilizes the base of the uterus with his or her dependent hand

4. An induction of a 42-week-gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunit per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunit per minute every 10 minutes until contractions are every 3 minutes x 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administer. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby who is post mature.

2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug

66. A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude? 1. The woman has an internal laceration. 2. The woman is about to deliver the placenta. 3. The woman has an atonic uterus. 4. The woman is ready to expel the cord bloods.

2. The woman is about to deliver the placenta

71. A woman, G1 P0000, 40 weeks' gestation, entered the labor suite stating that she is in labor. Upon examination it is noted that the woman is 2 cm dilated, 30% effaced, contracting every 12 min x 30 sec. Fetal heart rate is in the 140s with good variability and spontaneous accelerations. What should the nurse conclude when reporting the findings to the primary health care practitioner? 1. The woman is high risk and should be placed on tocolytics. 2. The woman is in early labor and could be sent home. 3. The woman is high risk and could be induced. 4. The woman is in active labor and should be admitted to the unit.

2. The woman is in early labor and could be sent home

67. An insulin-dependent diabetic, G3 P0200, 38 weeks' gestation, is being seen in the labor and delivery suite in metabolic disequilibrium. The nurse knows that which of the following maternal blood values is most high risk to her unborn baby? 1. Glucose 150 mg/dL. 2. pH 7.25. 3. PCO2 34 mm Hg. 4. Hemoglobin A1C 6%.

2. pH 7.25

100. A 4-day-old baby born via cesarean section is slightly jaundiced. The laboratory reports a bilirubin assessment of 6.0 mg/dL. Which of the following would the nurse expect the neonatalogist to order for the baby at this time? 1. To be placed under phototherapy. 2. To be discharged home with the parents. 3. To be prepared for a replacement transfusion. 4. To be fed glucose water between routine feeds.

2. To be discharged home with the parents

6. A client has been receiving magnesium sulfate for severe pre-eclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104 bpm. 2. Urinary output 240 mL/12 hr. 3. Blood pressure 160/120. 4. Temperature 100°F.

2. Urinary output 240 mL/12 hr

71. A client states that she is a strong believer in vitamin supplements to maintain her health. The nurse advises the woman that it is recommended to refrain from consuming excess quantities of which of the following vitamins during pregnancy? 1. Vitamin C. 2. Vitamin D. 3. Vitamin B2 (niacin). 4. Vitamin B12 (cobalamin).

2. Vitamin D

93. A nurse is caring for a gravid client who is G1 P0000, 35 week's gestation. Which of the following would warrant the nurse to notify the woman's healthcare practitioner that the client is in preterm labor? Select all that apply. 1. Contraction frequency every 15 minutes. 2. Effacement 10%. 3. Dilation 3 cm. 4. Cervical length of 2 cm. 5. Contraction duration of 30 seconds.

3, 4

65. During the third stage, the following physiological changes occur. Please place the changes in chronological order. 1. Hematoma forms behind the placenta. 2. Membranes separate from the uterine wall. 3. The uterus contracts firmly. 4. The uterine surface area dramatically decreases.

3, 4, 1, 2

12. When performing Leopold's maneuvers, the nurse notes that the fetus is in the left occiput anterior position. Which is the best position for the nurse to place a fetoscope best to hear the fetal heartbeat? 1. Left upper quadrant. 2. Right upper quadrant. 3. Left lower quadrant. 4. Right lower quadrant.

3. Left lower quadrant

1. A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week check-up." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

3. "Daily exercise will help to prevent you from becoming diabetic in the future."

38. A gravid client at term called the labor suite at 7:00 p.m. questioning whether she was in labor. The nurse determined that the client was likely in labor after the client stated: 1. "At 5:00 p.m., the contractions were about 5 minutes apart. Now they're about 7 minutes apart." 2. "I took a walk at 5:00 p.m., and now I talk through my contractions easier than I could then." 3. "I took a shower about a half hour ago. The contractions hurt more than they did before." 4. "I had some tightening in my belly late this afternoon, and I still feel it after waking up from my nap."

3. "I took a shower about a half hour ago. The contractions hurt more than they did before."

70. When assessing the fruit intake of a pregnant client, the nurse notes that the client usually eats one piece of fruit per day and drinks a 12 oz glass of fruit juice per day. Which of the following is the most important communication for the nurse to make? 1. "You are effectively meeting your daily fruit requirements." 2. "Fruit juices are excellent sources of folic acid." 3. "It would be even better if you were to consume more whole fruits and less fruit juice." 4. "Your fruit intake far exceeds the recommended daily fruit intake."

3. "It would be even better if you were to consume more whole fruits and less fruit juice."

14. A client with mild pre-eclampsia who has been advised to be on bedrest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bedrest will hep you to conserve energy for your labor." 2. "Bedrest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."

3. "Reclining will increase the amount of oxygen that your baby gets."

4. Pg. 68 The parent of an infant with cystic fibrosis (CF) asks the nurse how to meet the child's increased nutritional needs. Which is the nurse's best suggestion? 1. "You may need to increase the number of fresh fruits and retables you give your infant." 2. "You may need to advance your infant's diet to whole cow's milk because it is higher in fat than formula." 3. "You may need to change your infant to a higher-calorie formula." 4. "You may need to increase your infant's carboyhydrate intake."

3. "You may need to change your infant to a higher-calorie formula."

36. The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? 1. 6 2. 7 3. 8 4. 9

3. 8

97. Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3. A client with cardiac disease

74. On vaginal examination, it is noted that a woman with a well-functioning epidural is in the second stage of labor. The station is -2 and the baseline fetal heart rate is 130 with no decelerations. Which of the following nursing actions is appropriate at this time? 1. Coach the woman to hold her breath while pushing 3 to 4 times with each contraction. 2. Administer oxygen via face mask at 8 to 10 liters per minute. 3. Delay pushing until the baby descends further and the mother has a strong urge to push. 4. Place the woman on her side and assess her oxygen saturation.

3. Delay using until the baby descends further and the mother has a strong urge to push

10. A client is admitted to the hospital with severe pre-eclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform? 1. Strike the woman's patellar tendon. 2. Palpate the woman's ankle. 3. Dorsiflex the woman's foot. 4. Position the woman's feet flat on the floor.

3. Dorsiflex the woman's foot

65. A woman with severe pre-eclampsia, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin). Which of the following would warrant the nurse to stop the infusion? 1. Blood pressure 160/110. 2. Frequency of contractions every 3 minutes. 3. Duration of contractions of 130 seconds. 4. Fetal heart rate 156 with early decelerations.

3. Duration of contractions of 130 seconds

3. A nurse is counseling a pre-eclamptic client about her diet. Which should the nurse encourage the woman to do? 1. Restrict sodium intake. 2. Increase intake of fluids. 3. Eat a well-balanced diet. 4. Avoid simple sugars.

3. Eat a well-balanced diet

7. A woman is to receive Prepidil (dinoprostone gel) for labor induction. The nurse should be prepared to administer the medication via which of the following routes? 1. Intravenously. 2. Orally. 3. Endocervically. 4. Rectally.

3. Endocervically

66. The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terrible. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Posttrauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3. Ineffective individual coping related to hormonal shifts

42. Pg. 74 How will a child with respiratory distress and stridor and who is diagnosed with RSV be treated? 1. Intravenous antibiotics. 2. Intravenous steroids. 3. Nebulized racemic epinephrine. 4. Alternating doses of Tylenol and Motrin.

3. Nebulized racemic epinephrine

47. The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

3. Normal involution, lochia rubra moderate

11. The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior.

3. Occiput posterior

27. A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery with complaints of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO4 from cesarean delivery with complaints of firm and painful breasts.

3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL

29. A woman has been diagnosed with a ruptured ectopic pregnancy. Which of the following signs/symptoms is characteristic of this diagnosis? 1. Dark brown rectal bleeding. 2. Severe nausea and vomiting. 3. Sharp unilateral pain. 4. Marked hyperthermia.

3. Sharp unilateral pain

58. Pg. 98 During play, a toddler with a history of Tetralogy of Fallot (TOF) might assume which position? 1. Sitting 2. Supine 3. Squatting 4. Standing

3. Squatting

5. While performing Leopold maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3. The fetal lie is vertical

93. An ultrasound of a fetus' heart shows that normal fetal circulation is occurring. Which of the following statements should the nurse interpret as correct in relation to the fetal circulation? 1. The foramen ovale is a hole between the ventricles. 2. The umbilical vein contains oxygen-poor blood. 3. The right atrium contains both oxygen-rich and oxygen-poor blood. 4. The ductus venosus lies between the aorta and pulmonary artery.

3. The right atrium contains both oxygen-rich and oxygen-poor blood

60. After nutrition counseling, a woman, G3 P1101, proclaims that she certainly can't eat any strawberries during her pregnancy. Which of the following is the likely reason for this statement? 1. The woman is allergic to strawberries. 2. Strawberries have been shown to cause birth defects. 3. The woman believes in old wives' tales. 4. The premature baby died because the woman ate strawberries.

3. The woman believes in old wives' tales

69. A gravid woman who is 42 weeks' gestation has just had a 20-minute non stress test (NST). Which of the following results would the nurse interpret as a reactive test? 1. Moderate fetal heart baseline variability. 2. Maternal heart rate accelerations to 140 bpm lasting at least 20 seconds. 3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds. 4. Absence of maternal premature ventricular contractions.

3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds.

48. A woman is 36-weeks' gestation. Which of the following tests will be done during her prenatal visit? 1. Oral glucose tolerance test. 2. Amniotic fluid volume assessment. 3. Vaginal and rectal cultures. 4. Karyotype analysis.

3. Vaginal and rectal cultures

84. A woman is to receive RhoGAM at 28 weeks' gestation. Which of the following actions must the nurse perform before giving the injection? 1. Validate that the baby is Rh-negative. 2. Assess that the direct Coombs test is positive. 3. Verify the identity of the woman. 4. Reconstitute the globulin with sterile water.

3. Verify the identity of the woman

32. The nurse is about to elicit the Moro reflex. Which of the following responses should the nurse expect to see? 1. When the cheek of the baby is touched, the newborn turns toward the side that is touched. 2. When the lateral aspect of the sole of the baby's foot is stroked, the toes extend and fan outward. 3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex. 4. When the newborn is supine and the head is turned to one side, the arm on that same side extends.

3. When the baby is suddenly lowered or startled, the neonate's arms straighten outward and the knees flex

9. A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

4, 5

98. A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select all that apply. 1. Change in contraction pattern from q 2 min x 90 sec to q 3 min x 30 sec. 2. Change in fetal heart pattern from no decelerations to early decelerations. 3. Change in beat-to-beat variability from minimal to moderate. 4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.

4, 5

11. A primigravida client received Cervidil (dinoprostone) for induction 8 hours ago. The Bishop score is now 10. Which of the following actions by the nurse is appropriate? 1. Perform nitrazine analysis of amniotic fluid. 2. Report abnormal findings to the obstetrician. 3. Place the woman on her side. 4. Monitor for onset of labor.

4. Monitor for onset of labor

90. It is 4 p.m. A client, G1 P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies: 1. "Laboring clients are never allowed to eat." 2. "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." 3. "The dinner tray should arrive in an hour or two." 4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

4. "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."

41. Pg. 140 The parent of a 3-year-old is shocked to hear the diagnosis of Wilms tumor and says, "How could I have missed a lump this big?" What is the nurse's best response? 1. "Do not be hard on yourself. It's easy to overlook something that has probably been growing for months when we see our children on a regular basis." 2. "I understand you must be very upset. Your child would have had a better prognosis had you caught it earlier." 3. "It really takes a trained professional to recognize something like this." 4. "Do not blame yourself. This mass grows so fast that it was probably not noticeable a few days ago."

4. "Do not blame yourself. This mass grows so fast that it was probably not noticeable a few days ago."

4. A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is, "Bleeding and saturating a pad about every 1⁄2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please come in whenever you are ready."

4. "The physician should see you. Please go to the emergency department."

12. The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A an iron. Which of the following should the nurse recommend? 1. 1/2 cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounces yogurt mixed with 1 medium banana. 3. 12 ounces strawberry milk shake. 4. 1 1/2 cups raw broccoli.

4. 1 1/2 cups raw broccoli

32. Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and -3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide firm fundal pressure. 3. Move the client into a squat. 4. Assess for signs of rectal pressure.

4. Assess for signs of rectal pressure

69. A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 mL/hr. 3. Respiratory rate is 16 rpm. 4. Client has no grand mal seizures.

4. Client has no grand mal seizures

12. A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? 1. Low serum creatinine. 2. High serum protein. 3. Bloody stools. 4. Epigastric pain.

4. Epigastric pain

26. The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Periodically during the peak of contractions. 4. For 1 minute immediately after contractions.

4. For 1 minute immediately after contractions

23. The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4. Fundus 3 cm below the umbilicus, loch serosa

41. Pg. 73 Which physical findings would be of most concern in an infant with respiratory distress? 1. Tachypnea 2. Mild retractions 3. Wheezing 4. Grunting

4. Grunting

18. Pg. 93 During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse's first action should be to: 1. Lay the child flat to promote hemostasis 2. Lay the child flat with legs elevated to increase blood flow to the heart 3. Sit the child on the parent's lap, with legs dangling, to promote venous pooling 4. Hold the child in knee-chest position to decrease venous blood return

4. Hold the child in knee-chest position to decrease venous blood return

65. An insulin-dependent diabetic woman will require higher doses of insulin as which of the following pregnancy hormones increases in her body? 1. Estrogen. 2. Progesterone. 3. Human chorionic gonadotropin. 4. Human placental lactose.

4. Human placental lactose

8. A client has severe pre-eclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.

4. Intrauterine growth restriction

44. A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. 3. Blocked milk duct. 4. Low milk supply.

4. Low milk supply

10. The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2ºF. 2. White blood cell count of 14,500 cells/mm3. 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

4. Malodorous lochial dishcharge

8. A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

4. Notify the woman's primary health care provider

81. A nurse has identified the following nursing diagnosis for a prenatal client: Altered nutrition: less than body requirements related to poor folic acid intake. Which of the following foods should the nurse suggest the client consume? 1. Potatoes and grapes. 2. Cranberries and squash. 3. Apples and corn. 4. Oranges and spinach.

4. Oranges and spinach

88. A woman is scheduled to have an external version for a breech presentation. The nurse carefully assesses the client's chart knowing that which of the following is a contraindication to this procedure? 1. Station -2. 2. 38 weeks' gestation. 3. Reactive NST. 4. Previous cesarean section.

4. Previous cesarean section

107. A baby is born to a mother who was diagnosed with oligohydramnios during her pregnancy. The nurse notifies the neonatalogist to order tests to assess the functioning of which of the following systems? 1. Gastrointestinal. 2. Hepatic. 3. Endocrine. 4. Renal.

4. Renal

40. A nurse determines that a client is carrying a fetus in the vertical lie. The nurse's judgment should be questioned if the fetal presenting part is which of the following? 1. Sacrum. 2. Occiput. 3. Mentum. 4. Scapula.

4. Scapula

4. A fetus is in the LOA position in utero. Which of the following findings would the nurse observe when doing Leopold maneuvers? 1. Hard, round object in the fundal region. 2. Flat object above the symphysis pubis. 3. Soft, round object on the left side of the uterus. 4. Small objects on the right side of the uterus.

4. Small objects on the right side of the uterus

61. A nurse is coaching a woman who is in the second stage of labor. Which of the following should the nurse encourage the woman to do? 1. Hold her breath for twenty seconds during every contraction. 2. Blow out forcefully during every contraction. 3. Push between contractions until the fetal head is visible. 4. Take a slow cleansing breath before bearing down.

4. Take a slow cleansing breath before bearing down

89. A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Betamethasone (Celestone). 4. Terbutaline (Brethine).

4. Terbutaline (Brethine)

47. A woman, who is in active labor, is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1. The baby is in the breech position. 2. The baby is in the horizontal lie. 3. The baby's presenting part is engaged. 4. The baby's chin is resting on its chest.

4. The baby's chin is resting on its chest

36. A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4. The contractions are about a minute long and I am unable to talk through them."

55. After analyzing an internal fetal monitor tracing, the nurse concludes that there is moderate short-term variability. Which of the following interpretations should the nurse make in relation to this finding? 1. The fetus is becoming hypoxic. 2. The fetus is becoming alkalotic. 3. The fetus is in the middle of a sleep cycle. 4. The fetus has a healthy nervous system.

4. The fetus has a healthy nervous system

38. A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment? 1. Abundant lanugo. 2. Flat breast tissue. 3. Prominent clitoris. 4. Wrinkled skin.

4. Wrinkled skin

Fetal Circulation - Ductus Venosus

Bypasses the liver and goes to the heart

Fetal Circulation - Ductus Arteriosus

Bypasses the lungs and goes to the heart & brain

Secondary Powers

The mother's "bearing-down efforts" to aid in expulsion of the fetus, AKA Ferguson Reflex (Secondary Powers have NO effect on cervical dilation)

What are the 4 stages of labor?

First stage = onset of regular contractions to full dilation of cervix (the longest stage) Second stage = full cervical dilation to birth of fetus Third stage = birth of fetus until placenta is delivered Fourth stage = recovery period from delivery of placenta and up to at least 2 hours after birth

What does GTPAL stand for?

Gravida (pregnancies) Term Births (37.1 to 40.7) Preterm Births (before 37.0) Abortions (before 20.0) Living Children

Primary Powers

Involuntary uterine contractions responsible for effacement & dilation of the cervix, & descent of the fetus

15. Pg. 93 A child who has reddened eyes with no discharge; red, swollen, and peeling palms and soles of the feet; dry, cracked lips, and a "strawberry tongue" most likely has: ____________________.

Kawasaki disease

What makes up the First stage of labor?

Latent/Early Phase = cervical effacement with little dilation & little fetal descent Active Phase = rapid cervical dilation & increased fetal descent

What makes up the Second stage of labor?

Latent/Passive = fetus passively descends due to Primary Powers Active Phase = fetus descends rapidly and forcefully fue to Secondary Powers

Signs preceding labor

Lightening (fetal head drops into pelvis) Lower Back Pain Braxton Hicks Contractions Weight loss Surge of Energy Bloody show (loss of operculum) Cervical Ripening Possible ROM

Fetal Circulation - Foramen Ovale

Opening between the atria that shunts blood from Right atrium to Left atrium

The 5 Ps of Labor

Passenger, passageway, powers, position, and psychological response

2. Pg. 91 A newborn is diagnosed with a congenital heart defect (CHD). The test results reveal that the lumen of the duct between the aorta and pulmonary artery remains open. This defect is known as ____________________.

Patent Ductus Arteriosus

2. The physician has ordered oxytocin (Pitocin) for induction for 4 gravidas. In which of the following situations should the nurse refuse to comply with the order? 1. Primigravida with a transverse lie. 2. Multigravida with cerebral palsy. 3. Primigravida who is 14 years old. 4. Multigravida who has type 1 diabetes.

1. Primigravida with a transverse lie.

7. The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis.

2. Ischial spines

26. A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2. Fundus

73. A client informs the nurse that she is "very constipated." Which of the following foods would be best for the nurse to recommend to the client? 1. Pasta. 2. Rice. 3. Yogurt. 4. Celery.

4. Celery

57. In analyzing the need for health teaching in a client, G5 P4004 with gestational diabetes, the nurse should ask which of the following questions? 1. "How old were you at your first pregnancy?" 2. "Do you exercise regularly?" 3. "Is your partner diabetic?" 4. "Do you work outside of the home?"

2. "Do you exercise regularly?"

30. An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. Fetal heart rate

2. A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with pre-eclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.

1. Assess deep tendon reflexes

41. A nurse is educating a pregnant woman regarding the moves a fetus makes during the birthing process. Please place the following cardinal movements of labor in the order the nurse should inform the client that the fetus will make: 1. Descent. 2. Expulsion. 3. Extension. 4. External rotation. 5. Internal rotation.

1. Descent. 5. Internal rotation. 3. Extension. 4. External rotation. 2. Expulsion.

5. A 40-week-gestation woman has received Cytotec (misoprostol) for cervical ripening. For which of the following signs/symptoms should the nurse carefully monitor the client? 1. Diarrhea and back pain. 2. Hypothermia and rectal pressure. 3. Urinary retention and rash. 4. Tinnitus and respiratory distress.

1. Diarrhea and back pain

77. Which of the following choices can the nurse teach a prenatal client is equivalent to a 1 oz nonmeat serving of protein? 1. 2 tbsp peanut butter. 2. 1 egg. 3. 1 cup cooked lima beans. 4. 3 ounces mixed nuts.

2. 1 egg

96. A 28-week-gestation client with intact membranes is admitted with the following findings: Contractions every 5 min x 60 sec, 3 cm dilated, 80% effaced. Which of the following medications will the obstetrician likely order? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Magnesium sulfate. 4. Morphine sulfate.

3. Magnesium sulfate

1. The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following diseases? Select all that apply. 1. Hypothyroidism. 2. Sickle cell disease. 3. Glactosemia. 4. Cerebral palsy. 5. Cystic fibrosis.

1, 2, 3, 5

27. While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1. Provide caring labor support

36. A woman is to receive methotrexate IM for an ectopic pregnancy. The nurse should teach the woman about which of the following common side effects of the therapy? Select all that apply. 1. Nausea and vomiting. 2. Abdominal pain. 3. Fatigue. 4. Light-headedness. 5. Breast tenderness.

1, 2, 3, 4

19. The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the clients who had which of the following deliveries state that they understand why they must receive RhoGAM injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation Rh-positive baby.

1, 2, 3, 5

41. A 12-week-gravid client presents in the ED with abdominal cramps and scant dark red bleeding. Which of the following signs/symptoms should the nurse assess this client for? Select all that apply. 1. Tachycardia. 2. Referred shoulder pain. 3. Headache. 4. Fetal heart dysrhythmias. 5. Hypertension.

1, 3, 4, 5

61. Pg. 76 What does the therapeutic management of CF patients include? Select all that apply. 1. Providing a high-protein, high-calorie diet. 2. Providing a high-fat, high-carbohydrate diet. 3. Encouraging exercise. 4. Minimizing pulmonary complication. 5. Encouraging medication compliance.

1, 3, 4, 5

78. A nurse is discussing the serving sizes in the grain food group with a new prenatal client. Which of the following foods equals 1 oz serving from the grain group? Select all that apply. 1. 1 bagel. 2. 1 slice of bread. 3. 1 cup cooked pasta. 4. 1 tortilla. 5. 1 cup dry cereal.

2, 4, 5

41. A client, in her third trimester, is concerned that she will not know the difference between labor contractions and normal aches and pains of pregnancy. How should the nurse respond? 1. "Don't worry. You'll know the difference when the contractions start." 2. "The contractions may feel just like a backache, but they will come and go." 3. "Contractions are a lot worse than your pregnancy aches and pains." 4. "I understand. You don't want to come to the hospital before you are in labor."

2. "The contractions may feel just like a backache, but they will come and go."

37. A low-risk 38-week-gestation woman calls the labor unit and says, "I have to come to the hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Does it burn when you void?" 2. "You sound frightened." 3. "That is just the mucus plug." 4. "How much blood is there?"

2. "You sound frightened."

46. The birth of a baby, weight 4, 500 grams, was complicated by shoulder dystocia. Which of the following complications should the nursery nurse observe for? 1. Leg deformities. 2. Brachial palsy. 3. Fractured radius. 4. Buccal abrasions.

2. Brachial palsy

70. A nurse is assessing the vital signs of a client in labor at the peak of a contraction. Which of the following findings would the nurse expect to see? 1. Decreased pulse rate. 2. Hypertension. 3. Hyperthermia 4. Decreased respiratory rate.

2. Hypertension

85. It is discovered that a pregnant woman practices pica. Which of the following complications is most often associated with this behavior? 1. Hypothyroidism. 2. Iron deficiency anemia. 3. Hypercalcemia. 4. Overexposure to zinc.

2. Iron-deficiency anemia

13. Pg. 93 While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other findings are a wide pulse pressure, periods of apnea, increased PaCO2, and decreased PO2. The nurse suspects that the newborn has: 1. Pulmonary hypertension 2. Patent ductus arteriosus (PDA) 3. Ventricular septal defect (VSD) 4. Bronchopulmonary dysplasia

2. Patent ductus arteriosus (PDA)

85. A neonate has an elevated bilirubin and is slightly jaundiced on day 3 of life. What is the probable reason for these changes? 1. Hemolysis of neonatal red blood cells by the maternal antibodies. 2. Physiological destruction of fetal red blood cells during the extrauterine period. 3. Pathological liver function resulting from hypoxemia during the birthing process. 4. Delayed meconium excretion resulting in the production of direct bilirubin.

2. Physiological destruction of fetal red blood cells during the extrauterine period

64. A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2. Postpartum blues last about a week or two

38. A gravid client is admitted with a diagnosis of third-trimester bleeding. It is priority for the nurse to assess for a change in which of the following vital signs? 1. Temperature. 2. Pulse. 3. Respirations. 4. Blood Pressure.

2. Pulse

82. A client is being taught fetal kick counting. Which of the following should be included in the patient teaching? 1. The woman should choose a time when her baby is least active. 2. The woman should lie on her side with her head elevated about 30 degrees. 3. The woman should report fetal kick counts of greater than 10 in an hour. 4. The woman should refrain form eating immediately before counting.

2. The woman should lie on her side with her head elevated about 30 degrees.

43. A woman with postpartum depression has been prescribed Zoloft (sertraline) 50 mg daily. Which of the following should the client be taught about the medication? 1. Chamomile tea can potentiate the affect of the drug. 2. Therapeutic effect may be delayed a week or more. 3. The medication should only be taken whole. 4. A weight gain of up to ten pounds is commonly seen.

2. Therapeutic effect may be delayed a week or more

85. The nurse is providing acupressure to provide pain relief to a woman in labor. Where is the best location for the acupressure to be applied? Select all that apply. 1. On the malleolus of the wrist. 2. Above the patella of the knee. 3. On the medial aspect of the lower leg. 4. At the top one-third of the sole of the foot. 5. Below the medial epicondyle of the elbow.

3, 4

100. A preterm labor client, 30 weeks' gestation, who ruptured membranes 4 hours ago is being given IM dexamethasone (Decadron). When she asks why she is receiving the drug, the nurse replies: 1. "To help to stop your labor contractions." 2. "To prevent an infection in your uterus." 3. "To help to mature your baby's lungs." 4. "To decrease the pain from the contractions."

3. "To help to mature your baby's lungs."

52. During delivery, the nurse notes that the baby's head has just been delivered. The nurse concludes that the baby has just gone through which of the following cardinal moves of labor? 1. Flexion. 2. Internal rotation. 3. Extension. 4. External rotation.

3. Extension

31. Pg. 95 Which plan would be appropriate in helping to control congestive heart failure (CHF) in an infant? 1. Promoting fluid restriction 2. Feeding a low-salt formula 3. Feeding in a semi-Fowler position 4. Encouraging breast milk

3. Feeding in a semi-Fowler position

12. The nurse should expect to observe which behavior in a 3-week multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy.

3. Feelings of failure as a mother

76. Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration in comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparty. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

3. Fluid volume deficit related to blood loss

89. A nurse is providing diet counseling to a new prenatal client. Which of the following dairy products should the client be advised to avoid eating during the pregnancy? 1. Frozen yogurt. 2. Parmesan cheese. 3. Gorgonzola cheese. 4. Chocolate milk.

3. Gorgonzola cheese

61. Which of the following laboratory values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L.

3. Platelets 75, 000

29. A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Use a hydrotherapy tub.

3. Provide direct sacral pressure

62. A primigravida is pushing with contractions. The nurse notes that the woman's perineum is beginning to bulge and that there is an increase in bloody show. Which of the following actions by the nurse is appropriate at this time? 1. Report the findings to the woman's health care practitioner. 2. Immediately assess the woman's pulse and blood pressure. 3. Provide encouragement during each contraction. 4. Place the client on her side with oxygen via face mask.

3. Provide encouragement during each contraction

48. During a vaginal delivery of a macrocosmic baby, the nurse midwife requests nursing assistance. Which of the following actions by the nurse would be appropriate? 1. Estimate fetal length and weight. 2. Assess intensity of contractions. 3. Provide suprapubic pressure. 4. Assist woman with breathing.

3. Provide suprapubic pressure

10. A patient is placed on bedrest at home for mild pre-eclampsia at 38 weeks' gestation. Which of the following must the nurse teach the patient regarding her condition? 1. Eat a sodium-restricted diet. 2. Check her temperature 4 times daily. 3. Report swollen hands and face. 4. Limit fluids to 1 liter per day.

3. Report swollen hands and face

20. Pg. 71 Which should the nurse administer to provide quick relief to a child with asthma who is coughing, wheezing, and having difficulty catching her breath? 1. Prednisone 2. Montelukast (Singulair) 3. Albuterol 4. Fluticasone (Flovent)

3. Albuterol

13. A 29-week-gestation woman diagnosed with severe pre-eclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2 4. Nystagmus.

2. Papilledema

42. Pg. 96 A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is: 1. Feeding formula that is supplemented with additional calories 2. Allowing the infant to nurse at each breast for 20 minutes 3. Providing large feedings every 5 hours 4. Using firm nipples with small openings to slow feedings

1. Feeding formula that is supplemented with additional calories

79. A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following? 1. Alcohol. 2. Grapefruit. 3. Milk. 4. Cabbage.

1. Alcohol

99. A client is on terbutaline (Brethine) via subcutaneous pump for preterm labor. The nurse auscultate the fetal heart rate at 100 beats per minute via Doppler. Which of the following actions should the nurse perform next? 1. Assess the maternal pulse while listening to the fetal heart rate. 2. Notify the healthcare provider. 3. Stop the terbutaline infusion. 4. Administer oxygen to the mother via face mask.

1. Assess the maternal pulse while listening to the fetal heart rate.

43. A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

1. Assure the woman that frequent urination is normal after delivery

5. Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following? 1. Avoid eating greasy foods. 2. Drink orange juice before rising. 3. Drink 2 glasses of water with each meal. 4. Eat 3 large meals plus a bedtime snack.

1. Avoid eating greasy foods

51. Pg. 184 The parent of a 4-year-old brings the child to the clinic and tells the nurse the child's abdomen is distended. After a complete examination, a diagnosis of Wilms tumor is suspected. Which of the following is most important when doing a physical examination on this child? 1. Avoid palpation of the abdomen. 2. Assess the urine for the presence of blood. 3. Monitor vital signs, especially the blood pressure. 4. Obtain an accurate height and weight.

1. Avoid palpation of the abdomen

5. A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1. Encourage the woman exclusively to breastfeed her baby

53. A pregnant diabetic has been diagnosed with hydramnios. Which of the following would explain this finding? 1. Excessive fetal urination. 2. Recurring hypoglycemic episodes. 3. Fetal sacral agenesis. 4. Placental vascular damage.

1. Excessive fetal urination

25. A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk. 2. Assess the baby's blood pressure. 3. Tightly swaddle the baby. 4. Monitor the baby's urinary output.

1. Feed the baby formula or breast milk

8. The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA) 2. Left sacral posterior (LSP) 3. Right mentum anterior (RMA) 4. Right sacral posterior (RSP)

1. Left occipital anterior (LOA)

58. A gravid woman, 36 weeks' gestation its type 1 diabetes, has just had a biophysical profile (BPP). Which of the following results should be reported to the obstetrician? 1. One fetal heart acceleration in 20 minutes. 2. Three episodes of fetal rhythmic breathing in 30 minutes. 3. Two episodes of fetal extension and flexion of 1 arm. 4. One amniotic fluid pocket measuring 3 cm.

1. One fetal heart acceleration in 20 minutes

45. Pg. 140 The nurse is caring for a child due for surgery on a Wilms tumor. The child's procedure will consist of which of the following? 1. Only the affected kidney will be removed. 2. Both the affected kidney and the other kidney will be removed in case of recurrence. 3. The mass will be removed from the affected kidney. 4. The mass will be removed from the affected kidney, and a biopsy of the tissue of the unaffected kidney will be done.

1. Only the affected kidney will be removed

13. Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. Pain

66. A client is in labor and delivery with a diagnosis of HELLP syndrome. The nurse notes the following blood values: PT (prothrombin time) 99 sec (normal 60 to 85 sec). PTT (partial thromboplastin time) 30 sec (normal 11 to 15 sec). For which of the following signs/symptoms would the nurse monitor the client? 1. Pink-tinged urine. 2. Early decelerations. 3. Patellar reflexes +1. 4. Blood pressure 140/90.

1. Pink-tinged urine

86. A woman confides in the nurse that she practices pica. Which of the following alternatives could the nurse suggest to the woman? 1. Replace laundry starch with salt. 2. Replace ice with frozen fruit juice. 3. Replace soap with cream cheese. 4. Replace soil with uncooked pie crust.

2. Replace ice with frozen fruit juice

43. During neonatal cardiopulmonary resuscitation, which of the following actions should be performed? 1. Provide assisted ventilation at about 30 breaths per minute. 2. Begin chest compressions when heart rate is 0 to 20 beats per minute. 3. Compress the chest using the three-finger technique. 4. Administer compressions and breaths in a 5 to 1 ratio.

1. Provide assisted ventilation at about 30 breaths per minute

76. The physician has ordered a non stress test (NST) to be done on a 41-week-gestation client. During the half-hour test, the nurse observed three periods of fetal heart accelerations that were 15 bpm above the baseline and that lasted 15 seconds each. No contractions were observed. Based on these results, what should the nurse do next? 1. Send the client home and report positive results to the medical doctor. 2. Perform a nipple stimulation test to assess the fetal heart in response to contractions. 3. Prepare the client for induction with intravenous oxytocin. 4. Place the client on her side with oxygen via face mask.

1. Send the client home and report positive results to the medical doctor.

59. The nurse is assessing an internal fetal heart monitor tracing of an unmedicated, full-term gravida who is in transition. Which of the following heart rate patterns would the nurse interpret as normal? 1. Baseline of 140 to 150 with V-shaped decelerations to 120 unrelated to contractions. 2. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions. 3. Baseline of 140 to 142 with decelerations to 120 that return to baseline after the end of the contractions. 4. Baseline of 140 to 142 with no obvious decelerations or accelerations.

2. Baseline of 140 to 150 with decelerations to 100 that mirror each of the contractions

30. A client who was seen in the prenatal clinic at 20 weeks' gestation weighed 128 lb at that time. Approximately how many pounds would the nurse expect the client to weigh at her next visit at 24 weeks' gestation? 1. 129 to 130 lb. 2. 131 to 132 lb. 3. 133 to 134 lb. 4. 135 to 136 lb.

2. 131 to 132 lb

53. The nurse wishes to assess the variability of the fetal heart rate. Which of the following actions must the nurse perform at this time? 1. Place the client in the lateral recumbent position. 2. Carefully analyze the baseline data on the monitor tracing. 3. Administer oxygen to the mother via face mask. 4. Ask the mother to indicate when she feels fetal movement.

2. Carefully analyze the baseline data on the monitor tracing

10. A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6 mL per hour. Which of the following clinical signs would lead the nurse to stop the infusion? 1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart rate from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4 F.

2. Change in fetal heart rate from 128 to 102 bpm

4. To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with a povidone-iodine solution after toileting.

2. Change the peripad at each voiding

56. During a vaginal delivery, the obstetrician declares that a shoulder dystocia has occurred. Which of the following actions by the nurse is appropriate at this time? 1. Administer oxytocin intravenously per doctor's orders. 2. Flex the woman's thighs sharply toward her abdomen. 3. Apply oxygen using a tight-fitting face mask. 4. Apply downward pressure on the woman's fundus.

2. Flex the woman's thighs sharply toward her abdomen

9. The nurse turns off the oxytocin (Pitocin) infusion after a period of tachysystole. Which of the following outcomes indicates that the nurse's action was effective? 1. Intensity moderate. 2. Frequency every 3 minutes. 3. Duration 130 seconds. 4. Attitude flexed.

2. Frequency every 3 minutes

121. A client is seen at 8 weeks' gestation for her first prenatal visit. During her last gynecological visit, the client's blood pressure was 100/60. Her blood pressure is now 150/90. For which of the following pregnancy-related illnesses should this client be assessed? 1. Hyperemesis gravidarum. 2. Hydatidiform mole. 3. Pre-eclampsia. 4. Gestational diabetes.

2. Hydatidiform mole.

12. An 18-hour-old baby is placed under the bili-lights with an elevated bilirubin level. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration therapy after all feedings. 2. Rotate the baby from side to back to side to front every two hours. 3. Tightly swaddle in baby blankets to maintain normal temperature. 4. Administer intravenous fluids via pump per doctor orders.

2. Rotate the baby from side to back to side to front every two hours

15. The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage.

3, 4, 5

56. The nurse is educating a client who has been diagnosed with gestational diabetes how to perform home blood glucose testing. Which of the following information should be included in the teaching session? 1. When pricking the fingertip, always prick the center of the fingertip. 2. One-hour postprandial glucose values should be 146 mg/dL or lower. 3. Blood glucose testing should be performed 2 times per day - before breakfast and before bedtime. 4. All blood glucose results should be kept in a log for evaluation by the nurse and primary healthcare provider.

4. All blood glucose results should be kept in a log for evaluation by the nurse and primary healthcare provider.

15. A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time? 1. Discontinue the phototherapy. 2. Notify the health care practitioner. 3. Take the baby's temperature. 4. Assess the baby's skin integrity.

4. Assess the baby's skin integrity

32. A woman, 8 weeks pregnant, is admitted to the obstetric unit with a diagnosis of threatened abortion. Which of the following tests would help to determine whether the woman is carrying a viable or a nonviable pregnancy? 1. Luteinizing hormone level. 2. Endometrial biopsy. 3. Hysterosalpingogram. 4. Serum progesterone level.

4. Serum progesterone level

37. A woman who received an intravenous analgesic 4 hours ago has had prolonged late decelerations in labor. She will deliver her baby shortly. Which of the following is the priority action for the delivery room nurse to take? 1. Preheat the overhead warmer. 2. Page the neonatalogist on call. 3. Draw up Narcan (naloxone) for injection. 4. Assemble the neonatal eye prophylaxis.

2. Page the neonatologist on call

6. A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2. She feeds her baby every 2 to 3 hours

63. Which of the following physical findings would lead the nurse to suspect that a client with severe pre-eclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.

2, 3

58. One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell (WBC) count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

2, 3, 4

62. A gestational diabetic who requires insulin therapy to control her blood glucose levels telephones the triage nurse complaining of dizziness and headache. Which of the following actions should the nurse take at this time? 1. Have the client proceed to the office to see her physician. 2. Advise the client to drink a glass of juice and then call back. 3. Instruct the client to inject herself with regular insulin. 4. Tell the client immediately to telephone her medical doctor.

2. Advise the client to drink a glass of juice and then call back.

23. A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lbs 2 oz, 21 inches long, TPR: 96.6ºF, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following nursing actions is of highest importance? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2. Assess the glucose level of the baby

21. Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? 1. Baby with respirations 42... oxygen saturation 96%. 2. Baby with Apgar 9/9... weight 4,660 grams. 3. Baby with temperature 97.8ºF... length 21 inches. 4. Baby with glucose 55 mg/dL... heart rate 121.

2. Baby with Apgar 9/9, weight 4,660 grams

69. A woman states that she feels "dirty" during her menses so she often douches to "clean myself." The nurse advises the woman that it is especially important to refrain from douching while menstruating because douching will increase the likelihood of her developing which of the following gynecological complications? 1. Fibroids. 2. Endometritis. 3. Cervical cancer. 4. Polyps.

2. Endometritis

79. The practitioner is performing a fetal scalp stimulation test. Which of the following fetal responses would the nurse expect to see? 1. Spontaneous fetal movement. 2. Fetal heart acceleration. 3. Increase in fetal heart variability. 4. Resolution of late decelerations.

2. Fetal heart acceleration

41. Thirty seconds after birth, a baby who appears preterm has exhibited no effort to breathe even after being stimulated. The heart rate is assessed at 70 bpm. Which of the following actions should the nurse perform first? 1. Perform a gestational age assessment. 2. Inflate the lungs with positive pressure. 3. Provide external chest compressions. 4. Assess the oxygen saturation level.

2. Inflate the lungs with positive pressure

34. A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O- (negative), the baby's type is A+ (positive), and the direct Coombs test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week to receive her RhoGAM injection. 2. Make sure that the client receives a RhoGAM injection before she is discharged. 3. Notify the client that because her baby's Coombs test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

2. Make sure that the client receives a RhoGAM injection before she is discharged

95. The nurse is caring for a 30-week-gestation client who fetal fibronectin (fFN) levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor. 2. Signs of preterm labor. 3. Signs of pre-eclampsia. 4. How to do fetal kick count assessments.

2. Signs of preterm labor

109. A baby is just delivered. Which of the following physiological changes is of highest priority? 1. Thermoregulation. 2. Spontaneous respirations. 3. Extrauterine circulatory shift. 4. Successful feeding.

2. Spontaneous respirations

Which cardiac defects are considered Cyanotic disorders? Select all that apply. 1. Aortic Stenosis 2. Atrial Septal Defect (ASD) 3. Tetrology of Fallot (TOF) 4. Ventricular Septal Defect (VSD) 5. Coarctation of the Aorta (COA) 6. Truncus Arteriousus 7. Tricuspid Atresia 8. Patent Ductus Arteriousus (PDA) 9. Pulmonary Stenosis (PS)

3, 6, 7 All cyanotic disorders begin with "T" *All cyanotic disorders have Right to Left shunting

63. A multipara, LOA, station +3, who has had no pain medication during her labor, is now in stage 2. She states that her pain is 6 on a 10-point scale and that she wants an epidural. Which of the following responses by the nurse is appropriate? 1. "Epidurals do not work well when the pain level is above level 5." 2. "I will contact the doctor to get an order for an epidural right away." 3. "The baby is going to be born very soon. It is really too late for an epidural." 4. "I will check the fetal heart rate. You can have an epidural if it is over 120."

3. "The baby is going to be born very soon. It is really too late for an epidural."

38. Pg. 73 A parent asks the nurse how it will be determined if their child has respiratory syncytial virus (RSV). Which is the nurse's best response? 1. "We will do a simple blood test to determine whether your child has RSV." 2. "There is no specific test for RSV. The diagnosis is made based on the child's symptoms." 3. "We will swab your child's nose and send that specimen for testing." 4. "We will have to send a viral culture to an outside lab for testing."

3. "We will swab your child's nose and send that specimen for testing."

36. When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction, another occurred 10 seconds after the contraction, and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow.

3. Cord compression

25. Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatidiform mole)? 1. Protracted pain. 2. Variable fetal heart decelerations. 3. Dark brown vaginal bleeding. 4. Suicidal ideations.

3. Dark brown vaginal bleeding

18. The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3. Decreased blood volume

23. Pg. 71 The parents of a 6-year-old who has a new diagnosis of asthma ask the nurse what to do to make their home a more allergy-free environment. Which is the nurse's best response? 1. "Use a humidifier in your child's room." 2. "Have your carpet cleaned chemically once a month." 3. "Wash household pets weekly." 4. "Avoid purchasing upholstered furniture."

4. "Avoid purchasing upholstered furniture."

45. A bottle-feeding woman, 1 1/2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated two pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

83. A 12-week gestation client tells the nurse that she and her husband eat sushi at least once per week. She states, "I know that fish is good for me, so I make sure we eat it regularly." Which of the following responses by the nurse is appropriate? 1. "You are correct. Fish is very healthy for you." 2. "You can eat fish, but sushi is too salty to eat during pregnancy." 3. "Sushi is raw. Raw fish is especially high in mercury." 4. "It is recommended that fish be cooked to destroy harmful bacteria."

4. "It is recommended that fish be cooked to destroy harmful bacteria."

42. The nurse sees the fetal head through the vaginal introitus when a woman pushes. The nurse, interpreting this finding, tells the client, "You are pushing very well." In addition, the nurse could also state which of the following? 1. "The baby's head is engaged." 2. "The baby is floating." 3. "The baby is at the ischial spines." 4. "The baby is almost crowning."

4. "The baby is almost crowning."

14. One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4. 10 cm dilated, 100% effaced, and +5 station

37. The nurse is caring for a client who was just admitted to the hospital to rule out ectopic pregnancy. Which of the following orders is the most important for the nurse to perform? 1. Take the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Assess for complaint of dizziness or weakness.

4. Assess for complaint of dizziness or weakness

72. A vegan is being counseled regarding vitamin intake. It is essential that this woman supplement which of the following B vitamins? 1. B1 (thiamine). 2. B2 (niacin). 3. B6 (pyridoxine). 4. B12 (cobalamin).

4. B12 (cobalamin)

13. A client, G4 P1021, has been admitted to the labor and delivery suite for induction of labor. The following assessments have been made: Bishop score of 2, fetal heart rate of 156 with good variability and no decelerations, TPR 98.6F, P 88, R 20, BP 120/80, negative obstetric history. Cervidil (dinoprostone) has been inserted. Which of the following findings would warrant the removal of the prostaglandin? 1. Bishop score of 4. 2. Fetal heart rate of 152. 3. Respiratory rate of 24. 4. Contraction frequency of 1 minute.

4. Contraction frequency of 1 minute.

39. A nurse describes a client's contraction pattern as: frequency every 3 min and duration 60 sec. Which of the following responses corresponds to this description? 1. Contractions lasting 60 seconds followed by a 1-minute rest period. 2. Contractions lasting 120 seconds followed by a 2-minute rest period. 3. Contractions lasting 2 minutes followed by a 60-second rest period. 4. Contractions lasting 1 minute followed by a 120-second rest period.

4. Contractions lasting 1 minute followed by a 120-second rest period

22. A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heartbeat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? 1. Cervical cerclage. 2. Amniocentesis. 3. Nonstess testing. 4. Dilation and curettage.

4. Dilation and curettage

6. A woman, G3 P1010, is receiving oxytocin (Pitocin) via IV pump at 3 milliunits/min. Her current contraction patter is every 3 minutes x 45 seconds with moderate intensity. The fetal heart rate is 150 to 160 bpm with moderate variability. Which of the following interventions should the nurse take at this time? 1. Stop the infusion. 2. Give oxygen via face mask. 3. Change the client's position. 4. Monitor the client's labor.

4. Monitor the client's labor

44. The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? 1. Prepare epinephrine for administration. 2. Provide positive pressure oxygen. 3. Administer chest compressions. 4. Rub the back and feet of the baby.

4. Rub the back and feet of the baby

64. A client is on magnesium sulfate for severe pre-eclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.

4. Serum magnesium level of 9g/dL

55. Which of the following situations should the nurse conclude is a vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes. 2. Fetal heart rate dropping during contractions. 3. Three-vessel cord. 4. Shoulder dystocia.

4. Shoulder dystocia.

65. A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply. 1. Fever. 2. Flank pain. 3. Dark-colored urine. 4. Nausea. 5. Polycythemia.

1, 2, 3

78. The fetus of a 38-week-gestation client has been diagnosed with intrauterine growth restriction (IUGR). The nurse would expect that which of the following diagnostic assessments would be appropriate for the primary healthcare practitioner to order at this time? Select all that apply. 1. Biophysical profile. 2. Nonstress test. 3. Umbilical arterial Doppler assessment. 4. Chorionic villus sampling. 5. Human chorionic gonadotropin test.

1, 2, 3

58. A woman is in active labor and is being monitored electronically. She has just received Stadol 2 mg IM for pain. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? 1. Variable decelerations. 2. Late decelerations. 3. Decreased variability. 4. Transient accelerations.

3. Decreased variability

71. A 1,000 gram neonate is being admitted to the neonatal intensive care unit. The surfactant beractant (Survanta) has just been prescribed to prevent respiratory distress syndrome. Which of the following actions should the nurse take while administering this medication? 1. Flush the intravenous line with normal saline solution. 2. Assist the neonatologist during the intubation procedure. 3. Inject the medication deep into the vastus laterals muscle. 4. Administer the reconstituted liquid via an oral syringe.

2. Assist the neonatologist during the intubation procedure

19. A nurse is caring for a 25-year-old client who has just had a spontaneous first trimester abortion. Which of the following comments by the nurse is appropriate? 1. "You can try again very soon." 2. "It is probably better this way." 3. "At least you weren't very far along." 4. "I'm here to talk if you would like."

4. "I'm here to talk if you would like."

46. Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PROM)? Select all that apply. 1. 31 weeks' gestation with prolapsed mitral valve (PMV). 2. 32 weeks' gestation with urinary tract infection (UTI). 3. 33 weeks' gestation with twins post in vitro fertilization (IVF). 4. 34 weeks' gestation with gestational diabetes (GDM). 5. 35 weeks' gestation with deep vein thrombosis (DVT).

2, 3

83. An ultrasound is being down on an Rh-negative woman. Which of the following pregnancy findings would indicate the the baby has developed erythroblastosis fetalis? 1. Caudal agenesis. 2. Cardiomegaly. 3. Oligohydramnios. 4. Hyperemia.

2. Cardiomegaly

37. A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the practitioner. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.

2. Notify the practitioner

67. The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. Check each urine for presence of ketones. 2. Pad the client's bed rails and headboard. 3. Provide visual and auditory stimulation. 4. Place the bed in the high Fowler position.

2. Pad the client's bed rails and headboard

102. A 30-year-old, G2 P0010, in preterm labor, is receiving nifedipine (Procardia). Which of the following maternal assessments noted by the nurse must be reported to the healthcare practitioner immediately? 1. Heart rate of 100 bpm. 2. Wakefullness. 3. Audible rales. 4. Daily output of 2,000 mL.

3. Audible rales

41. A woman who is in pain from a diagnosis of mastitis has abruptly weaned her baby to a bottle. Her actions place the woman at high risk for which of the following? 1. Mammary rupture. 2. Postpartum psychosis. 3. Supernumerary nipples. 4. Breast abscess.

4. Breast abscess

77. A 39-year-old, 16-week-gravid woman has had an amniocentesis. Before discharge, the nurse teaches the woman to call her doctor if she experiences which of the following side effects? Select all that apply. 1. Fever or chills. 2. Lack of fetal movement. 3. Abdominal pain. 4. Rash or pruritus. 5. Vaginal bleeding.

1, 2, 3, 5

28. The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a site bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1. Apply an ice pack to the perineum

30. A client, G2 P1001, telephones the gynecology office complaining of left-sided pain. Which of the following questions by the triage nurse would help to determine whether the one-sided pain is due to an ectopic pregnancy? 1. "When did you have your pregnancy test done?" 2. "When was the first day of your last menstrual period?" 3. "Did you have any complications with your first pregnancy?" 4. "How old were you when you first got your period?"

2. "When was the first day of your last menstrual period?"

76. The nurse is evaluating the 24-hour dairy intake of four gravid clients. Which of the following clients consumed the highest number of dairy servings during 1 day? The client who consumed: 1. 4 oz whole milk, 2 oz hard cheese, 1 cup of pudding made with milk and 2 oz cream cheese. 2. 1 cup yogurt, 8 oz chocolate milk, 1 cup cottage cheese, and 1 1⁄2 oz hard cheese. 3. 1 cup cottage cheese, 8 oz whole milk, 1 cup of buttermilk, and 1⁄2 oz hard cheese. 4. 1⁄2 cup frozen yogurt, 8 oz skim milk, 4 oz cream cheese, and 1 1⁄2 cup of cottage cheese.

2. 1 cup yogurt, 8 oz chocolate milk, 1 cup cottage cheese, and 1 1⁄2 oz hard cheese

53. A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0000, delivered a fetal demise at 29 weeks' gestation. 2. G2 P1001, prolonged first stage of labor. 3. G2 P0010, delivery by cesarean section for failure to progress. 4. G3 P0200, delivered vaginally a 42-week, of 2,200-gram neonate. 5. G4 P3003, with a succenturiate placenta.

2, 5

23. A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform as a result? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask.

2. Cover the woman's perineum with a sheet

35. A client's assessments reveal that she is 4 cm dilated and 80% effaced with a fetal heart tracing showing frequent late decelerations, minimal variability, and strong contractions every 3 minutes, each lasting 90 seconds. The nursing management of the client should be directed toward which of the following goals? 1. Completion of the fist stage of labor. 2. Delivery of healthy baby. 3. Safe pain medication management. 4. Prevention of a vaginal laceration.

2. Delivery of a healthy baby

59. A gravid client, 27 weeks' gestation, has been diagnosed with gestational diabetes. Which of the following therapies will most likely be ordered for this client? 1. Oral hypoglycemic agents. 2. Diet control with exercise. 3. Regular insulin injections. 4. Inhaled insulin.

2. Diet control with exercise

10. Pg. 199 The nurse knows that teaching was successful when a parent states which of the following are early signs of muscular dystrophy? 1. Increased muscle strength 2. Difficulty climbing stairs 3. High fevers and tiredness 4. Respiratory infections and obesity

2. Difficulty climbing stairs

88. A woman tells the nurse that she would like suggestions for alternate vitamin C sources because she isn't very fond of citrus fruits. Which of the following suggestions is appropriate? 1. Barley and brown rice. 2. Strawberries and potatoes. 3. Buckwheat and lentils. 4. Wheat flour and figs.

2. Strawberries and potatoes

13. A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? 1. Cover the foot with an iced wrap for one minute prior to the procedure. 2. Avoid puncturing the lateral heel to prevent damaging sensitive structures. 3. Blot the site with a dry gauze after rubbing it with an alcohol swab. 4. Grasp the calf of the baby during the procedure to prevent injury.

3. Blot the site with a dry gauze after rubbing it with an alcohol swab