Cms practice B

A nurse is assisting in the care of a client who is in the second trimester of pregnancy. Which of the following statements by the client indicates effective adaptation to their new role as an expectant parents?

- "I like it when my baby moves around in my stomach"

A nurse is reinforcing, teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching?

- "your fluid intake will be limited to no more than 125 mL per hour". The nurse should restrict the clients fluid intake to prevent fluid overload.

A nurse is reinforcing teaching with a client who is trying to become pregnant. Which of the following foods to the nurse recommend as the best source of folate?

- 1 cup of spinach.

A nurse is assisting in the care of a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider.

- 2+ urinary proteins (proteinuria is a manifestation of preeclampsia. Therefore the nurse should report findings to the to the provider.)

A nurse is assisting in the care of a postpartum client which of the following findings should the nurse report to the provider? (Select all that apply.)

- BLOOD PRESSURE - EDEMA - REPORTED PAIN CONCERN - REPORT GI CONCERN

A nurse is assisting in the care of a client who has deep vein thrombosis. Which of the following actions should the nurse take?

- Elevate the clients affected limb management for a client who has DVT is bedrest with elevation of the effectively him to reduce swelling and discomfort. The client should wear elastic compression stockings once they can ambulate.

A nurse is monitoring a client after an amniocentesis. Which of the following findings should the nurse expect?

- FHR 120/min

A nurse in a postpartum unit is assisting in the care of a client who has endometriosis and is 40 hours postpartum following a cesarean birth. Which of the following findings should the nurse anticipate?

- HR 110/min an elevated heart rate is an expected finding for a client who has endometriosis other manifestations are chills, fever, nausea, anorexia, fatigue, pelvic pain, and lochia that has a foul odor

A nurse is reviewing the laboratory report of a term newborn who was born two hours ago. Which of the following laboratory results should the nurse expect?

- Hgb 22 g/dl

A nurse is assisting in the care of a client who is pregnant. The nurse should identify which of the following client statements as an indication of ambivalence?

- I always wanted a baby, but this is not a good time to be pregnant. Ambivalence is having conflicting feelings simultaneously.

Prescription for medroxyprogesterone, acetate injection for contraception. Which of the following statements by the client indicates understanding of the teaching?

- I am likely to gain weight this medication, (common adverse of this medication is weight gain.)

A nurse is reinforcing, home, care, safety, with the guardian of a newborn prior to discharge. Which of the following statements by the guardian indicates an understanding of the teaching?

- I should place my babies crib away from windows

A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching?

- I will ask the nurse to take my baby to the nursery if I need to leave my room.

A nurse is reinforcing teaching about car seat safety with the guarding of a newborn. Which of the following statements of the guardian indicates an understanding of the teaching?

- I will position all of the babies armpits the guardianship position the retainer clip at the level of the newborns axillae and not cover the neck or abdomen.

A nurse is assisting in the care of a postpartum client. Based on the nurses findings, which of the following conditions is the client at the greatest risk for developing? Drag one condition, and one client finding to fill in each blank in the following sentence.

- Preeclampsia - blood pressure

A nurse is collecting data from a client who is 32 hours postpartum which of the following findings should the nurse expect? Answer. Urine output of 3000 mL in 24 hours a nurse expect postpartum duration. Palpate as moderate intensity. Examination performed by RN. Cervix is dilated 2 centimeters and 50% effaced. Which of the following findings should the nurse report to the provider select three findings that should be reported:

- Uterine contractions - gestational age - Vaginal examination

A nurse is contributing to the plan of care for a client who has eclampsia. Which of the following intervention should the nurse plan to include as a priority immediately rollowing a seizure?

- administer oxygen via face mask at 10 L/minute the first action

A nurse is assisting in the care of a newborn who has an oral gastric tube feeding. Which of the following actions should the nurse take to promote weight gain in the newborn?

- allow the newborn to suck on a pacifier during feedings this has been found to promote weight gain, increase oxygenation and improve sucking skills.

A nurse is collecting data from a newborn who is eight hours old. Which of the following findings should the nurse report to the provider?

- apical heart rate of 90/min while crying.

A nurse is contributing to the plan of care for a client who had a spontaneous vaginal birth with perennial laceration six hour ago. Which of the following interventions should the nurse include?

- apply witch hazel pads to the clients perineum.

A nurse is reinforcing, teaching to a client who is breast-feeding, their six day old newborn. Which of the following client statements indicates an understanding of the teaching?

- baby should have at least six wet diapers per day.

A nurse is collecting data from a client who is 36 weeks of gestation during a prenatal examination. Which of the following findings should the nurse report to the provider?

- blurred vision.

Question 26 of 50 same example, as above a nurse is assisting in the care of postpartum client complete the following sentence by using a list of options the priority intervention of the nurse to perform is blank, followed by blank.

- check the clients deep tendon reflexes - checking the client for visual disturbances.

A nurse is assisting in the care of a newborn immediately following birth, which of the following images so the nurse identify as an indication that the newborn has a myelomeningocele?

- choose photo with wound above babies sacral area.

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and has gestational diabetes mellitus. Which of the following information should the nurse include in the teaching?

- consume at least 2000 cal a day.

A nurse is reinforcing teaching with a client who is at nine weeks of gestation and reports for twin episodes of nausea and vomiting. Which of the following instructions should the nurse include?

- consume small meals frequently each day.

A nurse on the Auntie part of unit is assisting in the care of a client who is at 33 weeks of gestation and has preeclampsia without severe features. For which of the following reasons to the nurse monitor the clients urine?

- decreased renal perfusion can increase the permeability of the glomeruli leading to excretion of proteins.

A nurse is assisting with the care of a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity? (select all that apply.)

- decreased respiratory rate. - Decrease the level of consciousness - Double vision

A nurse is reinforcing, teaching with a client who asked about continuing returning exercise during pregnancy. Which of the following responses to the nurse make?

- drink plenty of water after exercising.

A nurse is reinforcing teaching with a client who has a prescription for three hour oral glucose tolerance test. Which of the following instructions to the nurse include?

- four blood specimens will be obtained during the test.

A nurse is collecting data from a client who is in the second trimester of pregnancy. Which of the following findings should the nurse report to the provider

- frequent uterine contractions

A nurse is caring for a client who is at the 20 weeks of gestation and is in the clinic for a routine prenatal visit. Which of the following findings in the data from the clients medical record should the nurse report to the provider?

- fundal height.

A nurse is assisting in the care of a client six hours after a vaginal birth, who is going to breast-feed her newborn. The client reports perennial pain of six on a scale of 0 to 10 and Nurse. Also note smile, perennial edema, and Ekhymosis, with the fun to set is 2 cm about the umbilicus with deviation to the right. Which of the following actions is the nurses priority?

- help the client ambulate to the toilet.

A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation which of the following laboratory findings. Should the nurse report to the provider?

- hematocrit 30%

A nurse is assisting in the care of a client who has received methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication?

- hypertension rationale: methylergonovine is an oxytocic agent that stimulates uterine contractions and is used for postpartum hemorrhage. It can cause, nausea, vomiting, cramping, headache, and dizziness. The nurse report changes in blood pressure to the provider.

A nurse is assisting in the care of a newborn who is 24 hrs old. Complete the following sentence by usiiig the list of options, the newborn is at greatest risk for developing blank as evidence by the newborns blank.

- hypoglycemia, loss of heat

A nurse is assisting in the care of a client who is at 11 weeks of gestation and reports frequent vomiting. Which of the following findings should the nurse identify as an indication the client has hyper emesis gravidarum?

- ketonuria

A nurse is preparing to reinforce teaching for a client who is pregnant and has opioid use disorder. Which of the following medication should the nurse plan to include?

- methadone

A nurse is assisting in the care of a client who has experience of postpartum hemorrhage which of the following medication. Should the nurse expect the provider to prescribe?

- methylergonovine

A nurse is assisting in the care of a newborn who is receiving phototherapy. Which of the following actions should the nurse take?

- place an opaque mask over the newborns eyes.

A nurse is reinforcing teaching about formula, feeding a newborn with a group of new guardians. Which of the following instructions should the nurse include?

- position the bottle at a 45° angle during feedings

A nurse is reinforcing, teaching about risk factors for respiratory distress syndrome in newborns with a group of clients who are pregnant. Which of the following wrist factors should the nurse include?

- prematurity a newborn, who is premature, has an adequate surfactant production which can lead to RDS.

A nurse is assisting in the care of a client who is 18 hours postpartum and has fourth-degree perennial laceration the nurse reports of pain rating of 4 on a scale of 0 to 10 which of the following action should the nurse take (select all that apply)

- promote the use of witch hazel pads - give the client ice packs - have the client take a water, sitz bath, and encourage the client to practice relaxation techniques.

A nurse is reviewing the prenatal record of a client who is 34 weeks of gestation period which of following results to the nurse identify as a desirable outcome?

- reactive, nonstress test. The nurse should identify that a reactive, non-stress test indicates fetal well-being, and is a desirable outcome.

A nurse is assisting in planning, discharge teaching for a newborn which of the following information should the nurse plan to include?

- swaddle the newborn with legs

A nurse and a provider's office is reinforcing teaching with a client. Which of the following statements should the nurse include? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories) Exhibit one provider prescriptions norgestrel, 0.075 mg PO daily Medtronic dazzle 500 mg PO twice a day for seven days Exhibit to history and physical, spontaneous vaginal birth, 6 months ago, history of hypertension, Client reports vaginal discharge with a fish like a Then, watery, vaginal, secretions noted don't help me Exhibit 3 diagnostic results PH 5.0 Whiff test positive Positive microscopic screening for bacterial vaginosis

- you my experience, a metallic taste in your mouth while taking your medication, and metallic taste in the mouth is a common adverse effect of metronidazole, and does not warrant notification to the provider

A client request information about the use of a diaphragm for birth control. Which of the following statements should the nurse make?

- you will need to replace your diaphragm every two years.

After receiving a shift, change report and Nurse on a post partum unit is assisting with planning care for a group of clients. The nurse should recommend which of the following clients be seen first?

-> A client who has preeclampsia and reports a sudden severe headache

Question 28 of 50 same example as above: the nurse is reviewing the clients electronic medical record. Which of the following actions should the nurse take? Select the five actions that the nurse should take.

-> Check for worsening headache and epigastric pain hourly, and PRN. ->Assist with administration of magnesium sulfate IV bolus as prescribed -> Place the client on seizure precautions -> Obtain, creatinine platelet BUN and liver enzymes as -> Monitor level of consciousness, deep tendon reflexes, and visual disturbances, hourly.

The findings indicate the clients condition is not improving. To deselect a finding, click on the finding again.

-> Clonus is positive. Deep tendon reflexes 4+. -> Reports headache as a 4 on scale of 0 out of 10 pain scale -> Platelets 95,000/MM -> Aspartate aminotransferase (AST) 60 units/L -> Alanine aminotransferase (ALT) 50 units/L

A nurse is collecting data from a client who is at 33 weeks of gestation period which of the following findings should the nurse identify as an indication of a potential complication of pregnancy?

epigastric pain, epigastric pain is a manifestation of preeclampsia.

Nurse is collecting data from a 28 year old client who is requesting a prescription for an oral contraceptive. Which of the following information in the clients history should the nurse identify as a contraindication for the use of oral contraceptives?

frequent headaches with visual changes. rationale: Frequent headaches with visual changes indicate cardiovascular condition such as hypertension a cardiovascular disorder is a contra indication for oral contraceptive use because the combination can increase the risk of cerebral vascular accident, myocardial infarction and thromboembolism.