EXAM 3

The new mother has decided to formula-feed her infant and is unsure when to introduce soft foods. Which age should the nurse point out will be appropriate to introduce her infant to mashed fruit and vegetables?

6 TO 8 MONTHS

A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?

A DIPSTICK VALUE OF 2+ FOR PROTEIN

The nurse is monitoring a breast-feeding session and determines the infant is nursing well. Which assessment finding is the nurse using to make this determination?

THE MOTHER IS EXPERIENCING UTERINE CONTRACTIONS

A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?

DEPRESSED DEEP TENDON REFLEXES

A 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?

"I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet."

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

"THIS CAN BE FROM THE SUDDEN WITHDRAWAL OF YOUR HORMONES, IT IS NOT A CAUSE FOR ALARM"

A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration?

"YOUR BABY IS HAVING A LITTLE TROUBLE BREATHING, ILL LET THE RN KNOW"

A multipara woman at a birthing center is becoming very discouraged that her labor is taking so long. She is confused when her nurse-midwife indicates she has developed dystocia and needs to be transferred to a more advanced facility. What is the best response from the nurse to answer the woman's questions?

"YOUR DIFFICULT LABOR NEEDS TREATMENT THAT WE CANNOT PROVIDE HERE"

A young couple are discussing how long the mother should breast-feed and cannot agree on a time frame. What is the best response from the nurse when they question the nurse about it?

'THE RECOMMENDATION IS TO ONLY USE BREAST MILK FOR THE FIRST 6 MONTHS THEN ADD OTHER FOODS UNTIL 12 MONTHS"

A woman on the postpartum unit with her 1-day-old infant is asking when her milk will "come in." The nurse should point out this normally occurs at which time after delivery?

3 TO 5 DAYS

A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?

AMNIOCENTESIS

A first-time mother has been breast-feeding her baby for 3 days and is concerned she is not making enough milk. Which signs can the nurse teach the mother to look for that indicate the infant is getting enough milk?

APPEARS DROWSY OR ASLEEP AFTER FEEDING

The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?

ASSESS THE RH OF THE BABY

The nurse is assisting a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

US MCROBERTS MANEUVER

The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out that the mother and fetus are at an increased risk for which situation related to this procedure.

BABY DEVELOPING POST BIRTH JAUNDICE

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?

BLOOD SUGAR 42 MG/DL

A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, has concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality?

CHORIONIC VILLUS SAMPLING

The nurse is monitoring a primipara who has been receiving oxytocin and is now in hypertonic labor. If the nurse notes the fetal heart rate has suddenly dropped, which action should the nurse prioritize?

DECREASE THE OXYTOCIN DRIP RATERES

The nurse is preparing discharge instructions for a new mother who has been learning to breast-feed. Which response should the nurse prioritize when the mother questions her ability to produce enough milk for her infant

DRINK A LOT OF FLUIDS

A new mother is learning how to change the diaper of her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize?

EXPLAIN THIS IS NORMAL

The nurse is preparing a postpartum nursing care plan for a single HIV-positive primigravida client. The nurse should prioritize in the plan how to acquire which resource?

FORMULA

The nurse is assisting a primigravida woman make decisions and prepare for her baby. The nurse should point out that breastfeeding is not an option for this client based on which assessment finding?

HUMAN IMMUNODEFICIENCY VIRUS INFECTION

The infant born at 5 a.m. has moved to the transition phase and is progressing well. The nurse documents a HR 130, RR 42, axillary temperature 99.5oF (37.5oC), and blood pressure 60/40 at 6:45 a.m. When should the nurse plan to reassess the infant's vital signs?

IN 30 MINUTES

A woman at 9 weeks' gestation is admitted to the obstetrical unit for hyperemesis gravidarum. Which action should the nurse prioritize immediately?

INSTRUCT NPO STATUS

The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation?

JUGULAR DISTENTION

A pregnant woman at 38 weeks' gestation is receiving care for preeclampsia and suddenly complains of sharp abdominal pain. Which action should the nurse prioritize if the nurse notes a firm, distended and painful abdomen and dark red vaginal bleeding?

OBTAIN A FULL SET OF VITALS

The nurse is admitting a client at 23 weeks gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss.

PLACENTAL ABRUPTION

The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out which situation can potentially occur during their pregnancy.

POLYHYDRAMNIOS

The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize

PREPARE TO ASSIST WITH THE EXTERNAL VERSION

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couple correctly chooses the reason for using an antibiotic ointment.

PREVENT INFECTION OF THE EYES FROM VAGINAL BACTERIA

A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something 'came out' when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?

PUT HER IN THE BED IMMEDIATELY, CALL FOR HELP AND HOLD THE PRESENTING PART OF THE CORD

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 1, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?

REFLEXES

A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

RESPIRATORY DEPRESSION, HYPOTENSION, ABSENT TENDON REFLEXES

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex.

ROOTING

The nurse is caring for a pregnant client who has a class II heart disease. The nurse is prepared to intensify monitoring during which period of the pregnancy?

SECOND TRIMESTER

The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving betamethasone and magnesium sulfate. The nurse will continue to monitor this client for which condition?

SEVERE PREECLAMPSIA

The nurse is conducting class for pregnant women on problems associated with infections seen in women during gestation. One mother tells the nurse that she has never had the chicken pox (varicella) and is worried she will contract it before she delivers. What would the nurse explain to this mother to ease her anxiety?

SHE CAN RECEIVE HER VARICELLA IMMEDIATELY AFTER DELIVERY , FOLLOWED BY A SECOND DOSE AT HER 6-WEEK POSTPARTUM VISIT

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in its bed, lying on its side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

SUDDEN INFANT DEATH SYNDROME

An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?

TACHYPNEA

The nurse is assessing a 35-year-old Hispanic woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dL, hemoglobin 13 g/dL, and hematocrit 37%. Based on these results which instruction should the nurse prioritize?

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