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A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse?

"Ambivalent feelings are quite common for women early in pregnancy."

A laboring clients obstetrician has suggested amniotomy as a method for inducing labor. Which 'assessments must be made just before the amniotomy is performed?

Fetal presentation, position, and station

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest

at the nipple line

Which of the following creates the highest risk for an infant to pass their stool inutero?

being postterm or stress

A nurse is checking the heart rate of an infant immediately following delivery in order to get a quick check on the status of the infant. What is the BEST location on the infant to assess the heart rate at this time?

belly button or apical pulse

A 27-year-old who had her second baby 3 hours ago was just moved to the postpartum unit. Upon admission to the Postpartum unit, the nurse does an initial 'BUBBLE" assessment. What does this include!

breast, uterus, bowel, bladder, lochia, episiotomy (epidural)

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?

breech

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

cluster the newborn's care activities

What is the major adverse side effect of epidural anesthesia?

decreased or absent respiratory movements

Which of the following is a sign of dehydration in the newborn?

depressed fontanelle

The nurse knows that Leopold maneuvers help aid in.

fetal heart rate, position, presentation, and engagement of the fetus in utero

A laboring patient's obstetrician has suggested artificial rupture of membranes (AROM) with an amniohook as a method for augmenting labor. Which assessment(5) must be made just before the amniotomy is performed?

fetal presentation, position, and station

A nurse is educating a patient on the basal body temperature method of family planning. The nurse should instruct the patient to take her temperature at what time?

first thing in the morning

A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate?

fundus three finger breadths above the umbilicus

A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care?

have the client ambulate

A labor and delivery unit nurse just administered a vaginal exam on his laboring patient. The patient is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

have the client pant during the next contractions

A client who is 36 weeks' gestation has preeclampsia and comes in for a contraction stress test. The nurse explains to the client that the contraction stress test is being done to determine.

how the baby will be able to handle labor

A nurse is providing education to couples who are about to undergo fertility treatments. The nurse understands the couples understand the implantation process when they respond that:

implantation occurs 7-10 days after conception

When a nurse explains a procedure, the rationale for the procedure, and any associated risks to her patient, the nurse is protecting the patient's ethical right to:

informed consent

A patient's labor is progressing rapidly and the nurse determines delivery will occur before the provider has time to arrive. Select the most appropriate nursing action.

Nurse delivers baby

A nurse is completing a newborn gestational age assessment Ballard Tool). Which of the following fin dings should be recorded as part of this assessment on the newborn?

Observing the presence of creases on the plantar surface is one of the components of a gestational age assessment.

Prior to the onse of labor, which stage of the maternal process is the mother considered to be in?

antepartum

Which of the following answers best describes the stage of pregnancy in which maternal and fetal blood are exchanged?

around 17 days after concepttion

The nurse should expect to observe which behavior in a 3-week multigravid postpartum client with postpartum depression?

feelings of failure as a mother

Immediately after delivery, the women is shaking uncontrollably. Which of the followng nursing actions is most appropriate?

Provide the woman with warm blankets.

The client is at 42 weeks' gestation. Which order should the nurse guestion?

Return to the clinic in 1 week.

Ordered: Lanoxin 0.25 mg daily for a patient with CHF On hand: Lanoxin 125 mcg tablet How man tablets do vou administer per dose?

2 tabs

The nurse is teaching a pregnant client about Folic Acid Deficiency Anemia. Which client statement indicates that teaching has been effective?

"I will add spinach to my salad every evening."

The nurse is providing education regarding the transmission of toxoplasmosis. Which client statement indicates teaching has been effective?

"I will have someone else clean the cat litter box while I am pregnant."

A nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant clit tent to describe the process of quickening. Which of the following statements if made by the student indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

"It occurs during the first trimester and near the end of the pregnancy."

Anurse in a community clinic is counseling a client who received a posilive test result for chlamydia. Which of the following statements should the nurse provide?

"This infection is treated with one dose of azithromycin."

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

"You should place your nipple and some of the areola into her mouth."

A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching?

"You will need to double your intake of iron during pregnancy."

The nurse has completed instructions on ways to improve the client's symptoms related to her rectocele. Which statement by the client indicates a need for further education?

"heavy lifting will not affect my rectocele"

A nurse provides teaching for a patient scheduled for genetic testing. What should the nurse do to help the patent understand what is being taught? Select all that applv.

1. Use simply vocabulary. 2. Avoid the use of jargon. 3. Speak slowly and clearly. 4. Ask the patient to verbalize what was learned.

The nurse is discharging a client after hospitalization for pelvic inflammatory disease (PID. Which statement indicates that teaching was effective?

1. Women sometimes become infertile because of scarring in the fallopian tubes as a result of the inflammation of PID. 2. Antibiotic therapy should always be completed when a client is diagnosed with any infection. 3. The tubal scarring that occurs from tubal inflammation during PID can prevent a fertilized ovum from passing through the tube into the uterus, causing an ectopic or tubal pregnancy. "I might have infertility because of this infection. ""It is important for me to finish my antibiotics. ""Tubal pregnancy could occur after PID."

A client in the women's clinic asks the nurse about available contraceptives. Before responding. the nurse makes which of the following assessments? Select all that apply.

2. A factor to consider when choosing a method of contraception is how frequently the client has intercourse. 3. A factor to consider when choosing a method of contraception is whether the client has a history of thrombophlebitis or any other condition that would contraindicate its use. 5. A factor to consider when choosing a method of contraception is whether the client is in a monogamous relationship.

The nurse is caring for a newborn 30 minutes after birth. After assessing respiratory function. the nurse would report which findings as abnormal? (SELECT ALL THAT APPLY

2. Periodic breathing with pauses longer than 20 seconds (apnea) is an abnormal finding that should be reported to the physician. 4. Grunting on expiration is an abnormal finding that should be reported to the physician. 5. Nasal flaring is an abnormal finding that should be reported to the physician.

What is the recommended weight gain for an underweight pregnant patient carrying one fetus?

28-40 pounds

A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities: grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Agar score

6

A nurse is preparing to administer liquid mycostatin 600,000 units PO TID. Available is mycostatin 100,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

6

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days

A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor?

A client whose partner has von Willebrand disease

A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make?

A nonreactive test

During a nonstress test, the nurse notes the fetal heart rate accelerates about 15 beats during a period of fetal movement. The accelerations occur twice during the test, and last 20 seconds each. How does the nurse interpret these results?

A nonreactive test

A nurse in a clinic is reviewing the medical records of a group of clients who are prenant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients?

All of the clients

The nurse explains to a laboring woman that the relaxation periods between contractions are important for which of the following reasons?

Allows fetal oxygenation

A young couple is contemplating starting a family. What is the best time for genetic counseling?

Before they get pregnant

Induction of labor is planned for a 31-year-old client at 39 weeks due to insulin-dependent diabetes. Which nursing action is most important?

Begin Pitocin (oxytocin) at least 4 hours after last misoprostol (Cytotec)

The biophysical profile provides assessment data regarding which fetal biophysical variables? SELECT ALL THAT APPLY. Note: Credit will only be given if all correct choices are selected and no incorrect choices are selected

Fetal tone Amniotic fluid volume Fetal breathing movements Fetal movement

A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

Fetal tone, amniotic fluid volume, fetal breathing movements, fetal movement

The nurse reviewing charts for quality improvement notes that a client experienced a complication during labor. The nurse is uncertain whether the labor nurse took the appropriate action during the situation. What Is the best way for the nurse to determine what the appropriate action should have been?

Look in the policy and procedure book, and examine the practice guidelines published by a professional nursing organization.

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

Loose bedding such as sheets and blankets could cover the baby's head and lead to suffocation

Which best describes the signs and symptoms of trichomoniasis in women?

Malodorous, frothy yellow-green vaginal discharge

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the funds of the uterus and a long smooth surface on the client's right side. In which abdominal quadrant should the nurse except to auscultate fetal heart tones?

Right upper

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting on infant to remain in the mothers room

The nurse is providing education for a woman has been diagnosed with gestational diabetes mellitus. Which client statement indicates patient teaching has been effective?

She is at increased risk for type 2 diabetes mellitus after her baby is born.

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority?

Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns in which labor did not occur. can experience lung fluid retention, which leads to respiratory distress. The prioritv assessment when using the airway. breathing. circulation (ABC approach to client care is to monitor the newborn for respiratory distress

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

Sponge baths are appropriate until the stump falls off

A newborn infant on the initial assessment has a temperature of 35.5 Celsius. What indicates to the nurse that the infant is being affected by cold stress?

Tachypnea.

At 1 minute after birth, the infant has a heart rate of 100 beats per minute, and is crying vigorously. The limbs are flexed, the trunk is pink, and the feet and hands are cyanotic. The infant cries easily when the soles of the feet are stimulated. How would the nurse document this infant's Apgar score?

The infant has cyanotic limbs, so the Apgar score cannot be perfect.

A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest?

When the client's nipple is sore due to breastfeeding, the client should break the suction with her finger, remove the newborn from the breast, and try a different position. The newborn's mouth should be open wide before connecting with the nipple.

A nurse is teaching a client with infertilitv about the medication Clomid (clomiphene citrate). The nurse should instruct the client to report which side effect of Clomid to her HCP?

You may experience headaches​ and/or hot flashes. Your dose may have to be adjusted after the first cycle. You will need an ultrasound after taking the medication. visual disturbances

The nurse is reviewing contraception options for four clients. The nurse should identify which client is not a candidate for a combination oral contraceptive (COC).

a 38-year-old client who reports smoking one pack of cigarettes every day

A nurse is admitting a client who has severe hypertension at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification.

ambulate twice daily

The NICU nurse is caring for an infant diagnosed with Respiratory Distress Syndrome (RDS). In planning care for the shift, the nurse should plan the need for which interventions? (SELECT ALL THAT APPLY)

reducing stimuli & avoiding cold stress which can lead to hypoglycemia

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

respiratory depression

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

"It promotes fetal lung maturity"

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

"It sounds like you are feeling sad that things didn't go as planned."

A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is "bleeding and saturating a pad about every 1/2 hour." Which of the following is an appropriate response by the nurse?

"The physician should see you. Please go to the emergency department."

A postpartum client calls the nursery to report that her 3-day-old newborn has passed a green stool. What is the nurse's best response?

"This is a normal occurrence."

The labor and delivery nurse is caring for a laboring client who has asked for a priest to visit her during labor. The client's mother died during childbirth, and although there were no complications during her pregnancy, the client is fearful of her own death during labor. What would be the best way for the nurse to respond?

"Would you like me to contact your parish or our hospital chaplain to come see you?"

A breastfeeding client, G10 TPAL 6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time?

Fundus.

A nurse is preparing to administer buspirone 7.5 mg PO ever 12 hr to a client. The amount available is buspirone 15 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5

A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 33 lb. Available is amoxicillin 200 mg/5 mL suspension. How many me should the nurse administer? Round the answer to the nearest tenth. Use a leading zero it it app les Do not use a trailing zero.

5.6

A nurse is caring for a client who is to receive liquid medications via a gastrostomy tube. The client is prescribed phenytoin 250 mg. The amount available is phenytoin oral solution 25 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50

A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect?

A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. A systolic murmur is a clinical manifestation found in newborns who have a large patent ductus arteriosus.

The nurse is caring for a preeclamptic client who is on a Magnesium Sulfate drip. Which assessment finding warrants immediate action by the nurse.

A respiratory rate of 10 breaths/min

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell's sion. The nurse determines this sign Indicates:

A softening of the cervix

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

A surge of energy

The nurse is seeing clients in the women's clinic. Which client does the nurse expect to see orders to give an I.M. injection of ceftriaxone (Rocephen) and an oral dose azithromycin (Zithromax)?

A) A pregnant client with gonorrhea and a yeast infection B) A nonpregnant client with gonorrhea and chlamydia C) A pregnant client with syphilis D) A nonpregnant client with chlamydia and trichomoniasis B: a nonpregnant client with gonorrhea and chlamydia

The student nurse attempts to take a newborn's vital signs, but the newborn is cring. What nursing action would be appropriate?

Crying increases heart rate and respiratory rate, so vitals should not be taken when the newborn is crying

A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

Fundus firm, at the level of the umbilicus

The nurse is providing genetic counseling for an expectant couple who just found out that their child has Down syndrome. Which is the best way for the nurse to handle this?

Abnormality of chromosomal number Be supportive by answering questions and clarifying information and options.

A fetus that is not in any stress will respond to a fetal scalp stimulation test by showing which change on the monitor strip?

Accelerations

Two hours after an epidural infusion has begun, a client complains of itching on her face and neck. What should the nurse do?

Administer Benadryl

A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Administering oxygen via face mask

A 2 day-old newborn is asleep and the nurse assesses the apical pulse to be 111 beats/min. What would be the most appropriate nursing action based on this assessment finding?

An apical pulse rate of 88 beats/min is within the normal range of a sleeping full-term newborn. The average resting heart rate in the first week of life is 110 to 160 beats/min in a healthy full-term newborn but may vary significantly during deep sleep or active awake states. In full-term newborns, the heart rate may drop to a low of 80 to 100 beats/min during deep sleep.

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable?

An intrauterine device

A woman's history and appearance suggest drug abuse. Identify the nurse's best approach

Ask the woman directly, "Do you use any street drugs?"

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has u cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

Assist the client to turn onto her side.

A client received epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. This client is at increased risk for which problem during the fourth stage of labor?

Bladder distention

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will come in." Which of the following responses should the nurse make?

By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milK

A nurse teaches a pregnant woman to avoid lying on her back. The nurse has based this statement on the knowledge that the supine position can:

Cause decreased placental perfusion

A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

Cephalhematoma

The nurse is making an initial assessment of the newborn. Which of the following data would be considered normal?

Chest circumference 31.5 cm, head circumference 33.5 cm

A nurse is teaching a community health class of women and explains that an SITI is associated with an increased risk of infertility in women. Which STI should the nurse identify?

Chlamydia

Which of these are appropriate interventions for an infant receiving phototherapy for jaundice? (SELECT ALL THAT APPLY)

Close the newborn's eyelids before applying eye patches.Inspect the eyes each shift for conjunctivitis, drainage, and corneal abrasions.Reposition the baby every 2 hours.

A client has been diagnosed with water intoxication after having received IV oxtocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see?

Confusion, drowsiness, and vomiting.

A nurse Is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

Consume foods fortified with folic acid.

A nurse is admitting a client who is at 38 weeks of gestation with her water broken and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

Continuous contraction lasting 2 min

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention.

The nurse receives report on a client who delivered 36 hours ago: Gravida 1 Para 1, rubella-immune, blood type A-negative, newborn blood type B-positive. Discharge orders are written for both mother and newborn. Identify the priority nursing action.

Determine if RhoGAM has been given.

The condition occurring in infants where the heart is on their right side, rather than their left. is known as?

Dextrocardia

Which of the following would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?

Diaphragms should not be used if the client develops acute cervicitis.

The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form?

Do genetic diseases run in the family of the​ baby's father?

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

Dry the skin

a 58 y/o female tells the nurse that she started to experiencing pain during intercourse. The nurse should document that the clients experiencing what?

Dyspareunia

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

Dyspnea

The belief that one's cultural practices and beliefs are superior to those of others is defined is your textbook as

Ethnocentrism

You are the nursery nurse preparing to take care of a baby that is being born via c-section. As you get ready to receive the baby and begin your assessment, you know the best way to prevent evaporative heat loss is what?

Evaporation is heat loss through air drying of the skin, so drying the baby will reduce this type of heat loss

A nurse in a prenatal clinic is caring for a client suspected of having a hydatiform mole. Which of the following findings should the nurse expect to observe in this client?

Excessive uterine enlargement

A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

Expressions of excitement

In planning care for a new family immediately after birth, which procedure would the nurse most likelv withhold for 1 hour to allow time for the family to bond with the newborn?

Eye prophylaxis medication

The nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations?

Facial edema

During a prenatal visit a patient tells you her last menstrual period was May 21, 2019. Based on the Naegele's Rule, when is the estimated due date of her baby?"

February 28, 2020

The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?

Firm fundus, but excessive lochia

A neonate weighing 5.5 lb is prescribed to receive intravenous cefotaxime (Claforan) 50 mq/k/dose every 6 hours for treatment of sepsis. How many mg of the medication should the nurse anticipate the patient will need for 24 hours?

First convert the patient's weight in lb to kq by dividing by 2.2, or 5.5/2.2 = 2.5 kg. Then calculate the amount of medication needed for each dose by multiplying 50 mg x 2.5 kg = 125 mg. Then multiply the amount of medication for each dose by 4 (one dose every 6 hours) or 125 mg x 4 = 500 mg. The patient will receive 500 mg of the medication in a 24-hour period

A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is firm, displaced to the right of midline, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

Have the client urinate

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Heart rate 110/min

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant

A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse © include in the teaching as increasing the risk for contracting TSS?

High-absorbency tampons

The nurse is admitting a client with possible hydramnios. When is hydramnios most likely suspected?

Hydramnios is most likely suspected when the fundal height increases disproportionately to the gestation.

Before advising a 24-vear-old client desiring oral contraceptives for family planning. the nurse should assess the client for signs and symptoms of which of the following

Hypertension

A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

Hypothermia in the newborn requires immediately intervention

The nurse is doing preconceptual counseling with a 28-year-old nulligravida. Which client statement indicates to the nurse that the client has understood the teaching?

I need to stop drinking alcohol completely when I start trying to get pregnant.

The nurse is educating a group of preteen age girls about their changing bodies. The nurse understands that the group understands the teaching ~ when a preteen girl in the group states:

I will get my period between ages 12-14

A nurse in a prenatal clinic is caring for a client who is at 12 weeks' gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

Increased progesterone production causes decreased motility of smooth muscle.

A client with a history of herpes simplex virus (HSV-2) infection asks the nurse about future sexual activity. Which response is the MOST appropriate?

Inform all potential sexual partners about the infection, even if it is inactive

A 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° C (97.6° F). Which of the following is the priority nursing action?

Initiate IV access. 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.

A nurse is carina for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client?

It is a screening test for spinal defects in the fetus.

A laboring patient is having moderately strong contractions lasting 60 seconds every 2 minutes. The fetal head is presenting at -2 station. The cervix is 7cm dilated and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority?

Keep the client on bed rest at this time.

The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate?

Monitor the incision for drainage.

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention or hypoglycemia becomes the nurses priority focus of care

The nurse includes the addition of ice sit baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?

No swelling or edema to the perineal area

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min. but there has been no fetal movement for 15 min Which of the following actions should the nurse perform?

Offer the client a snack of orange juice and crackers

A woman has been having contractions since 4 a.m. At 8 a.m., her cervix is dilated to 5 cm. Contractions are frequent and mild to moderate in intensity. Cephalopelvic disproportion (CPD) has been ruled out. After giving the mother some sedation so she can rest, what would the nurse anticipate the physician would order next?

Oxytocin induction of labor

A nurse is planning care for a newborn who has a new diagnosis of phenvlketonuria (PKU). Which of the following actions should be included in the plan of care?

PKU is managed by eliminating phenylalanine from the diet. It is found in most natural food proteins, such as milk and infant formulas. A special low-protein, amino-acid formula that is low in phenvlalanine is initiated and included in the plan of care

The nurse attempts to elicit the Moro reflex on a newborn, and assesses movement of the right arm only. Based on this finding, the nurse immediately assesses for which of the following?

Palmar grasping reflex is elicited by stimulating the newborn's palm with a finger or obiect: the newborn grasps and holds the object or finger firmly enough to be lifted momentarilv from the crib

A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?

Patient who underwent thyriodectomy and has a positive trousseau's sign

The nurse is assessing a newborn at 1 hour of age. Which finding requires an immediate intervention?

Pauses in respirations greater than 20 seconds are considered episodes of apnea, and require further intervention.

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

Place the newborn in the prone position

Upon delivery of the newborn, what nursing intervention most promotes parental attachment?

Placing the newborn on the maternal abdomen.

The nurse determines the gestational age of an infant to be 40 weeks. Which characteristics are most likelv to be observed?

Plantar creases over entire sole & Testes are pendulous, and the scrotum has deep rugae

The client calls the nurse and states she has not had a mentrual ccle in 3 months. What does the nurse know is the most common cause of dvsmenorrhea?

Pregnancy

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incuozion.

A female client with an intrauterine device calls the clinic because she is unable to locate the stings after her last menstrual period. What should the nurse counsel this client?

Schedule an appointment immediately

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant?

Take the client's vital signs.

The nurse suspects that a client has developed a perineal hematoma. On which assessment findings) does the nurse base this conclusion?

Tense tissues with severe pain

A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching?

The baby's heart beat is audible by a doppler's stethoscope at 12 weeks of pregnancy.

A nurse is working with four clients desiring in vitro fertilization (IVF). Which clients would be good candidates for IVF. Select all that apply.

The client with tubal blockage. the client whose husband has a very low sperm count

A nurse is administering patient education to a 23-year-old patient, who has never been pregnant, about the recommendation for frequency of pap smears. The patient understands the information given when she states:

The current recommendations for pap smears is every 3 years unless otherwise specified by HCP.

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first.is the priority action.

The mother of a 3-day-old infant calls the clinic and reports that her baby's skin is turning slightly yellow. What should the nurse explain to the mother?

The liver of an infant is not fully mature at this point.

At birth, a newborn weighs 8 pounds 4 ounces. When discussing the infant's weight over the next week, what is the maximum amount of weight the mother should expect that the infant will lose? (Calculate to the first decimal point

The maximum amount of weight loss over the first 5 to 10 davs of extrauterine life is 10%. If the infant weighs 8 pounds 4 ounces, this weight in ounces is 132 ounces. Multiolv this weight by 10% to mind that the mother can expect the infant to lose 13.2 ounces. When converted to pounds and ounces. the infant should not weight less than 7 pounds 5 ounces

A 17-year-old patient receives emergency contraception in a clinic. What it is the priority nursing education for this patient at this time?

The need for further contraception because the emergency contraception is only temporary

A nurse is caring for a newborn and observes signs of hypotonia, jitteriness, and lethargy. Which of the following actions should the nurse take?

The newborn is exhibiting early signs of hypoglycemia. The nurse should obtain blood by heel stick to check glucose. A therapeutic serum glucose level for a newborn is 40 to 60 mg/dL. Less than 40 mg/dL indicates hypoglycemia. Other findings of hypoglycemia include poor feeding, tremors, hypothermia, flaccid muscle tone, irregular respirations, apnea, cyanosis, and a weak. shrill cry. Early breastfeeding also should be encouraged to prevent hypoglycemia

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse?

The normal range for respirations of a newborn within 2 hours after birth is 60 to 70 breaths per minute.

The nurse assesses the newborn's ears to be parallel to the outer and inner canthus of the eye. The nurse documents this finding to be which of the following?

The top of the ear (pinna) is parallel to the outer and inner canthus of the eye in the normal newborn.

A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make?

There is no evidence of uteroplacental insufficiency.

At birth, an infant weighed 6 pounds 12 ounces. Three days later, he weighs 5 pounds 2 ounces. What conclusion should the nurse draw regarding this newborn's weight?

This weight loss is greater than the expected 5% to 10%

A client describes breast swelling and tenderness. What piece of data would be most important for the nurse to gather initially?

Timing of the symptoms

A multiparous patient is admitted to labor and delivery with contractions that are regular, 2 minutes apart, and last 60 seconds. She reports that her labor began about × 6 hours ago, and she had bloody show earlier that morning. A vaginal exam reveals a vertex presentation, with cervix 100% effaced and 9 cm dilated. The patient asks what part of labor she is in. The nurse informs the patient that she is in the

Transition

nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome. Which of the following are common characteristics? (Select all that apply.)

Transverse palmar creases, Protruding tongue, low set ears

A woman arrives to the labor unit at 19:00pm to be prepared for induction of labor, with hopes of delivering her full term infant the next day. The woman's partner, two sets of grandparents, and the woman's sister are all with her to bless the woman prior to labor. You hear them chanting. What is the nurse's response?

UNKNOWN - I know it is something about allowing them to do it as long as it doesn't cause harm but don't know exact wording

A postpartum patient is scheduled for a tubal ligation at 09.00 am. She tells the nurse, "I have no idea what a tubal thingy even is, I hope it goes okay.": Select the best response

UNKNOWN - something about obtaining informed consent, usually the physicians job

Which client coming to the women's clinic is a candidate for Emergency Contraception (EC)?

UNKNOWN of exact answer - something about the person who had unprotected intercourse within 72 hours

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

Unilateral, abdominal pain

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Uteroplacental insufficiency.

A nurse is observing the electronic fetal heart rate monitor tracina for a client who is at 40 weeks' of gestation and is in labor. The nurse should suspect a problem with the • umbilical cord when she observes which of the following patterns?

Variable decelerations

A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. The nurse explains to the parents that due to oxygen therapy, their infant is at a greater risk for which of the following?

Visual impairment.

The nurse is teaching new parents how to dress their newborn. Which statements indicate that teaching has been effective? (SELECT ALL THAT APPLY).

it is important that we dry the baby off as soon as we give him a bath or shampoo his hairwhen we change the baby's diaper, we should change any wet clothing or blankets, tooif the baby's body temperature gets too low, he will warm himself up without any shiveringour baby will have a much faster rate of breathing if he is not dressed warmly enough

The nurse is providing education regarding the use of the diaphragm as a form of contraception. Which of the following should the nurse include in the instruction? Select all that apply.

leave in for 6 hours after intercoursedo not leave in more than 24 hours due to TSS riskwash hands before placement to help reduce riskwomen with history of TSS should not use a diaphragm

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?

massage the client's fundus to promote contractions

The client reports using an alternative therapy that involves the manipulation of soft tissues. This therapy has reduced the client's stress, diminished pain, and increased circulation. Which therapy has this client most likely received?

massage therapy

A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?

my baby will be placed under special lights if the test result is positive

The nurse is caring for a female client with a historv of pelvic inflammatory disease (PID) who reports having difficulty conceiving after unprotected sex for over 2 years. Which ... deviation from the norm does the nurse recognize is most likely the cause of the client's infertility?

obstruction and non-patent fallopian tubes

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

painless red vaginal bleeding

A nurse is seeing a pregnant client in the prenatal clinic who is taking an iron supplement for the treatment of iron deficiency anemia. Which client statement indicates a need for further teaching?

patient takes iron supplement with milk

A postpartum nurse assesses a new patient who is 1-hour post vaginal delivery and had an epidural still causing numbness in the patient's extremities. Upon assessment, the patients fundus is displaced to the right. What is the nurse's first action?

perform a straight cath to empty their bladder

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?

place the client in a knee-chest or trendelenburg position

Acrocvanosis in infants results from:

poor peripheral circulation

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

positive moro reflex, cracked peeling skin

What is true concerning the expected time of human pregnancy to produce a fully developed fetus? (Select all that apply.)

pregnancy lasts 10 lunar monthsfull term gestation is 37 weekspregnancy lasts 40 weeks

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 in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?

preparation for a c-section

A nurse is teaching a group of nursing students how to identify true labor versus false labor. Which of the following are indications of true labor? (Select all that apply).

progressive dilation and effacement changes the fetus presenting part will engage in the pelvis

A woman's one-hour oral glucose challenge test (GCT) results are 155 mg/dL. Which action, as ordered by the physician, is appropriate?

send the woman for a glucose tolerance test

The client has a body mass index (BMI) of 17. How does the nurse interpret this finding?

the client is underweight

A 16-year-old female client who lives in a state without an emancipated minor law needs to have a procedure to decrease her postpartum bleedingt, followling the delivery of her infant. Who can legally give in-formed consent for the client to have this procedure?

the client's mother

A nurse is assessing a client who is in active labor and notes that the presenting part is at O station. Which of the following is the correct interpretation of this clinical findings?

the lowermost portion of the fetus is at the level of the ischial spines

A nurse is assessing the funds of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly?

the nurse stabilizes the base of the uterus with his or her dependent hand

A woman has been admitted for an external version. She has completed an ultrasound exam and is attached to the fetal monitor. Prior to the procedure, why will terbutaline X (Brethine) be administered?

to relax the uterus

A 36 year-old female client presents at the women's clinic requesting birth control. The client has a BMI of 31, is monogamous, and does not smoke. The nurse understands that which contraceptive method is inappropriate for this client?

transdermal hormonal contraception

According to AWOHNN regulations, which of these professionals carries the licensure to deliver a baby? (SELECT ALL THAT APPLY.

unknown

The nurse assesses a client with severe preeclampsia and notes: blood pressure 158/100 mmHg; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick: and 1+ pitting edema of the hands, ankles. and feet. on the next hourly assessment, which new finding indicates worsening preeclampsia?

urinary output 20 mL/hour

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

vastus lateralis

The nurse is working in a high-risk maternity unit. Which mother does the nurse counsel against breastfeeding? A mother:

who is HIV positive

The nurse is preparing a patient for amniocentesis. Which statement indicates that the patient clearly understands the risks of an amniocentesis?

​"I might go into labor​ early."

Which client in the Gynecology Clinic should the nurse see first?

​22-year-old with​ fever, hypotensive, using tampons