ITA - #2 - Baby

A nurse is caring for a client who is receiving IV Oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart (FHR) tracing. Which of the following actions should the nurse take? a. Increase the rate of intravenous fluid infusion b. Discontinue the infusion of oxytocin c. Re-evaluate the FHR tracing in 15 minutes d. Request a prescription for amnioinfusion

Re-evaluate the FHR tracing in 15 minutes

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication a. IV narcotics administered to the mother during labor b. Maternal drug use c. Hyaline membrane disease d. Meconium aspiration

a. IV narcotics administered to the mother during labor

A nurse is caring for a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform? a. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure b. assess the fetal heart rate pattern for 10 min prior to the procedure c. Position the client upright and erect on the edge of the bed prior to the procedure d. Monitor vital signs every 15 min after the anesthetic is placed

a. Infuse a 500 mL bolus of 0.9% sodium chloride immedieately prior to the procedure

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? a. Intraventricular hemorrhage b. Hyperglycemia c. Hyperthermia d. Meconium aspiration syndrome

a. Intraventricular hemorrhage

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner? a. Lightly stroke the upper thighs b. Steadily apply pressure to the sacrum c. Gently massage the mid-abdominal area d. Firmly squeeze both hips

a. Lightly stroke the upper thighs

A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy? a. Nausea in the morning b. Positive home pregnancy test c. Increased sensitiity of the cervix noted upon examination d. Gestational sac observed by transvaginal ultrasound

a. Nausea in the morning

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include? a. Notify your provider if you notice cracking on your nipples b. Notify your provider if you have not had a bowel movement within 5 days c. Notify your provider if your breasts leak when you shower d. Notify your provider if your vaginal discharge is a brownish-red color

a. Notify your provider if you notice cracking on your nipples

A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? a. Perform a vaginal exam b. Perform continuous external fetal monitoring c. Insert a large-bore IV catheter d. Obtain a blood sample for laboratory testing

a. Perform a vaginal exam

A nurse is providing care for a client who is in the second stage of labor. The fetal heart tracing indicates multiple variable decelerations. Which of the following actions should the nurse take? a. Prepare an amnioinfusion b. Place the client in a supine position c. Administer oxygen 2 L/min via nasal cannula d. Give a glucocorticoid

a. Prepare an amnioinfusion

A nurse is reviewing the medication record of a client who is at 20 weeks of gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy? a. Report of fetal movement by the client b. Auscultation of the fetal heart rate with Doppler ultrasound c. Presence of Chadwick's sign on pelvic examination d. Report of Braxton-Hicks contractions by the client

a. Report of fetal movement by the client

A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect? a. Symmetric rib cage b. Dry, wrinkled skin c. Vernix over the entire body d. Abundant lanugo on the back

a. Symmetric rib cage

A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should notify the provider about which of the following assessment findings? a. The client reports a frequent cough b. The client reports that none of her shoes fit anymore c. The client reports a weight gain of 2 lb. in a 2-week period d. The client reports leg cramps in the evening

a. The client reports a frequent cough

A nurse is assessing a client at 27 weeks gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? a. The fundal height measures greater than gestation age b. A rigid abdomen is noted on palpation c. The client reports a pain level of 8-10 d. A urine drug screen is positive for cocaine

a. The funal heigh measures greater than gestation age

A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make? a. This type of monitoring will allow us to measure the intensity of your contractions b. This type of monitoring is necessary for timing the frequency of your contractions c. This type of monitoring is noninvasive, so it is the best way to monitor your labor contractions. d. This type of monitoring allows us to evaluate your baby's heart rate while you are in labor

a. This type of monitoring will allow us to measure the intensity of your contractions

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? a. This will resolve in 3 to 6 weeks without treatment b. This will resolve on its own within 3 to 4 days c. The provider might drain this area with a syringe d. This appearance is expected at birth, so you don't need to worry.

a. This will resolve in 3 to 6 weeks without treatment

A nurse at a family planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching? a. Use spermicidal jelly whenever you use your diaphragm b. Insert the diaphragm about 8 hours before sex c. You should remove the diaphragm 30 min after intercourse d. A diaphragm comes in a single size and does not require fitting.

a. Use spermicidal jelly whenever you use your diaphragm

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? a. Uterine tone b. Fetal heart rate c. Blood pressure d. Amount of bleeding

a. Uterine tone

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? a. uteroplacental insufficiency b. Fetal head compression c. Fetal ventricular septal defect d. Umbilical cord compression

a. Uteroplacental insufficiency

A nurse is caring for a client at 12 weeks gestation who has a BMI of 45. Which of the following pieces of information should the nurse provide for the client regarding the recommended weight gain during her pregnancy? a. You should plan to gain no more than 20 pounds during your pregnancy b. You should plan to gain between 25 and 35 pounds during your pregnancy c. You should not plan to gain any weight during y our pregnancy because you are already well-nourished d. Since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 pounds.

a. You should plan to gain no more than 20 pounds during your pregnancy

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritis gravidarum. Which of the following pieces of information should the nurse provide? a. you should slightly increase your exposure to sunlight b. You will need extensive dermatological treatment for this condition after you deliver your baby c. Your provider will schedule weekly lab testing to monitor your liver function d. Your provider will prescribe isotretinoin cream

a. You should slightly increase your exposure to sunlight

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? a. They can cause increased pain from the cord b. They can cause delayed cord separation c. They can cause swelling of the surrounding tissue d. They can cause skin discoloration

b. They can cause delayed ocrd separation

A nurse is teaching a client about using the Lazaxe method to manage pain during labor. Which of the following pieces of information should the nurse include? a. Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions b. You will learn how to prevent pain during labor by focusing your mind to control your breathing c. During labor, you will be encouraged to disassociate by using an internal focal point d. During labor, you will use conscious relaxation and levels of progressive breathing

b. You will learn how to prevent pain during labor by focusing your mind to control your breathing

A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? a. Your provider will insert a hand into your uterus and turn your baby around b. You will receive medication to relax your uterus prior to the procedure c. This procedure will be performed in the clinic at your next visit d. Your baby's heartbeat will be monitored occasionally throughout the procedure

b. You will receive a medicaiton to relax your uterus prior to the procedure

A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse care for first? a. a 1-week-old newborn who needs another phenylketonuria screening test b. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy c. A 10-day-old newborn who is small for gestational age and requires daily weighing d. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge

b. a 4-day-old newborn who has an elevated bilirubin level and requires phototherapy

A nurse is caring for a client in active labor whose fetus is in a persistent occiput posterior position. Which of the following actions should the nurse take to promote rotation of the fetal head? a. apply counterpressure to the client's back b. Place heat on the client's lower back c. Instruct the client to squat during contractions d. Encourage the client to ambulate in the hall

c. Instruct the client to squat during contraction

A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following? a. Effacement b. Dilation c. Lightening d. Quickening

c. Lightening

A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take? a. Assess fetal heart rate and contraction pattern every 15 min after insertion b. Thaw the frozen gel in a warm water bath prior to insertion c. Maintain the client in a side-lying position for 30 min after insertion d. Initiate an oxytocin infusion for induction 1 hr after gel insertion

c. Maintain the client in a side-lying position for 30 min after insertion

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? a. Monitor the client's intake and output b. Initiate a high-fiber diet for the client c. Monitor the client's weight weekly d. Initiate bedrest with the head of the be elevated

c. Monitor the client's weight weekly

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take? a. Encourage the client to bear down with contractions b. Request a prescription to initiate oxytocin c. Offer the client hydrotherapy d. Assist the client with ambulation

c. Offer the client hydrotherapy

A nurse is assessing a postpartum client who has pre-eclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? a. Terbutaline b. Magnesium sulfate c. Oxytocin d. Methylergonovine

c. Oxytocin

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? a. Uterine rupture b. Placental abruption c. Prolapsed umbilical cord d. Amniotic fluid embolus

c. Prolapsed umbilical cord

A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take? a. Increase the rate of intravenous fluid infusion b. Discontinue the infusion of oxytocin c. Re-evaluate the FHR tracing in 15 minutes d. Request a prescription for an amnioinfusion

c. Re-evaluate the FHR tracing in 15 minutes

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? a. Pos-term birth b. Macrosomia c. Respiratory distress syndrome d. Maternal gestational diabetes

c. Respiratory distress syndrome

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? a. Breast engorgement b. Hypothermia c. Urinary retention d. Rupture of membranes

c. Urinary retention

A nurse is providing teaching to a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse provide the client? a. If you lose weight, you will need to have your IUD refitted b. An IUD provides protection from certain sexually transmitted infections c. Your risk for ectopic pregnancy increases with an IUD d. You shouldn't use an IUD if you want to have children later

c. Y our risk for ectopic pregnancy increases with an IUD

A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following should the nurse include in the teaching? a. During the last trimester, you should sleep mainly on your back b. During the second trimester, you will notice increased urinary frequency and urgency c. You will probably first notice your baby moving when you are around 20 weeks gestation d. You should plan to gain 40-45 pounds during your pregnancy

c. You will probably first notice your baby moving when you are around 20 weeks gestation.

A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? a. You will need to wait 3 months before resuming sexual intercourse b. You don't need to use contraception until you are 4 months postpartum c. As long as you breastfeed, you will experience an overproduction of vaginal lubrication d. A reduction in sexual interest could indicate postpartum depression

d. A reduction in sexual interest could indicate postpartum depression

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to theuse of this medication? a. Prolonged rupture of membranes at 38 weeks gestation b. Intrauterine growth restriction c. Post-term pregnancy d. Active genital herpes

d. Active genital herpes

A nurse is creating a plan of care for a client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse include? a. Encourage the client to listen to music b. Instruct the client how to use informational biofeedback c. Ask the client to reconsider using a regional anesthetic d. Assist the client into a warm shower

d. Assist the client into a warm a shower

A nurse is caring for a client who is postpartum and having difficulty voiding. Which of the following actions should the nurse take first? a. Place the client's hand in warm water b. Administer an analgesic to the client c. Pour water from a squeeze bottle over the client's perineum d. Assist the client to the bathroom

d. Assist the client to the bathroom

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globin? a. While the client is in labor b. Following an episode of influenza during pregnancy c. Prior to a blood transfusion d. At 28 weeks gestation

d. At 28 weeks gestation

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instrutions should the nurse include in the teaching? a. Dilute ready-to-feed formula if the newborn is gaining weight too qickly b. Prop the bottle with a blanket for the last feeding of the day c. Discard unused refrigerated formula after 72 hr d. Boil water for powdered formula for 1-2 min

d. Boil water for powdered formula for 1-2 min

A nurse is assessing a client who has hyperemesis gravidarum. What findings should the nurse expect? a. Elevated serum potassium level b. Rapid weight gain c. Peripheral edema d. Presence of ketones in the urine

d. Presence of ketones in the urine

While assessing a client who is in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention? a. The fundus is at midline b. The fundus is below the umbilicus c. The bladder is resonant with percussion d. The bladder fluctuates with palpation

d. The bladder fluctuates with palpation

A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide? a. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor b. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery c. The fundus is located halfway between the umbilicus and moms pubis on the sixth day postpartum d. The fundus is not palpable abdominally at 2 weeks postpartum

d. The fundus is not palpable abdominally at 2 weeks postpartum

A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report? a. Superficial cracking and peeling are evident on the skin of the hands and feet b. The palmar grasp occurs spontaneously when newborn is sucking c. The bulge of the testes is palpable in the inguinal canal d. There is decreased abdominal movement with breathing

d. There is decreaed abdominal movement with breathing

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? a. This is an attempt by your body to retain the fluid gained during pregnancy b. This is caused by an increase in your estrogen hormonal levels c. This is caused by the increased pressure on your veins in your lower legs d. This is a source of your fluid loss after delivery

d. This is a source of your fluid loss after delivery

A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? a. This medication can cause your blood pressure to rise b. This medication can cause dry mouth c. This medication can cause you to urinate excessively d. This medication can make you sleepy

d. This medication can make you sleepy

A nurse is assessing a client who is supected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first? a. Complete blood count b. Lilver enzymes c. Bilirubin d. Urine ketones

d. Urine ketones

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? a. Apply barrier ointment to the newborn's perineal region b. Offer the newborn glucose feedings c. Keep the newborn's eye patches on during feedings d. Use a photometer to monitor the lamp's energy

d. Use a photometer to monitor the lamp's energy

A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation? a. Calcium b. Iron c. Vitamin D d. Vitamin C

d. Vitamin C

A nurse is teaching a client who is 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? a. Breastfeed your newborn to provide passive immunity b. Abstain from sexual intercourse throughout your pregnancy c. You will be in isolation after delivery d. You should continue to take Zidovudine throughout the pregnancy

d. You should continue to take zidovudine throughout the pregnancy

A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? a. You should eat foods served at warm temperatures b. You should brush your teeth right after you eat c. You should try to eat sweet foods when you feel nauseated d. You should eat dry foods that are high in carbohydrates when you wake

d. You should eat dry foods that are high in carbohydrates when you wake

A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? a. Carbohydrates should make up 55% of your diet b. Protein should make up 70% of your diet c. Fats should make up 45% of your diet d. Fiber should make up 10% of your diet

Carbohydrates should make up 55% of your diet

A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider (SATA) a. Massage the fundus b. Give oxygen at 2 L/min via nasal cannula c. Administer oxytocin with IV fluids d. Insert an indwelling urinary catheter e. Place the client in a lateral position with her legs elevated 30"

a, c, d, e

A nurse is caring for a client who is scheduled to undergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an )-positive blood type. Which of the following interventions should the nurse perform? a. Apply an external fetal monitor to the client b. Instruct the client to drink fluids and not to void prior to the procedure c. Administer Rho(D) immunoglobulin after the procedure d. Instruct the client to take a deep breath and hold it during the entry of the needle.

a. Apply an eternal fetal monitor to the client

A nurse is caring for a client during her first prenatal visit and notes thaat she is lactose-intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? a. Collard greens b. Cottage cheese c. Orange juice d. Broccoli

a. Collard greens

A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? a. Copper intrauterin device b. Combination pill c. Vaginal ring d Medroxyprogesterone injection

a. Copper intrauterine device

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? a. Do not become pregnant for at least 1-year b. Seek genetic counseling for yourself and your partner prior to getting pregnant again c. You should have an hCG level drawn in 6 weeks d. Have your blood pressure checked weekly for the next month

a. Do not become pregnant for at least 1 year

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take? a. Encourage the client to frequently change positions b. Instruct the client to take breaths and hold them for 10 seconds while pushing c. Assess maternal vital signs every 1-hour d. Assist the client to the restroom

a. Encourage the client to frequenly change positions

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take? a. Encourage the client to frequently change positions b. Instruct the client to take breaths and hold them for 10 seconds while pushing c. Assess maternal vital signs every 1-hour d. Assist the client to the restroom

a. Enourage the client to frequently change positions

A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can only be obtained from continuous electronic fetal monitoring? a. Determination of a baseline b. Determination of variability c. Presence of accelerations d. Presence of decelerations

b. Determination of variability

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which actions should the nurse take? a. Request a prescription for pre-eclampsia laboratory studies b. Advise the client to lie on her side c. Request an ultrasound to evaluate fetal wellbeing d. Advise the client to add a calcium supplement to her diet

b. Advise the client to lie on her side

A nurse is teaching the guardians of a newborn about the facility's safety measures. Which of the following pieces of information should the nurse include? a. Expect staff to identify the newborn by verifying the information on the bassinet card b. Check for a photo identification badge before allowing a nurse to remove the newborn from the room c. Place the newborn in the bassinet when using the bathroom d. Hold the newobrn securely when walking in the hallway

b. Check for a photo identification badge before allowing a nurse to remove the newborn from the room

A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitor tracing? a. Contractions that last for 60 sec each with a 4 min rest between contractions b. Contractions that last for 60 sec each with a 3 min rest between contractions c. A contraction that lasts for 4 min followed by a period of relaxation d. Contractions that last for 45 sec each with a 3 min rest between contractions

b. Contractions that last for 60 sec each with a 3 min rest between contractions

A nurse is assessing a client who is at 12 weeks gestation and has hydatidiform mole. Which of the following findings should the nurse expect? a. Hypothermia b. Dark brown vaginal discharge c. Decreased urinary output d. Fetal heart tones

b. Dark brown vaginal discharge

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? a. Hyperthermia b. Decreased blood glucose c. Rapid pulse rate d. irritability

b. Decreased blood glucose

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication? a. Slow respirations b. Decreased blood pressure c. Bradycardia d. Flushed skin

b. Decreased blood pressure

A nurse is assessing a client who is pregnant, and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort. a. Relaxin b. Estrogen c. Progesterone d. Human chorionic somatomammotropin (HCS)

b. Estrogen

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include? a. This test is an invasive procedure that presents minimal risk to the fetus b. If the test is reactive, that means your baby's heart rate is healthy c. When your baby moves, the test should record the baby's heart rate decreasing by about 15 beats per minute d. The results of the test will be recorded as positive if no fetal movement occurs during the 20-minute testing period

b. If the test is reactive, that means your baby's heart rate is healthy

A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? a. Assist the client to the bathrrom to empty her bladder b. increase the rate of the primary IV infusion c. Position the client in a semi-Fowler's position d. Provide glucose via oral hydration or IV

b. Increase the rate of the primary IV infusion

A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority? a. Blood pressure 90/52 b. Ketones 2+ c. Specific gravity 1.035 d. Sodium 130 mEq/L

b. Ketones 2+

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device? a. Hypertension b. Menorrhagia c. History of multiple gestations d. History of thromboembolic disease

b. Menorrhagia

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? a. Administer the oxytocin with manual IV tubing b. Monitor the fetal heart rate every 15 minutes initially c. Begin the infusion at 10 milliunits/min d. titrate the dosage until the client has 1 contraction every minute

b. Monitor the fetal heart rate every 15 minutes initially

A nurse is assessing a 12-hour-old newborn notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? a. Administer phytonadione IM b. Obtain a stat prescription for a bilirubin level c. Obtain a bagged urine specimen d. Perform a gestational age assessment

b. Obtain a state prescription for billirubin level

A nurse is providing teaching to client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? a. Stand under the hot shower with your breast exposed b. Place ice packs on your breasts c. Wear a loose-fitting comfortable bra d. Limit fluid intake to 1 L per day

b. Place ice packs on your breast

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? a. Hgb 11.3 g/dL b. Platelet count 135,000/mm3 - HELLP c. WBC count 10,500/mm3 d. Hct 38%

b. Platelet count 135,000/mm3 - HELLP

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? a. Rapidly advance oral feedings b. Position the naked newborn on the parent's bare chest c. Provide frequent periods of visual and auditory stimulation d. Discourage the use of pacifiers

b. Position the naked newborn on the parent's bare chest

A nurse is revewing the laboratory vaues of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expet? a. Gestational diabetes b. Preterm labor c. Inadequate milk supply d. Inadequate uterine growth

b. Preterm labor

A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention? a. Withhold analgesics to prevent urinary retention b. Run water in the sink while the client sits on the toilet c. Perform Credes maneuver every 4 hours d. Restric oral hydration

b. Run water in the sink while the client sits on the toilet

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? a. A fetal stethoscope can first detect your baby's heart rate at 22 weeks b. After week 16, we can see if your baby is a boy or a girl c. A Doppler device can detect your baby's heart rate at 12 weeks d. You will first feel the baby move at about 8 weeks

c. A doppler device can detect your baby's heart rate at 12 weeks

A nurse is assisting with an amniocentesis for a client who is Rh negative. Which of the following actions should the nurse take following the procedure? a. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia b. Send a sample of amniotic fluuid to the laboratory to test for an elevated Rh-negative titer c. Administer immune globulin to the client to prevent fetal isoimmunization d. Administer intravenous antibiotics to prevent an infection

c. Administer immune globulin to the client to prevent fetal isoimmunization

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? a. Shellfish b. Gelatin c. Baker's yeast d. Eggs

c. Baker's yeast

A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. a. Soy-based formula is recommended to decrease colic b. Amino acid formula is recommended to increase the newborn's protein intake c. Cow's milk-based formula is recommended for healthy newborns d. Low-iron formula is recommended to prevent excess iron intake

c. Cow's milk-based formula is recommended for healthy newborns

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate a. Heel creases over the entire sole of the foot b. Pendulous testes c. Extended extremities d. Leathery cracked skin

c. Extended extremities

A nurse is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? a. Urinary output b. Blood pressure c. Fundal consistency d. Pulse rate

c. Fundal consistency

A nurse is discussing diphragm use with a client. Which of the following statemtns by the client indicates the understanding of the teaching? a. I should clean my diaphragm with alcohol each time I use it b. I should leave the diaphragm in place for 4 hours after intercourse c. I should replace my diaphragm every 2 years d. I should use a vaginal lubricant to insert my diaphragm

c. I should replace by diaphragm every 2 years

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? a. I should clean my diaphragm with alcohol each time I use it b. I should leave the diaphragm in place for hours after intercourse c. I should replace my diaphragm every 2 years d. I should use a vaginal lubricant to insert my diaphragm

c. I should replace my diaphragm every 2 years

A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? a. Nitrous oxide could make my baby sleepy when he is born b. I should inhale the nitrous oxide between contractions c. I will feel the effects of the nitrous oxide almost immediately d. Nitrous oxide can make me feel disoriented

c. Ill feel the effects of the nitrous oxide almost immediately

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? a. Placenta previa b. Multiple gestation c. Infection d. Anemia

c. Infection

A nurse is caring for a client in labor whose cervix is dilated to 9 cm. She is experiencing strong contractions every 2 min lasting 75 sec. The nurse should recognize that the client is in which of the following phases or stages of labor? a. Latent phase of first stage b. Active phase of first stage c. Second stage d. Transition phase of the first stage

d, Transition phase of first stage

A nurse is providing postpartum dishcarge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? a. You will not get pregnant while you are breastfeeding, so you will not need any birth control b. A birth control pill that contains only estrogen is available for use while you are breastfeeding. c. Condoms are the only method contraception that is appropriate while you are breasfeeding d. A progestin-only pill or injection is available for use while you are breastfeeding.

d. A progestin-only pill or injection is available for use while you are breastfeeding

A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take? a. Teach the client to lie on her side b. Request a prescription for an opioid analgesic c. Offer a sitz bath to the client d. Encourage the client to interact with the newborn

d. Enourange the client to interact with the newborn

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? a. Fundal height of 34 cm (13.4 in) b. Total pregnancy weight gain of 3.6 kg (8 lb) c. Gestational hypertension d. Fetal gastrointestinal anomaly

d. Fetal gastrointestinal anomaly

A nurse is providing education to a female client of child-bearing age. The nurse should state that which of the following structures expels the mature ovum? a. Blastocyst b. Fallopian tube c. Corpu lutem d. Graafian follicle

d. Graafian follicle

A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellites. Which of the following statements should the nurse include in the teaching? a. I can continue to breastfeed b. I still need to have my provider perform a rubella titer check during my next pregnancy c. I cannot receive the rubella immunization during pregnancy d. I can conceive anytime I want after 10 days

d. I can conceive anytime I want after 10 days

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? a. I should stop swaddling my baby once she is able to roll over by herself b. My baby's legs should be extended straight out when I swaddle her c. I should be able to slide just 1 finger between my baby's chest and the swaddled blanket d. After swaddling, I should place my baby on her side in her crib or bassinet

d. I should stop swaddling my baby once she is able to roll over by herself

A nurse is caring for a client in the early stage of labor who has preeclampsia with severe features. Which of the following interventions should the nurse perform? a. Assess the fetal heart rate and contractions hourly b. Encourage oral intake of clear, low sodium fluids c. Instruct the client to ambulate during the early phase of labor d. Implement seizure precautions

d. Implement seizure precaustions

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? a. I must drink milk every day in order to ensure good-quality breast milk b. Drinking lots of fluids will increase my breast milk production c. After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore d. My baby may sometimes feed every hour for several hours in a row

d. My baby may sometimes feed every hour for several hours in a row.

A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority a. My ankles are swollen at the end of the day b. I can feel the baby kicking my ribs, and it is very uncomfortable c. I'm growing more and more worried everyday d. My heart feels like it is racing

d. My heart feels lik it is racing

A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the client for the first time. Which of the following factors is the nurs's priority to evaluate? a. Psychological readiness b. Partner support c. Socioeconomic status d. Nutritional status

d. Nutritional status

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? a. Anemia b. Frequent urinary tract infections c. Previous cesarean birth d. Pelvic inflammatory disease (PID)

d. Pelvic inflammatory disease (PID)