test 2

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads.

Preparation for cesarean birth

A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in the breech presentation. Which complications should the nurse observe?

Prolapsed umbilical cord

The priority nursing intervention following an amniotomy is to: a. change the client's gown. b. assess the fetal heart rate. c. assess the color of the amniotic fluid. d. estimate the amount of amniotic fluid.

b. assess the fetal heart rate.

A nurse in a prenatal clinic is teaching a client Who is in her second trimester and has a new diagnosis of gestational diabetes. Which statement needs further teaching?

"I will reduce my exercise schedule to 3 days a week"

A client is suspected of having a hydatidiform mole. What should the nurse expect to assess in this client? Select all that apply. 1. Elevated blood pressure 2. Absence of fetal heart tones 3. Frequent urination and thirst 4. Dark brown vaginal drainage 5. Larger than gestational age fundal height

1. Elevated blood pressure 2. Absence of fetal heart tones 4. Dark brown vaginal drainage 5. Larger than gestational age fundal height

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

What order should the nurse expect for a patient admitted with a threatened abortion? a. Bed rest b. Ritodrine IV c. NPO d. Narcotic analgesia every 3 hours, prn

A

he primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum to determine whether the fetus has which condition. A. A neural tube defect B. Hemophilia C. Sickle cell anemia D. Abnormal lecithin - to sphingomyelin ratio

A. A neural tube defect

Which phone call should the prenatal clinic nurse return first? A. Primip at 32 weeks, reports headache and blurred vision B. Multip at 18 weeks, reports no fetal movement this pregnancy C. Primip at 16 weeks, reports increased urinary frequency D. Multip at 40 weeks, reports sudden gush of fluid and contractions

A. Primip at 32 weeks, reports headache and blurred vision

Which is the major advantage of chorionic villus sampling over amniocentesis? a. It is not an invasive procedure. b. It does not require a hospital setting. c. It requires less time to obtain results. d. It has less risk of spontaneous abortion.

ANS: C

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure.

A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest? 1. That a mild analgesic be administered 2. An epidural 3. A local anesthetic block 4. Nonpharmacologic methods of pain relief

Answer: 4

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A) Respiratory rate of 16 breaths per minute B) Diminished deep tendon reflexes C) Urine output of 45 mL/hour D) Alert level of consciousness

B) Diminished deep tendon reflexes

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? A. A client who is experiencing fetal death at 32 weeks of gestation B. A client who is experiencing preterm labor at 26 weeks of gestation C. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation D. A client who has a post-term pregnancy at 42 weeks of gestation

B. A client who is experiencing preterm labor at 26 weeks of gestation

nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4 degrees celsius (97.6 degrees Fahrenheit). Which of the following is the priority nursing action? A. Insert an indwelling urinary catheter. B. Initiate IV access. C. Witness the signature for informed consent for surgery. D. Prepare the abdominal and perineal areas.

B. Initiate IV access.

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect? A. Fetal heart rate 100/min B. Weakened uterine contractions C. Enhanced production of fetal lung surfactant D. Maternal blood glucose 63 mg/dL

B. Weakened uterine contractions

A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus is at risk for developing ? A) Intrauterine growth restriction B)Hyperglycemia C)Meconium aspiration D)Polyhydramnios

C)Meconium aspiration

A nurse is admitting a client who is at 30 weeks gestation and is in preterm labor. The provider prescribes betamethasone (Celestone) stat. When the client asks the nurse about the purpose of the medication, the nurse should reply that it will help A. Stop preterm labor contractions B. Halt cervical dilation C. Boost fetal lung maturity D. increase the fetal heart rate

C. Boost fetal lung maturity

A nurse is caring for a client who is having a nonstress test performed. The FHR is 130 to 150 bpm, but there has been no fetal movement for 15 min. Which of the following is an appropriate nursing intervention? A. Immediately report the situation to the client's provider and prepare the client for induction of labor B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring C. Offer the client a snack of orange juice and crackers D. Turn the client on her left side

C. Offer the client a snack of orange juice and crackers

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide? A. There is an increased risk of introducing infection B. This could initiate preterm labor C. This could result in profound bleeding D. There is an increased risk of rupture of membranes

C. This could result in profound bleeding

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? A) cephalic B) transverse C) posterior D) breech

D) breech

Which sign or symptom leads the nurse to suspect that a client is experiencing a tubal pregnancy? A. A painful, tender area in the epigastric region after meals B. Lower abdominal cramping of 1 week's duration with constipation C. Leukorrhea or dysuria occurring a few days after the first missed menstrual period D. A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder

D. A sharp pain in the lower right or left side of the abdomen, radiating to the shoulder

A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take?A. Infuse a bolus of IV fluid B. Administer Hydralazine 2.5 mg. IV C. Prepare the client for immediate delivery D. Administer betamethasone 12 mg. IM

D. Administer betamethasone 12 mg. IM

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks gestation with a diagnosis of pregnancy induced hypertension. Which of the following findings should the nurse identify as inconsistent with the admitting diagnosis? A. 1+ pitting sacral edema B. 3+ protein in the urine C. Blood pressure 148/98 mm Hg D. Deep tendon reflextes of +1

D. Deep tendon reflextes of +

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? A. Cover the cord with a sterile, moist saline dressing B. Prepare the client for an immediate birth C. Place the client in knee-chest position D. Insert a gloved hand into the vagina to relieve pressure on the cord

D. Insert a gloved hand into the vagina to relieve pressure on the cord

A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin (RhoGam) after delivery of an infant who is Rh-positive. Which information should the nure provide this client? A. RhoGam is not necessary unless all her pregnancies are Rh-positive B. The R-positive factor from the fetus threatens her blood cells C. The mother should receive RhoGam when the baby is Rh-negative D. RhoGam prevents maternal antibody formation for future Rh-positive babies

D. RhoGam prevents maternal antibody formation for future Rh-positive babies

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? Anaphylactoid syndrome of pregnancy Disseminated intravascular coagulation Preeclampsia Puerperal infection

Disseminated intravascular coagulation

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? a. temperature b. pulse c. respirations d. blood pressure

b. pulse

Which patient situation presents the greatest risk for the occurrence of hypotonic dysfunction during labor? a. A primigravida who is 17 years old b. A 22-year-old multiparous woman with ruptured membranes c. A multiparous woman at 39 weeks of gestation who is expecting twins d. A primigravida woman who has requested no analgesia during her labor

c. A multiparous woman at 39 weeks of gestation who is expecting twins

A patient in labor suddenly grasps her chest, has cyanosis, tachycardia, difficulty breathing and her blood pressure is declining rapidly. What problem would the nurse suspect? a. Pulmonary embolism b. Hypovolemic shock c. Amniotic fluid embolism d. Oligohydramnios

c. Amniotic fluid embolism

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? a. Slow the client's rate of breathing b. Increase the rate of infusion of the IV oxytocin c. Decrease the rate of infusion of the maintenance IV solution d. Discontinue the infusion of the IV oxytocin

d. Discontinue the infusion of the IV oxytocin

A woman who had two previous cesarean births is in active labor, when she suddenly complains of pain between her scapulae. The nurse's priority action is to a. Reposition the woman with her hips slightly elevated. b. Observe for abnormally high uterine resting tone. c. Decrease the rate of nonadditive intravenous fluid. d. Notify the physician promptly and prepare the woman for surgery.

d. Notify the physician promptly and prepare the woman for surgery.

When should an IVP narcotic be injected to a laboring patient?

during the early part of active labor. cervical dilation of at least 4 cm with a fetus that is engaged.

A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block?

hypotension

the labor of a pregnant woman at 43 weeks gestation is being induced the nurse caring for this woman must be alert for which of the following associated with postterm labor and postmaturity syndrome

stillbirth

A 38-week-gestation woman is in labor and delivery with a painful, board-like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. Fetal heart rate. 2. Cervical dilation. 3. White blood cell count. 4. Maternal lung sounds.

1. Fetal heart rate.

he nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1."I will need to increase my insulin dosage during the first 3 months of pregnancy. "2."My insulin dose will likely need to be increased during the second and third trimesters. "3."Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4."My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

1."I will need to increase my insulin dosage during the first 3 months of pregnancy.

A nurse is preparing to administer ticarcillin/clavulanate 3.1 g by intermittent IV bolus over 30 min. Available is ticarcillin/clavulanate 3.1 g in 50 mL 0.9% sodium chloride (NSS). The nurse should set the IV pump to deliver how many mL/hr? (Round the anser to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

100

Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? 1. 3 pitting edema and pulmonary edema. 2. Epigastric pain and systemic jaundice. 3. 4 deep tendon reflexes and clonus. 4. Oliguria and elevated specific gravity.

2. Epigastric pain and systemic jaundice.

the physician has ordered Prepidil (dinoprostone) for four gravidas at term. the nurse should question the order for which woman? 1. primigravida with Bishop score of 4 2. multigravida with late decelerations 3. G1 P0000 contracting every 20 mins x 30 sec 4 G6 P3203 with bp 140/90 and pulse 92

2. multigravida with late decelerations

A 21-year-old at 12 weeks' gestation with her first baby has known cardiac disease, class III, as a result of childhood rheumatic fever. During a prenatal visit, the nurse reviews the signs of cardiac decompensation with her. The nurse will know that the client understands these signs and symptoms if she states that she would notify her doctor if she had which symptom?

4. "A frequent cough"

he nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client? 1. Total abstinence from sexual intercourse is necessary during the entire pregnancy. 2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. 3. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy. 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.

4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.

a nurse is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a training zero.)

60

A nurse is assisting in the care of a client who is scheduled for a C-section birth based on the fetal lungs having maturity. Which of the following findings indicates that the fetal lungs are mature?

Lecithin/sphingomyelin (l/S) ratio of 2:1

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? Respirations 16/min Headache for 30 min Urinary output 40 ml in 2 hr Fetal heart rate 156/min

Urinary output 40 ml in 2 hr

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use: a. Counterpressure against the sacrum b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Biofeedback.

a. Counterpressure against the sacrum

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

a. come to the clinic today for an ultrasound

A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? Placenta previa Prolapsed cord Incompetent cervix Abruptio placentae

abruptio placentae

daily fetal movement counts are done:

after meals and to detect if there is any change

A client has been admitted with the diagnosis of hyperemesis gravidarum. Which of the following physician's orders is of highest priority? a. Obtain CBC b. Start IV infusion with multivitamins c. Check admission weight d. Obtain urine for urinalysis

b. Start IV infusion with multivitamins

a nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. which of the following is the priority action for the nurse to take? a. cut the umbilical cord b. apply perineal pressure to the emerging fetal head c. prevent the perineum from tearing d. promote delivery of the placenta

b. apply perineal pressure to the emerging fetal head

a woman receiving magnesium sulfate IV for preeclampsia has deep tendon reflexes of +1 respiratory rate of 12 a urinary output of 90 ml in 4 hours and a magnesium level of 9 what nursing intervention would be expected

stop the infusion