312 Exam 2 Practice Questions

The nurse is teaching a G2P1 client about her upcoming labor. Which response would indicate to the nurse that further teaching is necessary?

"I can wait until my contractions are every 2 minutes to contact the physician because my first labor was so long." Although a woman having her second baby (gravida 2) may have a shorter labor than her first labor, she should still contact the healthcare provider when the contractions are every 5 minutes for at least 1 hour. Waiting until the contractions are every 2 minutes is too late

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth. When she asks whether her baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

"Your child may have acquired HIV in utero, but we won't know for sure until the child is older."

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next?

Administer a prescribed mild analgesic.

During a neonate's assessment shortly after birth, the nurse observes a large pad of fat at the back of the neck, widely set eyes, simian hand creases, and epicanthal folds. Which action is most appropriate?

Notify the health care provider (HCP) immediately. A large pad of fat at the back of the neck, widely set eyes, a simian crease in the hands, and epicanthal folds are typically associated with Down syndrome.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma. Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor.

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first?

a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally risk of postpartum hemmorrhage

While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider because these findings indicate which problem?

biliary atresia Jaundice that persists past the third or fourth day of life and pale, light stools are associated with biliary atresia.

The nurse is caring for a client who has had a postpartum hemorrhage. The healthcare provider has prescribed methylergonovine maleate. What would be a contraindication for a client who has been prescribed this medication? Select all that apply.

history of high blood pressure known drug sensitivity to methylergonovine maleate cardiac disease

What assessment data of a laboring woman would require further intervention by the nurse?

maternal heart rate 125 beats/minute Normal maternal heart rate is 60-100 beats/minute.

The nurse is caring for a primigravida in active labor when the client's membranes rupture spontaneously. The nurse should assess the client for which condition?

prolapsed cord

After teaching a pregnant client about potential complications of amniocentesis that must be reported immediately, the nurse determines that the client understands the instruction when she says that she will report which problem?

vaginal bleeding

In 6 months, a client is expecting a second child. During the psychosocial assessment, the client says to the nurse, "I've been through this before. Why are you asking me these questions?" What is the nurse's best response?

"Each pregnancy has a unique psychosocial meaning."

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?

Administer pain medication per prescription.

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that her baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia?

excessive fetal activity and fetal tachycardia Fetal tachycardia and excessive fetal activity are the first signs of fetal hypoxia

A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that she "has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which condition?

hypokalemia Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in hypokalemia

The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the health care provider (HCP) because these signs are indicative of which problem?

pyloric stenosis Marked visible peristaltic waves in the abdomen and projectile vomiting are signs of pyloric stenosis.

A client who's being admitted to labor and delivery has these assessment findings: gravida 2 para 1, estimated 40 weeks' gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which nursing intervention would be the priority at this time?

preparing for immediate delivery

At 32 weeks' gestation, a client is admitted to the facility with a diagnosis of gestational hypertension. Based on this diagnosis, the nurse expects the assessment to reveal:

3+ edema in the lower extremities. Classic signs of gestational hypertension include edema (especially of the face) and elevated blood pressure.

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. What should the nurse should tell the mother?

"Oxygen is drying to the mucous membranes unless it is humidified."

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission?

Assess the imminence of birth. This is the client's fifth baby, and she has been in labor for 3 hours. Given that multipara clients experience the stages of labor at a significantly faster rate than nullipara clients, it is critical that the nurse assess for the imminence of birth. After this has been established, the nurse will know how much time is available to review the obstetrical history, assess the client's coping skills, and ensure the presence of a support person for the labor and birth.

When developing a teaching plan for the mother of an infant about introducing solid foods into the diet, the nurse should expect to include which measure in the plan to help prevent obesity?

decreasing the amount of formula or breast milk intake as solid food intake increases

On arrival at the emergency department, a client tells the nurse that she suspects that she may be pregnant but has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood pressure is 70/50 mm Hg, and her pulse rate is 120 bpm. The nurse notifies the primary health care provider (HCP) immediately because of the possibility of which complication?

ectopic pregnancy.

The nurse is admitting a client with a suspected diagnosis of abruptio placentae. When assessing client symptoms, which symptoms require healthcare provider notification of this medical emergency? Select all that apply.

overt vaginal bleeding rigid abdomen Increased blood pressure rapid uterine contractions

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes a heart rate of 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and the body is pink. The neonate also has a vigorous cry. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?

Assign an Apgar score of 9, place the neonate in modified Trendelenburg's position, and suction the neonate's nose and oropharynx.