206 Final

During routine preconception counseling a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?

"8 days after conception."

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions.

The obstetric nurse is performing a nonstress test on a 30 week primigravida client sent from a healthcare provider's office. The client reports a decrease in fetal movement over the past 24 hours. The nurse documents the above nursing note. Which nursing statement is appropriate at this time?

"I will check with the healthcare provider to see if further tests are needed."

The nurse is teaching pain management to a prenatal class. The nurse knows that the instruction has been effective when a participant says

"I will feel most of my pain in my pelvis during early labor."

A client with type 1 diabetes has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide?

"Insulin requirements usually decrease during the first trimester."

A client asks the nurse if it is safe to have sex during the third trimester. How should the nurse respond?

"Sex is safe in any trimester."

A primigravid client is 8 weeks' pregnant and has had her first examination. The healthcare provider stated the client has a positive Hegar's sign. The client is concerned that this sign means something is wrong. How should the nurse respond to this client's concerns?

"This is a good sign. It means the uterus is softened."

The prenatal client wants to know why the nurse is asking about her use of herbal supplements. What is the nurse's best response?

"Understanding the full picture of what herbal supplements you use to manage your health will help us better provide coordinated and safe care."

The prenatal client tells the nurse that she has been eating ginger cookies to treat her nausea and vomiting. Which response by the nurse is best?

"When consumed as a spice in foods, ginger is generally considered safe in pregnancy."

A nurse is assessing a pregnant client in the second trimester. The nurse weighs the client then compares the current and previous weights. During the second trimester how much weight should the client gain per week?

1 lb (0.45 kg)

A client comes to the office for a routine prenatal visit at 26 weeks gestation The urine dipstick is negative for protein but 2+ for glucose The nurse would teach the client about what testing that needs to be performed?

1-hour glucose tolerance test

A nurse is using Doppler ultrasound to assess a pregnant client. When should the nurse expect to begin hearing fetal heart tones?

11 weeks' gestation

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method the unsafe period for sexual intercourse is indicated by

3 full days of elevated basal body temperature and clear, thin cervical mucus.

A primigravid client with severe preeclampsia exhibits hyperactive very brisk patellar reflexes with two beats of ankle clonus present. How does the nurse document the patellar reflexes?

4+

During neonatal resuscitation immediately after delivery chest compressions should be initiated when the heart rate falls below

60 beats/minute.

A client who is 5 weeks' pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by:

9 to 12 weeks' gestation.

A newly postpartum client is asking to go to the bathroom 45 minutes after birth. She had an epidural for labor and birth and has an IV infusing and every 15 minutes assessments are in progress. What should the nurse do to provide the safest care for this client?

Assess the client's ability to stand and bear weight before going to the bathroom.

A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?

By positioning the neonate so that the head remains still

A primigravid client who was successfully treated for preterm labor at 30 weeks' gestation had a history of mild hyperthyroidism before becoming pregnant. What instructions should the nurse include in the plan of care?

Continue taking low-dose oral propylthiouracil as ordered.

A woman with preeclampsia is receiving magnesium sulfate via infusion pump at 1 g/h. The nurse's assessment includes temperature 36.7°C; pulse 78; respirations 12/minute; blood pressure 128/82 mm Hg; urinary output 90 mL in last 4 hours via urinary catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 beats/min; cervix 4 cm dilated 80% effaced station -1. Which is the most appropriate action for the nurse to take?

Discontinue the magnesium sulfate infusion and notify the health care provider (HCP).

When auscultating the heart sounds of a client who's 34 weeks pregnant the nurse detects a systolic ejection murmur. Which action should the nurse take?

Document the finding, which is normal during pregnancy.

A client at 37 weeks' gestation is scheduled for an ultrasound. What should the nurse instruct the client to do before the test?

Drink 1 to 2 L of fluid.

A pregnant client arrives in the emergency department and states "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. What should the nurse do first?

Hold pressure on the fetal head.

A 10-week pregnant client tells the nurse she is worried about the fatigue that is causing difficulty with functioning at work. How can the nurse best instruct this client about the relief of fatigue?

Instruct the client to take at least two rest breaks during the workday.

Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes?

It is noninvasive using real-time ultrasound.

"During an annual checkup a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth.

A client at 36 weeks gestation has been admitted to the hospital for gestational hypertension. The client's blood pressure is 188/98 mm Hg and the client has no proteinuria. What is the priority nursing action at this time?

Notify the physician immediately.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min is grunting when exhaling and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated?

Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures.

At the 28th week visit the prenatal client's hemoglobin is 13 g/dL( 130 g/L). What is the best intervention?

Reinforce that the client should continue taking her prenatal vitamins for her entire pregnancy.

The nurse is performing Leopold's maneuver on a woman who is at 37 weeks gestation and finds the fetus in the following position. Which action by the nurse is anticipated?

Support the client while the healthcare provider performs external cephalic version.

A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?

The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment.

A client is being admitted to the labor and childbirth unit. Her GTPAL classification is 5-2-1-1-2. When providing shift report which information would the nurse include? Select all that apply.

The client has had four previous pregnancies The client has had two full-term children, one premature child, and one abortion The client has two living children and is pregnant again.

A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation?

The volume of amniotic fluid needed for testing will be available by 15 weeks.

Which is an initial sign of Parkinson's disease?

Tremor

During the admission assessment of a female neonate a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that

a cephalohematoma doesn't cross the suture lines.

In the fourth stage of labor

a full bladder increases the risk of what postpartum complication? , hemorrhage

When assessing the client with Parkinson's disease the nurse should observe the client for:

a stiff, masklike facial expression.

A nurse is assessing a client who is 6 weeks pregnant. Which findings best support a suspicion of ectopic pregnancy?

amenorrhea and adnexal fullness and tenderness

The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess?

amenorrhea and quickening

After developing severe hydramnios a primigravid client exhibits dyspnea along with edema of the legs and vulva Which procedure should the nurse expect the client to undergo and why?

amniocentesis to temporarily relieve discomfort

A client has had a cerebrovascular accident which has affected the left side of the client's brain. The nurse should assess the client for which symptom?

aphasia

A client is Rh(D)-negative and D-negative and hasn't formed Rh antibodies. When should the client receive RHO(D) immune globulin (RhoGAM) to prevent isoimmunization?

at about 28 weeks' gestation and again within 72 hours after birth

The nurse is caring for an expectant mother who asks how decisions are made if complications place both the mother and fetus at risk. What ethical principle will the nurse cite when responding to the client's question?

autonomy

An appropriate for gestational age neonate should weigh

between the 10th and the 90th percentiles for age.

At a preconception visit a 24-year-old client is found to have malformation of the uterus. The nurse uses the accompanying figure to explain which type of uterine malformation?

bicornuate uterus

A client is undergoing fertility testing and it has been determined that she is oligo-ovulatory. Which drug would be used to stimulate ovulation in this type of menstrual cycle?

clomiphene

A neonate born several hours ago shows signs of a tracheoesophageal fistula (TEF). During the initial assessment what does the nurse expect to find?

continuous drooling

The end of the third stage of labor is marked by what event?

delivery of the placenta

After determining that a pregnant client is Rh-negative a physician orders an indirect Coombs' test. The purpose of performing this test with a pregnant client is to:

detect maternal antibodies against fetal Rh-positive factor.

A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row the nurse should instruct the client to

discard the pack, use an alternative contraceptive method until her period begins , and start a new pack on the regular schedule:

During the sixth month of pregnancy a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms?

eustachian tube vascularization

During each prenatal checkup a nurse obtains a client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup?

evaluating the client for edema

When developing a series of parent classes on fetal development the nurse should include which feature as being developed by the end of the third month (9 to 12 weeks)?

external genitalia

A nurse recognizes that labor is divided into how many stages?

four

A 37-year-old client of Native American/First Nations/Aboriginal descent visits the clinic for the first time. She is about 12 weeks pregnant and this is her first pregnancy. Which test does the nurse anticipate will be prescribed?

glycosylated hemoglobin

A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use?

helps lungs remain expanded after the initiation of breathing improving oxygenation

A client with human immunodeficiency virus (HIV) infection gives birth to a neonate. When assessing the neonate the nurse is most likely to detect

hepatosplenomegaly.

While assessing a male neonate whose mother desires him to be circumcised the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder?

hypospadias

The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following topics would be important for the nurse to include in the teaching plan?

increased risk for urinary tract infections

A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used.

increment acme decrement relaxation

A pregnant client's hepatitis B report reads "HBsAg = positive." Which correctly describes the client's hepatitis B status?

infected

After giving birth to an 8-lb (3.6-kg) girl a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate the first feeding usually consists of

iron-fortified infant formula.

A nurse is preparing to auscultate fetal heart tones in a pregnant client Abdominal palpation reveals a hard round mass under the left side of the rib cage a softer round mass just above the symphysis pubis small irregular shapes in the right side of the abdomen and a long firm mass on the left side of the abdomen. Based on these findings where is the best place to auscultate fetal heart tones?

left upper abdominal quadrant

While caring for a pregnant adolescent client the nurse should develop a care plan that incorporates the adolescent's:

level of emotional maturity.

A multigravid client at 32 weeks' gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which source?

maternal blood

A nurse is assessing a client who's 29 weeks pregnant. What is the most cost-effective method for assessing fetal well-being?

maternal fetal activity count

During labor a primigravid client receives an epidural anesthetic and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?

maternal hypotension

Which client is most appropriate for the registered nurse to assign to the licensed practical nurse (LPN)?

multiparous woman with Klebsiella pneumoniae cystitis

As part of the respiratory assessment a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because

neonates are obligate nose breathers.

When magnesium sulfate is administered to a client in labor its action occurs at which site?

neural-muscular junctions

The nurse is assisting a client who just received an epidural during the first stage of labor. Which medication does the nurse know may be needed at this time?

oxytocin

A client who is 14 weeks pregnant states "Ever since I've been pregnant, I've had a hard time moving my bowels." Increased levels of what hormone are responsible for this common discomfort of pregnancy?

progesterone

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing

raccoon's eyes and Battle's sign.

A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy?

recommending the use of analgesia for circumcision

Which statement describes the term fetal position?

relationship of the fetus's presenting part to the mother's pelvis

When caring for a client with preeclampsia during labor the nurse should:

restrict the amount of fluid administered.

The nurse is performing a routine assessment of a 37-week pregnant client. What should the nurse implement during this prenatal visit?

screening for group B strep and STIs

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds

While caring for a client who has just given vaginal birth to a neonate the nurse is monitoring for signs of placental separation. What signs indicate that the placenta has separated? Select all that apply

sudden gush of vaginal blood change in shape of the uterus , lengthening of the umbilical cord

A client with gestational hypertension is likely to exhibit

sudden weight gain headaches and double vision.

The nurse instructs a primigravid client to increase her intake of foods high in magnesium. This nutrient plays a role in which process?

synthesis of proteins, nucleic acids, and fats

Which finding is the most serious adverse effect associated with oxytocin administration during labor?

tetanic contractions

During the fourth stage of labor

the client should be assessed carefully for , uterine atony.

When assessing the fetal heart rate tracing a nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if

the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.

A client is concerned that her 2-day-old breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

the neonate latches onto the areola and swallows audibly.

The nurse observes that when a client with Parkinson's disease unbuttons the shirt

the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? , The tremors sometimes disappear with purposeful and voluntary movements.

The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown. Which maneuver is the nurse performing?

third maneuver

A multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm completely effaced (100%), and at 0 station. Based on these findings, the nurse should recognize that the client is in which phase of labor?

transitional phase

When caring for a client in the first stage of labor the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?

transitional phase

A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation?

unequal gluteal folds

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?

unequal pupil size

A nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the client to:

use birth control for at least 1 year.