ATI A+B PRACTICE NEWBORN

A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr?

50 ml/hr

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? 1) a client who is at 11 weeks of gestation and reports abdominal cramping 2) a client who is at 15 weeks of gestation and reports tingling and numbness in right hand 3) a client who is at 20 weeks of gestation and reports constipation for the past 4 days 4) a client who is at 8 weeks of gestation and reports having 3 bloody noses in the past week

A client who is at 11 weeks of gestation and reports abdominal cramping

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed bethamethasone 12 mg IM. Which of the following outcomes should the nurse expect? 1) decreased uterine contractions 2) an increase in the client's hemoglobin levels 3) a reduction in respiratory distress in the newborn 4) increased production of antibodies in the newborn

A reduction in respiratory distress in the newborn

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? A. Bilirubin 9 mg/dL B. Hemoglobin 18 g/dL C. Platelets 175,0000/mm3 D. Hematocrit 45%

A. Bilirubin 9 mg/dL

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? A. Cover the newborn's eyes while under the phototherapy light. B. Keep the newborn in a shirt while under the phototherapy light. C. Apply a light moisturizing lotion to the newborn's skin. D. Turn and reposition the newborn every 4 hr while undergoing phototherapy

A. Cover the newborn's eyes while under the phototherapy light.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? A. Oligohydramnios B. Hyperemesis gravidarum C. Leukorrhea D. Periodic tingling of the fingers

A. Oligohydramnios

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? 1) abruptio placenta 2) placenta previa 3) preeclampsia 4) maternal bradycardia

Abruptio placenta

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for bedamethasone. Which of the following statements should the nurse make about the indication for medication administration? A. "This medication will stop your labor." B. "This medication stimulates fetal lung maturity." C. "This medication will decrease your risk for uterine infections." D. "This medication will increase your baby's weight."

B. "This medication stimulates fetal lung maturity."

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? A. ????? B. "This procedure should have no effect on your sexual performance or adequacy." C. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." D. "If this concerns you, perhaps you should reconsider and use another form of contraception."

B. "This procedure should have no effect on your sexual performance or adequacy."

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non-pharmacological interventions should the nurse include in the plan of care for lactation suppression? A. Place warm, moist packs on the breasts. B. Apply cabbage leaves to the breasts. C. Wear a loose-fitting bra. D. Put green tea bags on the breasts.

B. Apply cabbage leaves to the breasts.

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? 1) 2+ DTR 2) proteinuria of 200 mg in a 24-hr specimen 3) polyuria 4) blurred vision

Blurred Vision

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider? A. Hgb 20 g/dL B. Total bilirubin 5 mg/dL C. Blood glucose 30 mg/dL D. WBC count 20,000/mm3

C. Blood glucose 30 mg/dL

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? 1) calcium gluconate 2) hydralazine 3) medroxyprogesterone acetate 4) methylergonovine

Calcium Gluconate

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? A. "The nurse will carry your newborn to the nursery for procedures." B. "We will document the relationship of visitors in your medical record." C. "Your baby will stay in the nursery while you are asleep." D. "Staff members who take care of your baby will be wearing a photo identification badge."

D. "Staff members who take care of your baby will be wearing a photo identification badge."

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? A. Discuss contraceptive options with the client and her partner. B. Repeat information to ensure client understanding. C. Listen to the client and her partner as they reflect upon the birth experience. D. Demonstrate to the client how to perform a newborn bath.

D. Demonstrate to the client how to perform a newborn bath.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following action should the nurse take? A. Perform a vaginal exam to determine cervical dilation every 2 hr. B. Instruct the client to ambulate in the hallway once every 4 hr. C. Administer betamethasone to the client via IM injection. D. Initiate continuous external fetal monitoring.

D. Initiate continuous external fetal monitoring.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? A. Maintain the client NPO throughout the procedure. B. Place the client in a supine position. C. Instruct the client to massage the abdomen to stimulate fetal movement. D. Instruct the client to press the provided button each time fetal movement is detected.

D. Instruct the client to press the provided button each time fetal movement is detected.

A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? A. Large for gestational age B. Hyperglycemia C. Bradypnea D. Vomiting

D. Vomiting

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? 1) depression 2) polyuria 3) hypotension 4) urticaria

Depression

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? 1) give the client orange juice 2) elevate the client's legs 3) have the client change positions 4) establish IV access

Have the client change positions

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the infusion of the oxytocin infusion and should be reported to the provider? 1) late decelerations 2) moderate variability of the FHR 3) cessation of uterine dilation 4) prolonged active phase of labor

Late Decelerations

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? 1) administer ASA for pain 2) maintain the client on bed rest 3) massage affected leg every 12 hours 4) apply cold compressed to the affected calf

Maintain the client of bed rest

A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? 1) check the client's temp 2) observe for contractions 3) administer Rho-Gam 4) monitor the FHR

Monitor the FHR

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? 1) determine dilation and effacement 2) perform Leopold maneuvers 3) complete a sterile speculum exam 4) prepare a Nitrazine paper test

Perform Leopold Maneuvers

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbillirubinemia. Which of the following actions should the nurse include in the plan? 1) feed the newborn 1 oz of water every 4 hours 2) apply lotion to the newborn's skin three times a day 3) remove all clothing from the newborn except the diaper 4) discontinue therapy if the newborn develops a rash

Remove all clothing form the newborn except the diaper

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? 1) visual disturbances 2) tingling of the fingers 3) urinary frequency 4) leg cramps

Report of visual disturbances

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? 1) reports increased urinary output 2) sweating 3) blurred vision 4) shallow respirations

Reports increased urinary output

A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? 1) fundal height 34cm 2) report of decreased fetal movement 3) report of occasional ankle swelling 4) BP 110/80

Reports of decreased fetal movement

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? 1) nausea 2) urinary output 40 mL/hr 3) respiratory rate 10/min 4) flushing

Respiratory rate 10/min

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? 1) Verify that the parent's identification band matches the newborn's identification band 2) Scan the newborn's ID band to verify their identity 3) check the newborn's security tag number to ensure it matches the newborn's medical record 4) match the newborn's date and time of birth to the information in the parent's medical record

Verify that the parent's identification band matches the newborn's identification band

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? 1) erythema toxicum on the face 2) not passed a meconium stool 3) pink-tinged urine 4) axillary temp of 99.9

A newborn who is 18 hr old and has an axillary temperature of 99.9° F

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? A. Jitteriness B. Hypertonia C. Abdominal distention D. Mottling

A. Jitteriness

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider? A. Shortness of breath B. Breakthrough bleeding C. Vomiting D. Breast tenderness

A. Shortness of breath

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? A. Just above the umbilicus B. Just above the symphysis pubis C. The right lower quadrant D. The left lower quadrant

B. Just above the symphysis pubis

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

BUN 25 mg/dL

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? A. "You will need to drink the glucose solution 2 hours prior to the test." B. "Limit your carbohydrate intake for 3 days prior to the test." C. "A blood glucose of 130 to 140 is considered a positive screening result." D. "You will need to fast for 12 hours prior to the test."

C. "A blood glucose of 130 to 140 is considered a positive screening result."

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients? A. Calcium B. Vitamin E C. Iron D. Vitamin D

C. Iron

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant

C. Left lower quadrant

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? 1) I won't gain more than 15-20 pounds during my pregnancy 2) I will likely need to use alternative sex positions 3) I'm glad I had a breast reduction years ago, so they will not enlarge 4) I'm glad I have a light complexion, so I don't get stretch marks

"I will likely need to use alternative positions for sexual intercourse".

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicated an understanding of the teaching? A. "I will eat foods that taste good instead of balancing my meals." B. "I will avoid having a snack before I go to bed each night." C. "I will have a cup of hot tea with each meal." D. "I will eliminate products that contain dairy from my diet."

A. "I will eat foods that taste good instead of balancing my meals."

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? A. Decreased platelet count B. Increased erythrocyte sedimentation rate (ESR) C. Decreased megakaryocytes D. Increased WBC

A. Decreased platelet count

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? A. Massage the client's fundus. B. Insert an indwelling urinary catheter. C. Administer oxygen at 10 L/min. D. Elevate the client's right hip.

A. Massage the client's fundus.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? A. "You should replace the diaphragm every 5 years." B. "You should leave the diaphragm in place for at least 6 hours after intercourse." C. "You should use an oil-based product as a lubricant when inserting the diaphragm." D. "You should insert the diaphragm when your bladder is full."

B. "You should leave the diaphragm in place for at least 6 hours after intercourse."

A nurse is planning care for a client who is in labor and is having an amniotomy. Which of the following assessments should the nurse identify as the priority? A. O2 saturation B. Temperature C. Blood pressure D. Urinary output

B. Temperature

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor? A. Active B. Transition C. Latent D. Descent

B. Transition

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? A. "I will get injections of the medication once daily until my labor stops." B. "My blood sugar may be low while I'm on this medication." C. "I will have blood tests because my potassium might decrease." D. "My blood pressure may increase while I'm on this medication."

C. "I will have blood tests because my potassium might decrease."

A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? A. "You will receive IV fluids prior to this test." B. "The procedure will take approximately 10 to 15 minutes." C. "You will be offered orange juice to drink during the test." D. "You will need to sign an informed consent form each time you have this test."

C. "You will be offered orange juice to drink during the test."

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? A. Acrocyanosis of the extremities B. Murmur at the left sternal border C. Substernal chest retractions while sleeping D. Positive Babinski reflex

C. Substernal chest retractions while sleeping

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make? A. "Let me help you into a comfortable pushing position so you can begin bearing down." B. "I am going to call the doctor to get a prescription for medication to ripen your cervix." C. "I will give you some IV pain medicine to strengthen your contractions." D. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."

D. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."

A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? 1) lays the newborn across her lap and gently sways 2) places the newborn in the crib in a prone position 3) offers the newborn a pacifier dipper in the formula 4) prepares a bottle of formula mixed with rice cereal

Lays the newborn across her lap and gently sways

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old in accepting the new family memeber?

Obtain an gift from the newborn to present to the sibling

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?

Report the client's condition to the local health department

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? 1) I should increase my protein to 60 grams each day 2) I should drink 2 liters of water each day 3) I should increase my calories by 300 4) I should take 600 mcg folic acid every day

"I should take 600 micrograms of folic acid every day"

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? A. "You can miss your period for several other reasons. Describe your typical menstrual cycle." B. "If you have been sexually active and haven't used protection, it is likely that you are pregnant." C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" D. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."

A. "You can miss your period for several other reasons. Describe your typical menstrual cycle."

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? A. "You can share your room with your baby for the next few weeks." B. "Cover your baby with a light blanket while sleeping." C. "Check the temperature of your baby's bath water with your hand." D. "Your baby can nap in the car seat during the daytime."

A. "You can share your room with your baby for the next few weeks."

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? A. "You should take the medication within 72 hours following unprotected sexual intercourse." B. "You should avoid taking this medication if you are on an oral contraceptive." C. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." D. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

A. "You should take the medication within 72 hours following unprotected sexual intercourse."

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? Exhibit 1: Diagnostic Results​ Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-negative Exhibit 2: Medication Administration Record​ Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM onceNalbuphine 10 mg IV every 3 hr PRN pain Exhibit 3: Progress Report 1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 - Fetal heart rate 130/min with moderate variability Uterine contractions q 5 to 8 min lasting 30 to 60 sec durationUterine contractions palpated at 1+ intensityClient reports uterine contraction pain of 2 on a scale of 0 to 10 A. Administer terbutaline B. Discuss possible genetic anomalies with the client. C. Administer nalbuphine. D. Discontinue external fetal monitoring.

A. Administer terbutaline

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? A. Apply sacral counterpressure. B. Perform transcutaneous electrical nerve stimulation (TENS). C. Initiate slow-paced breathing. D. Assist with biofeedback.

A. Apply sacral counterpressure.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? A. Determine respiratory function. B. Increase the IV fluid rate. C. Access emergency medications from cart. D. Collect a maternal blood sample for coagulopathy studies.

A. Determine respiratory function

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interperate the client's statement as an indication of which of the following? A. Emotional lability B. Focusing phase C. Cognitive restructuring D. Couvade syndrome

A. Emotional lability

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (SATA) A. Flaccid uterus B. Cervical laceration C. Excess vaginal bleeding D. Increased afterbirth cramping E. Increased maternal temperature

A. Flaccid uterus. C. Excess vaginal bleeding

A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? A. Hemoglobin 10 g/dL B. WBC count 15,000/mm3 C. RBC count 5.8 million/mm3 D. Hematocrit 34%

A. Hemoglobin 10 g/dL

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL B. A client who is at 34 weeks of gestation and reports epigastric pain C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria

B. A client who is at 34 weeks of gestation and reports epigastric pain

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? A. Place a rolled towel beneath one of the client's hips. B. Apply internal upward pressure to the presenting part using two gloved fingers C. Administer oxygen to the client via a nonrebreather mask at 10 L/min D. Increase the IV infusion rate.

B. Apply internal upward pressure to the presenting part using two gloved fingers

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? A. Decreased heart rate B. Chin quivering C. Pinpoint pupils D. Slowed respirations

B. Chin quivering

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? A. Tell the client to follow up with a dermatologist. B. Explain to the client this is an expected occurrence. C. Instruct the client to increase her intake of vitamin D. D. Inform the client she might have an allergy to her skin care products.

B. Explain to the client this is an expected occurrence.

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? A. Restrict hourly fluid intake to 150 mL/hr. B. Have calcium gluconate readily available. C. Assess deep tendon reflexes every 6 hr. D. Monitor intake and output every 4 hr.

B. Have calcium gluconate readily available.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? A. Increased fetal movement B. Leakage of fluid from the vagina C. Upper abdominal discomfort D. Urinary frequency

B. Leakage of fluid from the vagina

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? A. Confirm the newborn's Apgar score. B. Verify the newborn's identification. C. Administer vitamin K to the newborn. D. Determine obstetrical risk factors.

B. Verify the newborn's identification.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." C. "I will continue taking my insulin if I experience nausea and vomiting." D. "I will ensure that my bedtime snack is high in refined sugar."

C. "I will continue taking my insulin if I experience nausea and vomiting."

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? A. Reassess the client in 2 hr. B. Administer simethicone. C. Assist the client to empty her bladder. D. Instruct the client to lie on her right side.

C. Assist the client to empty her bladder.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? A. Percutaneous umbilical blood sampling B. Amnioinfusion C. Biophysical profile (BPP) D. Chorionic villus sampling (CVS)

C. Biophysical profile (BPP)

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? A. Shortness of breath when climbing stairs B. Swelling of feet and ankles at the end of the day C. Headache that is unrelieved by analgesia D. Braxton Hicks contraction

C. Headache that is unrelieved by analgesia

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? A. Place the client in a supine position for 30 min following the first dose of anesthetic solution. B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. C. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.

C. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse priority? 1) check capillary refill 2) massage the client's fundus 3) insert an indwelling urinary catheter 4) prepare the client for a blood transfusion

Massage the client's fundus

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? 1) minimal arm recoil 2) popliteal angle of 90 degrees 3) creases over the entire foot sole 4) raised areolas with 3-4mm buds

Minimal arm recoil

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a C-section. The nurse notes a respiratory rate of 8/min. Which of the following medications should be administered?

Naloxone

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? 1) apply a cool pack for 10 minutes to the heel prior to the puncture 2) request IM analgesic 3) use a manual lance blade to pierce the skin 4) place the newborn skin to skin on the mothers chest

Place the newborn skin to skin on the mothers chest

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) the nurse should determine the location of the fetal back. palpate the client's fundus to identify the fetal part. the nurse should palpate the cephalic prominence to identify the attitude of the head. the nurse should palpate for the fetal part presenting at the inlet.

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? 1) DTR +4 2) fundal height 14 cm 3) urine protein 2+ 4) FHR 152/min

FHR 152/min

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1g orally now." Available is 250 mg tablets. How many tablets should the nurse administer?

4

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic test? 1) biophysical profile 2) amniocentesis 3) cordocentesis 4) Kleihauer-Betke test

Biophysicial profile

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? 1) acrocyanosis 2) transient strabismus 3) jaundice 4) caput succedaneum

Jaundice

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicated an understanding of the teaching? A. "I will receive this medication if my baby is Rh-negative." B."I will receive this medication when I am in labor." C. "I will need a second dose of this medication when my baby is 6 weeks old. "D. "I will need this medication if I have an amniocentesis."

"D. "I will need this medication if I have an amniocentesis."

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?

"You can still become pregnant if you are breastfeeding"

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? A. Swelling of the face B. Varicose veins in the calves C. Nonpitting 1+ ankle edema D. Hyperpigmentation of the cheeks

A. Swelling of the face

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? Select all that apply. 1) yellow schlera 2) acrocyanosis 3) posterior fontanel larger than the anterior 4) positive Babinski reflex 5) two umbilical arteries visible

Acrocyanosis Positive Babinski reflex Two umbilical arteries visible is correct

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client head to the side, which of the following actions should the nurse take immediately after the seizure? 1) monitor the FHR 2) assess uterine activity 3) administer O2 via nonbreather mask 4) start an IV bolus

Administer oxygen via a nonrebreather mask

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include? A. Place the shoulder harness in the slots above the newborn's shoulders. B. Place the retainer clip at the level of the newborn's armpits. C. Place the newborn at a 60° angle in the car seat. D. Place the newborn in a blanket before securing them in the car seat.

B. Place the retainer clip at the level of the newborn's armpits.

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke". Which of the following interventions is the nurse's priority? 1) perform Nitrazine testing 2) assess the fluid 3) check cervial dilation 4) begin FHR monitoring

Begin FHR monitoring

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives? Select all that apply Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder

Cholecystitis, Hypertension, Migraine headaches

A nurse is providing teaching about nonpharmological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? 1) cold cabbage leaves 2) purified lanolin cream 3) a snug-fitting support bra 4) breast shells

Cold cabbage leaves

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? A. Hct 39% B. Serum albumin 4.5 g/dL C. WBC 9,000/mm3 D. Platelets 50,000/mm3

D. Platelets 50,000/mm3

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? A. Insert the syringe tip before compressing the bulb. B. Suction each of the nares before suctioning the mouth. C. Insert the tip of the syringe into the center of the newborn's mouth. D. Stop suctioning when the newborn's cry sounds clear.

D. Stop suctioning when the newborn's cry sounds clear.

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider?

Fundal Height Measurement

A nurse is performing a vaginal exam on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? 1) Insert two gloved fingers into the vagina and apply upward pressure to the presenting part 2) wrap the cord tightly with sterile gauze 3) apply O2 at 2L via nasal cannula 4) place the client in the lithotomy position and apply fundal pressure

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? 1) monitor the client's BP every hour 2) restrict the total hourly intake to 200 mL 3) monitor the FHR continiously 4) administer protamine sulfate for toxicity

Monitor the FHR continously

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? 1) bruising over the buttocks 2) har nodules on roof of the mouth 3) petechiae over the head 4) bilateral periauricular papillomas

Petechiae over the head

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopoid maneuvers. Which of the following images indicates the first step of Leopoid maneuvers?

Picture of nurse palpating top of belly; where bottom is

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following should the nurse identify as a risk factor for the development of preeclampsia? 1) singleton pregnancy 2) BMI of 20 3) Maternal age 32 years 4) pregestational DM

Pregestational Diabetes Mellitus

A nurse is creating a plan of care who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? 1) protect the client's head and feet from cold air 2) bathe the client within 12 hour following birth 3) ambulate the client within 24 hours following birth 4) offer the client cold milk with her first meal

Protects the client's head and feet from cold air

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? 1) hypertonia 2) increased feeding 3) hyperthermia 4) respiratory distress

Respiratory distress

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? 1) administer antiviral medication 2) schedule an ultrasound 3) administer flu type b vaccine 4) schedule an indirect Coomb's test

Schedule an ultrasound examination

A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

September 3rd

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? 1) substernal retractions 2) acrocyanosis 3) overlapping suture lines 4) head circumference of 13 in

Substernal Retractions

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? 1) to estimate fetal weight 2) to locate a pocket of fluid 3) to determine multiparity 4) to prescreen for fetal anomalies

To locate the pocket of fluid

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?

Wipe eyes Wash Neck Cleanse skin around umbilical cord stump Wash legs and feet Clean diaper area

A nurse is providing teaching for a client who have birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? 1) my sister will be able to carry my baby from the nurse to my room when she arrives 2) the nurse will match my wrist band to my baby's crib card when they bring him to me 3) the person who comes to take my baby's pictures will be wearing a photo identification badge 4) my baby doesn't need to wear the electronic secuirty bracelet when he's in my room

the person who comes to take my baby's pictures will be wearing a photo identification badge

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? 1) obtain informed consent before getting the specimen 2) collect at least 1 mL of urine for the test 3) ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen 4) premature newborns may have a false-negative test due to immature development of liver enzymes

"Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen"

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? 1) "I can administer oxytocin 4 hours after the insertion of the medication" 2) "you will need a full bladder prior to the insertion of the medication" 3) "remain in a side-lying position for 15 minutes after medication is given" 4) "an antacid will be given 20 minutes prior to the insertion of the medication"

"I can administer oxytocin 4 hours after the insertion of the medication"

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include? 1) the test should take 10-15 minutes 2) you will lay supine during the test 3) you should be NPO for 2 hours before the test 4) "You should press the handheld button when you feel your baby move."

"You should press the handheld button when you feel your baby move."

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? A. Persistent abdominal striae B. Temperature 37.8° C (100° F) C. Unilateral breast pain D. Brownish-red discharge on day 5

C. Unilateral breast pain

A nurse is performing a physical assessment of a newborn. Which of the following clinical finding should the nurse expect? Select all that apply. 1) heart rate 154/min 2) axillary temperature of 96.8 3) respiratory rate 58/min 4) length 43cm 5) weight 5lb & 12 oz

Heart Rate 154/ min Respiratory rate 58/ min Weight 2,600 g (5lb 12 oz)

A nurse is reviewing the prenatal laboratory value for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? 1) hemoglobin 10 g/dL 2) WBC count 10,000 3) Platelets 250,000 4) fasting blood glucose 90

Hemoglobin 10 g/dL

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? 1) HTN 2) hypothermia 3) constipation 4) muscle weakness

Hypertension

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? 1) Kleihauer-Betke test 2) progesterone serum level 3) L/S ratio 4) material alpha-fetoprotein

Kleihauer-Betke test

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? 1) excessive bleeding 2) oligohydramnios 3) premature ROM 4) proteinuria

Premature rupture of membranes

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? 1) lochia serosa 2) vaginal pressure 3) intermittent vaginal pain 4) yellow exudate vaginal drainage

Vaginal pressure

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? 1) blood pressure 136/88 2) insomnia 3) weight gain of 4.8 lbs 4) report of Braxton Hicks contractions

Weight gain of 2.2 kg (4.8 lb)