repro-exam-nclex questions
Which assessment data would be of the greatest concern in a sleeping 1-hour-old newborn of 39 weeks' gestation? Select all that apply. A) Respirations of 68 per minute B) Temperature of 97.9°F C) Blood pressure of 72/44 mmHg D) Acrocyanosis present E) Heart rate of 166 bpm
a e
What is the test or measurement that provides an early indicator of fetal lung maturity in high-risk pregnancies? A) Serum or urine human chorionic gonadotropin (hCG) B) Fetal heartbeat by Doppler C) Fetal heartbeat by fetoscope D) Fetal movement
a
What should the nurse instruct a pregnant client with a history of back pain regarding childbirth exercises? A) Perform the pelvic rock exercise only in the standing position. B) Exercise in the supine position throughout the pregnancy. C) Perform the pelvic rock exercise while in the hands and knees position. D) Soak in a hot tub for approximately 30 minutes after exercise.
a
) A client at 8 weeks' gestation has been advised to have the embryo undergo genetic testing. The nurse instructs the client that the area of the embryo being tested is which of the following? A) Chorion B) Amnion C) Ectoderm D) Endometrium
a
A Latina client who has just delivered a newborn son wants to breastfeed but says she would like to bottle-feed for the first few days. After talking with the client, the nurse learns that the primary reason for the desire to delay breastfeeding is based on which cultural belief? A) Colostrum is bad for the baby. B) Breast milk causes skin rashes. C) It will cause "evil eye." D) Thin milk causes diarrhea.
a
A client informs the nurse of a positive result from an early pregnancy test but wants to be sure that she is pregnant. Which response is the most appropriate for the nurse to make? A) "Pregnancy can be detected 24 to 48 hours after conception, depending on the test." B) "Pregnancy cannot be detected before 12 days after conception." C) "Most early pregnancy tests are not reliable." D) "Most pregnancy tests cannot differentiate between pregnancy and premenstrual hormone levels."
a
A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time through a Doppler. What does this assessment finding indicate to the nurse? A) The mother is at 8 to 12 weeks' gestation. B) The mother is at 16 weeks' gestation. C) The mother is at 4 to 8 weeks' gestation. D) The mother is at 20 weeks' gestation
a
After learning that she is pregnant, an adolescent client asks for information that she needs to know about the pregnancy and the baby because she cannot afford to see a doctor. The nurse should do which of the following? A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery. B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery. C) Ask the client if her parents are aware that she is pregnant and if she is covered by their medical insurance. D) Tell the client that the father of the baby is responsible to pay for medical care for her during the pregnancy and after delivery
a
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. What nursing action is best? A) Document the fetal heart rate. B) Prepare for imminent delivery. C) Apply oxygen via mask at 10 liters. D) Assist the client into the Fowler's position
a
The nurse is placing a newborn baby in the nursery crib with the baby's back down. The mother tells the nurse that she doubts the baby will be able to sleep that way, as all the family members sleep on their stomachs. What should the nurse do? A) Instruct the mother that placing the baby on the back will reduce the risk of sudden infant death syndrome (SIDS). B) Place the baby on the stomach. C) Suggest the mother place the baby on the stomach when at home. D) Instruct the mother that babies do not really care in which position they are in but placing on the back is easier to provide care
a
The nurse is planning care for a baby of African-American descent born to a mother who smoked during the pregnancy. Which diagnosis would be appropriate for this baby? A) Risk for Sudden Infant Death Syndrome B) Readiness for Enhanced Parenting C) Anxiety D) Deficient Knowledge
a
The student nurse attends a workshop on culture and diversity with regard to sudden infant death syndrome (SIDS) and is now aware that the rate of occurrence is highest among which group of infants? A) American Indians B) African-Americans C) Asians D) Hispanics
a
What information would a nurse use as a primary consideration in distinguishing physiologic versus pathologic jaundice in a newborn? A) Signs of physiologic jaundice in a newborn appear after the first 24 hours postnatally, whereas those of pathologic jaundice manifest at birth or within the first 24 hours of life. B) Signs of physiologic jaundice in a newborn appear at birth or before the first 24 hours postnatally. C) The skin of the newborn with physiologic jaundice tends to be yellow; in pathologic jaundice the newborn's skin tends to be very pale. D) Pathologic jaundice is not masked by artificial lighting, whereas physiologic jaundice may be difficult to discern in artificial lighting.
a
A client in the first trimester of pregnancy complains of a vaginal discharge and is concerned that the baby is infected. The nurse should instruct the client to do which of the following? Select all that apply. A) Avoid douching. B) Keep the vaginal area clean and wear cotton underwear. C) See the primary care physician to assess for a vaginal infection. D) Limit bathing to 2 times a week. E) Limit dairy products and use lactose-free products whenever possible.
a b
The nurse is planning care for a client who had a cesarean birth 4 hours ago. What should be included in this client's plan of care? Select all that apply. A) Encourage the use of breathing, relaxation, and distraction. B) Encourage deep breathing and coughing every 2 to 4 hours. C) Encourage to ambulate to the bathroom to void. D) Discourage leg exercises. E) Withhold all analgesics.
a b
The nurse is providing postpartum care to a client from a different culture. What actions should the nurse take when planning care for this client? Select all that apply. A) Assess for any assistance required during breastfeeding. B) Ask if there are any specific customs the client wants to follow. C) Assess for any specific foods or fluids to hasten recovery. D) Limit visitors. E) Restrict interactions.
a b c
A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which of the following should the nurse include when presenting information on environmental factors that contribute to the occurrence of SIDS? Select all that apply. A) Use of bedding that is firm B) Avoiding overheating the sleeping room C) Avoiding smoking around infants D) Blanket secured lower than chest E) Prone-position sleeping
a b c d
A nurse is preparing to educate a group of parents on sudden infant death syndrome (SIDS). Which should the nurse include when presenting significant stressors that contribute to SIDS? Select all that apply. A) Prone sleeping B) Side sleeping C) Face-down sleeping D) Bed sharing E) Supine sleeping
a b c d
A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen a pregnant client in her second trimester has a hemoglobin of 10 g/dL and a serum ferritin level of 11 mg/L. The woman states that she has felt tired a lot, but otherwise feels fine. What actions would be expected in caring for this client? Select all that apply. A) Complete a further history and exam to carefully assess for any potential cause of bleeding. B) Review a list of iron-rich foods and explore with the client how she can increase dietary iron. C) Have the client continue her usual daily prenatal vitamin dose. D) Stress the importance of complying with an increase in iron supplementation to 100 mg per day. E) Ask the client to return in 2 months for a repeat check of her serum iron levels. F) Order a screening for sickle cell anemia.
a b c d
The Emergency Department nurse provided care to an infant that arrived in cardiac and respiratory arrest. The death of the infant was determined to be caused from sudden infant death syndrome (SIDS). The parents are grieving and will need collaborative interventions. The nurse is aware that which collaborative intervention would be appropriate for the parents? A) A psychosocial assessment B) A grief counselor referral C) A psychotherapist referral D) A visit from the chaplain
a b c d
When assessing the risk of a newborn for SIDS, what are some of the factors the nurse should consider? Select all that apply. A) Race B) Gender C) Father's age D) Age E) Eye color
a b d
A client at 16 weeks' gestation is diagnosed with tuberculosis. What should the nurse instruct the client regarding the care needs for both the client and fetus? Select all that apply. A) Take Isoniazid as prescribed. B) Contact with the baby after delivery will be limited for several months. C) Take pyridoxine (vitamin B6) as prescribed. D) No extra rest periods will be needed. E) Take Rifampin as prescribed.
a c
A pregnant woman presents to the Emergency Department and reports that she has started labor and is certain the baby is coming "any minute now" and asks to be taken up to the delivery suite. The nurse assigned to provide care for this woman over a couple of hours determines that the woman is in "false" labor and is preparing her to return home. Which observation or observations support this conclusion? Select all that apply. A) The contractions do not have a regular pattern. B) Her cervix has dilated 2 cm over the 2 hours of observation. C) The frequency and intensity of the contractions have stayed about the same. D) Walking seems to increase the strength of the contractions. E) The contractions are mostly in her abdomen.
a c e
A nurse is caring for the 1-hour-old infant of a diabetic mother. What should be included in the plan of care for this newborn? Select all that apply. A) Assess blood glucose hourly and then every 4 hours. B) Evaluate blood glucose levels at birth and at 6-hour intervals. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Use formula for all feedings, avoiding 5% dextrose
a e
Nurses caring for clients in labor anticipating a vaginal birth after cesarean (VBAC) typically would want to verify that orders are in place to obtain a blood count, type, and screen on admission, to insert a heparin lock for IV access if needed, to provide continuous electronic fetal monitoring, and to allow clear fluids. What additional care actions are generally required for women expecting a VBAC whose previous birthing history places them at higher risk (e.g., had a previous caesarean birth and other than a low transverse uterine incision)? Select all that apply. A) Maintaining NPO status B) Limiting visitors in the labor room to one individual C) Verifying that the woman has no allergies to any drugs D) Placing a urinary catheter to more accurately measure urinary output E) Insertion of an intrauterine catheter to monitor intrauterine pressure during labor
a e
The nurse is instructing the parents who delivered their first child at 34 weeks. Which statement or statements indicate that additional teaching is needed? Select all that apply. A) "Tube feedings will be required because his stomach is small." B) "Breathing might be harder for our baby because he is early." C) "Our baby will be in an isolette to keep him warm." D) "The growth of our baby will be slower than if he were term." E) "Because he came early, he will not produce urine for two days."
a e
) The nurse is evaluating care provided to a new mother whose infant is at risk for sudden death syndrome (SIDS). Evidence that care has been effective would be the mother expressing: A) The need to purchase loose-fitting sheets and blankets for the bed. B) A plan to quit smoking. C) The proper way to place the infant in the crib as being prone or side-lying. D) The reasons why bottle-feeding is preferred over breastfeeding.
b
A client is surprised to learn of being pregnant because the home pregnancy test was negative when it was used a month ago. What should the nurse respond to this client? A) "Home pregnancy tests are unreliable and should not be used without an ultrasound afterward to confirm pregnancy." B) "Home pregnancy tests can provide a false negative and should be repeated in a week if your period has not yet started." C) "Home pregnancy tests are unreliable and should not be used without a blood sample being drawn afterward." D) "Home pregnancy tests lose their effectiveness after 6 months, and your kit was probably old."
b
A client who gave birth to her first child 12 hours ago has the following assessment findings: nauseated but has not vomited for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on scale of 1-10. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this client? A) Acute Pain related to perineal trauma B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea C) Deficient Knowledge related to birth of first child D) Readiness for Enhanced Family Coping related to partner involvement
b
A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following? A) Drink a glass of water every time nausea occurs. B) Take a multivitamin without iron each day. C) Take over-the-counter Benadryl for the nausea. D) Take a multivitamin with iron each day
b
A new mother asks what needs to be done to prevent the baby from sudden infant death syndrome. What should the nurse do to assist the mother? A) Instruct the mother to keep the baby with her at all times to assess for apnea periods. B) There is no one cause for the syndrome; the best thing is to keep the baby healthy. C) Encourage the mother to place the child in a face-down position for sleep. D) Suggest the mother avoid immunizing the child
b
A nurse has been caring for several weeks for a premature infant with a central line. The baby had been growing and doing well, but suddenly developed apnea, bradycardia, and metabolic acidosis. What is the most likely condition causing this change in health status? A) Hyperbilirubinemia B) Bacterial sepsis C) Hypoglycemia D) Intracranial hemorrhage
b
An adolescent client at 34 weeks' gestation tells the nurse that she cannot wait for "all of this to be over" so she can resume her normal life. With which question should the nurse respond to this client? A) "Are your friends excited about the baby coming and planning a shower for you?" B) "Have you done anything to prepare for the baby coming home after delivery?" C) "Do you miss school and spending time with your friends?" D) "Have you been able to get enough rest while keeping up with your studies?"
b
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. The nurse determines that which assessment finding needs follow up? A) Moderate lochia rubra B) Steady trickle of blood C) Fundus at the umbilical level D) Firm fundus
b
The nurse caring for a pregnant client experiencing nausea, vomiting, and heartburn should instruct the client on which of the following? A) Avoiding small meals and drinking fluids to limit nausea, vomiting, and heartburn B) Having a dental checkup because pregnancy causes gum tenderness and swelling C) How the physician can prescribe medication to treat the nausea, vomiting, and heartburn D) Using herbal home remedies to control the nausea, vomiting, and heartburn
b
The nurse caring for the new mother of African-American descent should implement which intervention regarding sudden infant death syndrome (SIDS)? A) Instruct on side-lying and face-down positions when in the crib. B) Instruct on face-up position when in the crib. C) Ensure adequate nutritional intake for the mother and newborn. D) Encourage good hand washing.
b
The nurse is caring for a newborn male client recovering from a circumcision. Which nursing diagnosis would be appropriate for the client after the procedure? A) Risk for Injury B) Risk for Infection C) Risk for Imbalanced Nutrition D) Risk for Ineffective Breathing Pattern
b
The nurse is preparing to provide an enteral feeding to a preterm infant. What should the nurse do prior to administering this feeding? A) Weigh the current diaper. B) Measure abdominal girth. C) Weigh the baby. D) Measure pulse oximetry
b
A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier. What should the nurse instruct this client? Select all that apply. A) Avoid shrimp, salmon, and catfish because these have higher mercury levels. B) Eat up to 12 ounces a week of a variety of fish and shellfish. C) Avoid albacore tuna because it has more mercury than other canned tuna. D) Eat plenty of fish such as swordfish and shark while pregnant. E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish
b c
The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statement or statements indicate that the nurse's education session was effective? Select all that apply. A) "I should not use petroleum jelly on the penis." B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." D) "Swelling is expected." E) "I am to use soap and water to remove yellow tissue on the penis."
b c
The nurse is instructing a pregnant adolescent client on how the baby's condition is evaluated during labor. The nurse knows that education was successful when the client states which of the following? A) "During labor, the nurse will verify that my contractions are strong but not too close together." B) "During labor, the nurse will look at the color and amount of bloody show that I have." C) "During labor, the nurse will assess the baby's heart rate with an electronic fetal monitor." D) "During labor, the nurse will check my cervix by doing a pelvic exam every two hours."
c
A client in her 5th month of pregnancy who is attending an antepartum clinic remarks to the nurse that her long-standing chronic disease has markedly improved since she's been pregnant. What teaching would the nurse provide about conditions that often go into remission during the antepartum period? Select all that apply. A) "Systemic lupus erythematosus (SLE) is often difficult to diagnose; perhaps because you are improving during pregnancy this diagnosis was made in error and should be revisited." B) "Rheumatoid arthritis (RA) tends to go into remission during pregnancy; unfortunately, relapses typically occur in the postpartum period." C) "For whatever reason, having HIV during pregnancy leads to a remission of signs and symptoms and, thankfully, helps to stall the progression of the disease, including following delivery." D) "Medical researchers aren't sure why signs and symptoms of multiple sclerosis often get better during pregnancy, but be aware that there also tends to be a slight increase in relapse rates after delivery." E) "Women with epilepsy who have frequent seizures often find that their level of seizure activity significantly improves during pregnancy, but then seizure episodes tend to return to pre-pregnancy levels."
b d
When administering an intramuscular dose of vitamin K (AquaMEPHYTON) to a newborn, the nurse will do which of the following? Select all that apply. A) Use a 23-gauge 1/2-inch needle. B) Clean the skin with an alcohol swab. C) Prepare 5 mg of the medication for injection. D) Use the middle third of the vastus lateralis muscle. E) Wash the skin with soap and water.
b d
When caring for a preterm infant, the nurse will add interventions to address thermoregulation because the infant: Select all that apply. A) Will have flexed extremities. B) Will lose heat faster than a full-term infant. C) Has hyperconstriction of the blood vessels. D) Has less subcutaneous fat. E) Has thicker skin.
b d
A postpartum client is experiencing pain from an episiotomy. What can the nurse instruct this client to aid with pain relief? Select all that apply. A) Wash the area with soap and water every day. B) Tighten the buttocks before sitting. C) Change peripads daily. D) Perform leg scissor kicks several times a day. E) Increase the intake of meat, cheese, fish, eggs, and nuts
b e
) A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which nursing diagnosis would be of the highest priority for the client at this time? A) Ineffective Breastfeeding B) Dysfunctional Family Processes C) Nausea D) Fatigue
c
6) Upon delivery of the newborn, the nursing intervention that most promotes parental attachment is which of the following? A) Placing the newborn under the radiant warmer B) Placing the newborn on the bed next to the mother C) Placing the newborn on the maternal abdomen D) Taking the newborn to the nursery for the initial assessment
c
A client at 12 weeks' gestation with her first child tells the nurse that she is concerned that her husband does not want the baby because he has a renewed interest in playing tennis and visiting with college friends after work. The nurse realizes the client is describing a(n): A) Father's reaction normally seen in the second trimester of pregnancy. B) Father's reaction normally seen in the third trimester of pregnancy. C) Father's reaction normally seen in the first trimester of pregnancy. D) Atypical reaction of the father to pregnancy that should be further examined.
c
A client in labor with the fetus in the vertex position has a spontaneous rupture of membranes. The nurse sees that the amniotic fluid is meconium-stained and immediately takes what action? A) Notifies the physician that birth is imminent B) Changes the client's position in bed C) Begins continuous fetal heart rate monitoring D) Administers oxygen at 2 liters per minute
c
A clinic nurse who works in a community health clinic is reviewing the immunization status of a young woman whose parents were opposed to childhood vaccination. The client and her partner have been trying to conceive, and the woman admits that she's worried about how her lack of immunizations might affect her unborn child and any children she might have. Given her interest in reducing the risk of childhood diseases through vaccination, what vaccine would the nurse absolutely recommend that this client not receive at this time? A) Pertussis vaccine B) Annual influenza vaccine C) Rubella D) Tetanus
c
A postpartum client who delivered 4 hours ago and has a mediolateral episiotomy and large hemorrhoids is rating her pain at 7 on a scale of 1-10. She has a history of anaphylactic reaction to acetaminophen (Tylenol). Which nursing action would be best? A) Encourage use of benzocaine topical anesthetic spray (Dermoplast). B) Provide 2 oxycodone with acetaminophen (Percocet) by mouth. C) Offer the client 800 mg ibuprofen (Advil) orally with food. D) Run very warm water into the tub and assist her into the bath.
c
An infant born after 37 weeks' gestation weighs 1,750 g (3 pounds, 10 ounces). The head circumference and length are at the 25th percentile. What statement would the nurse use to describe these assessment findings? A) Preterm appropriate for gestational age, asymmetrical intrauterine growth restriction B) Preterm appropriate for gestational age, symmetrical intrauterine growth restriction C) Preterm small for gestational age, asymmetrical intrauterine growth restriction D) Term small for gestational age, symmetrical intrauterine growth restriction
c
In palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. What action should the nurse take first? A) Contact the client's nurse midwife to notify the midwife of this condition. B) Have a nursing colleague reexamine the client to verify the nurse's finding. C) Have the client void to empty the bladder and then remeasure fundal height. D) Catheterize the woman to empty the bladder and then remeasure fundal height
c
The labor and delivery nurse is planning care needs for clients in labor. Which client is the priority for further intervention? A) Nullipara at 10 cm and pushing, external fetal monitor applied B) Nullipara in preterm labor, external monitor in place C) Multipara at 7 cm, fetal heart tones auscultated every 90 minutes D) Multipara with meconium-stained fluid, internal fetal scalp electrode in use
c
The nurse is instructing a client who is at 10 weeks' gestation on smoking cessation and avoiding substance abuse because these substances will: A) Interfere with hormone excretion of the fetus. B) Facilitate the transfer of viruses and other diseases into the developing fetus. C) Pass into the developing fetus through the placenta very easily. D) Stop the synthesis of protein in the developing fetus.
c
The nurse is providing discharge instructions to a 15-year-old first-time mother and her baby. What should be included in these instructions? A) "Your baby's stools will change to a golden yellow color when your milk comes in." B) "Call your pediatrician if the baby's temperature is 97°F." C) "Your infant should wet a diaper at least six times per day." D) "You can wipe away any eye drainage that might form."
c
The nurse on an obstetric unit is caring for a client who has asthma. The client has a cold and has an exacerbation of asthma symptoms, including mild wheezing. To help avoid hypoxia-related complications in the fetus, what medication is likely to be used to treat her symptoms? A) IV corticosteroid (e.g., prednisone) B) Oral pseudoephedrine (e.g., Sudafed) C) Inhaled beta2-agonist (e.g., albuterol) D) Oral acetylsalicylic acid (e.g., aspirin)
c
The spouse of a pregnant client tells the nurse that he is not sure he is ready to be a father and wishes his wife had not gotten pregnant. Which response should the nurse make to the husband? A) "Do you think you wife got pregnant on purpose, without your consent?" B) "If you don't want the baby, it can be given up for adoption to another family." C) "There are many ways that you can be of support to your wife at this time." D) "Every husband has these feelings, and many times they never go away."
c
During an assessment, the nurse notes the postpartum client is experiencing intense shaking chills. What does this assessment finding indicate to the nurse? Select all that apply. A) This is evidence of incomplete expulsion of the placenta. B) The client has a full bladder. C) This may be a reaction to maternal adrenal production during labor and birth. D) This may be a reaction to epidural anesthesia. E) The client has a fever from a postpartum infection.
c d
The nurse caring for a stabilized preterm infant for the past 3 weeks would expect that the infant is receiving adequate nutritional intake if the baby consistently gains how many grams a day? A) 1,870-1,940 grams (or 70-140 grams over 14 days, or between 5 and 10 g/day since regaining birth weight) B) 1,940-2,010 grams (or 140-210 grams over 14 days, or between 10 and 15 g/day since regaining birth weight) C) 2,010-2,080 grams (or 210-280 grams over 14 days, or between 15and 20 g/day since regaining birth weight) D) 2,080-2,220 grams (or 280-420 grams over 14 days, or between 20 and 30 g/day since regaining birth weight)
c d
The nurse notes that a client who is 18 weeks pregnant is experiencing gum hyperplasia with areas of inflammation. What actions should the nurse take regarding this finding? Select all that apply. A) Encourage the use of dental floss to reduce gum overgrowth. B) Do nothing because this is a normal finding with pregnancy. C) Suggest seeing a dentist. D) Discuss current dental habits. E) Recommend flushing the mouth with hydrogen peroxide daily.
c d
The nurse is instructing new parents on ways to avoid sudden infant death syndrome with their newborn son. What should be included in these instructions? Select all that apply. A) There is nothing that can be done, so requirements for toys and bedding are of no consequence. B) Instruct that it is more common in babies from ages 6 months to 18 months. C) Avoid placing the baby in the prone or side-lying position for sleep. D) Remind the parents that the syndrome is more common in females than males, and that they have a male child. E) Do not smoke near the child and reduce all exposure to secondhand smoke
c e
A client in the fourth stage of labor is crying out in pain. Which nursing diagnosis would be the most appropriate for the client at this time? A) Health-Seeking Behaviors B) Fear C) Anxiety D) Acute Pain
d
After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit, an adolescent client says, "My baby doesn't seem real because she's in the hospital and I'm at home." What can the nurse do to promote parent-infant attachment? A) Limit visits to the intensive care unit so as not to disrupt care of the baby needs. B) Explain that once the baby is discharged to home, she will have evidence that the baby is real. C) Have the mother visit when the baby is asleep or resting. D) Provide a picture of the infant including a footprint and current weight and length.
d
During the fourth stage of labor, a client's blood pressure is 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse? A) Massage the fundus. B) Turn the client onto the left side. C) Place the bed in the Trendelenburg position. D) Continue to monitor
d
Supportive care for the parents of an infant who died from sudden infant death syndrome (SIDS) would include: A) Advising the parents that an autopsy is not necessary. B) Sheltering the parents from their grief by not giving them any personal items of the infant, such as footprints. C) Interviewing the parents to determine the cause of the SIDS incident. D) Allowing the parents to hold, touch, and rock the infant
d
The mother of a preterm infant tells the nurse that she was not looking forward to having a baby and now that the baby is sick, she feels worse. Which nursing diagnosis is the most appropriate for this situation at this time? A) Parental Role Conflict B) Impaired Parenting C) Dysfunctional Family Processes D) Ineffective Family Coping
d
The nulliparous client asks the nurse why the cervix has only dilated from 1 to 2 cm in 3 hours of contractions, occurring every 5 minutes. What is the best response by the nurse? A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
d
The nurse conducting a 5-minute Apgar assessment on a newborn female assigns the following ratings: Heart rate < 100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). What is the most appropriate set of actions for the nurse to take? A) Have the nursery aide initiate measures to increase the baby's heart rate and respirations by gently stimulating the baby, with the nurse then repeating the Apgar in 10 minutes. B) Swaddle the infant to keep her warm and calm to avoid having the newborn expend energy due to being distressed, fussy, or crying. C) Swaddle the newborn, place the baby in the mother's arms, and ask the mother to continue to observe the infant's respirations for change. D) Provide suctioning and oxygen as needed, repeat the scoring every 5 minutes for up to 20 minutes, and prepare for resuscitation if needed.
d
The nurse has received a shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first? A) 37 weeks' gestation male, respiratory rate 45 B) 1-day-old female who has not voided C) 8 pound, 1 ounce female, pulse 150 D) Term male, grunting respirations
d
The nurse is instructing a postpartum client on when she can resume her normal exercise regimen of running for exercise most days of the week. Which statement indicates that teaching was effective? A) "I can start running in 2 weeks and breastfeed the baby when I return." B) "I will not be able to run because it is not recommended for breastfeeding women." C) "I can run if I get 8 hours of sleep per day." D) "I should check my energy level at home and increase my activity slowly."
d
The nurse is monitoring the intake and output for a male preterm infant. What will the nurse do to correctly assess the infant's output? A) Document "unable to obtain" on the graphic sheet. B) Apply an external condom catheter. C) Insert an indwelling urinary catheter. D) Weigh diapers using the estimate that 1 ml = 1 gram of weight
d
When planning the care for a preterm infant with ineffective thermoregulation, the nurse should include which intervention? A) Keep the baby's head uncovered. B) Rinse hands with cold water before providing care to the infant. C) Place incubator near a window or source of fresh air. D) Allow skin-to-skin contact with the mother to maintain warmth.
d
Which statement indicates that instruction provided to a pregnant client and spouse about amniocentesis was effective? A) The client tells the spouse that the test has to be done before the 14th week of pregnancy. B) The client tells the spouse that childbirth classes are not necessary if the baby has Down syndrome. C) The client and spouse state that it is not unusual for amniocentesis to misdiagnose a problem with the baby. D) The client and spouse state that the results of the amniocentesis will take up to 2 weeks.
d
While reviewing exercises to do when pregnant, a client of European descent tells the nurse that she was taught never to reach over the head because this will harm the baby. What should the nurse include in this client's plan of care? A) Provide dietary instruction to ensure the client does not gain excessive weight. B) Suggest limiting exercise to household chores. C) Provide alternative activities to do instead of exercise. D) Assure that reaching over the head will not harm the baby.
d
The nurse is planning care for a new mother of African-American descent who smoked during the pregnancy and whose sister lost a child to sudden infant death syndrome (SIDS). What should be included in this client's plan of care? Select all that apply. A) Information on bottle-feeding the infant B) Reasons why the child should sleep with others C) Ages at which the child should receive immunizations D) Using bedding that is firm E) Smoking cessation information
d e