Maternal Newborn
A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort?
"Apply ice packs to your breasts to reduce the amount of milk being produced."
A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.
Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count.
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
Bladder distention
A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?
Decrease activity and rest more often.
Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?
Dry the newborn and place it skin-to-skin on mother.
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
Parents tell the nurse that they have been told to keep their newborn away from windows and be sure to cover the baby with a light blanket. They do not understand why this is necessary. What rationale would the nurse provide for this care?
Since newborns cannot shiver to produce heat, parents need to be sure to keep them covered up and away from sources of heat loss like a window.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?
a moderate amount of lochia rubra
The AGPAR score is based on which 5 parameters?
heart rate, muscle tone, reflex irritability, respiratory effort, and color
A patient who experiences premature rupture of membranes can expect to be put on pelvic rest. The nurse should explain to the patient that pelvic rest involves which of the following?
placing nothing in the vagina
All the options are signs of respiratory distress in the newborn except:
respiratory rate >50 breaths/minute.
The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?
yellowy mustard color with seedy appearance
A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding?
elevated liver enzymes
A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect?
uterine hyperstimulation
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?
1 cm below the umbilicus
On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?
500 additional calories per day
A woman with a history of systemic lupus erythematosus comes to the clinic for evaluation. The woman tells the nurse that she and her partner would like to have a baby but that they are afraid her lupus will be a problem. Which response would be most appropriate for the nurse to make?
Be sure that your lupus is stable or in remission for 6 months before getting pregnant."
The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method?
Conduction
1. A nurse is working with a pregnant woman to schedule follow-up visits for her pregnancy. Which statement by the woman indicates that she understands the scheduling? (Ch-15; P-272; DL-25; B-Analyze; CO-6) a. "From now until I'm 28 weeks, I'll be coming once a month." b. "I need to make visits every 2 months until I'm 36 weeks pregnant." c. "Once I get to 28 weeks, I have to come twice a month." d. "I'll make sure to get a day off every 2 weeks to make my visits."
From now until I'm 28 weeks, I'll be coming once a month."
The nurse is teaching a client with gestational diabetes about complications that can occur either following birth or at delivery for her baby. Which statement by the mother indicates that further teaching is needed by the nurse?
If my blood sugars are elevated, my baby's lungs will mature faster, which is good."
A patient is admitted with a diagnosis of ectopic pregnancy. For what should the nurse anticipate preparing the patient?
Immediate surgery
A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation
Massage the fundus
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client?
Monitor the client's vital signs and bleeding.
The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?
Moro
The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack.
After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placentae and placenta previa. Which statement should the nurse include in the teaching?
Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor."
1. After teaching a class on the stages of fetal development, the nurse determines that the teaching was successful when the group identifies which stages? Select all that apply. (Ch-15; P-253-256; DL-14; B-Analyze; CO-10) a. Pre-embryonic b. Embryonic c. Placental d. Umbilical Fetal
Pre-embryonic Embryonic Fetal
A client at 27 weeks' gestation is admitted to the OB unit afer reporting headaches and edema of her hands. Review of the prenatal notes reveals BP consistently above 136/90 mm Hg. The nurse anticipates the health care provider will order magneisum sulfate to accomplish which primary goal?
Prevent maternal seizures
1. A nurse is preparing a teaching plan for a woman who is planning to become pregnant. Which hormone secreted by the corpus luteum would the nurse include in the discussion when describing how the endometrium is prepped for egg implantation? (Ch-14; P-242; DL-34; B-Apply; CO-13) a. Progesterone b. Estrogen c. Testosterone d. Luteinizing hormone
Progesterone
1. A woman in the third trimester of her first pregnancy expresses fear about the birth canal being wide enough for her to push the baby through it during labor. She is a petite person, and the baby seems so large. She asks the nurse how this will be possible. To help alleviate the client's fears, the nurse should mention the role of the hormone that softens the cervix and collagen in the joints, which allows dilation and enlargement of the birth canal. What is this hormone? (Ch-15; P-259; DL-29; B-Apply; CO-13) a. Relaxin b. Progesterone c. Estrogen d. Human placental lactogen
Relaxin
The client is 32 weeks pregnant and has been referred for biophysical profile (BPP) after a nonreassuring nonstress test (NST). Which statement made by the client indicates that the nurse's explanation of the procedure was effective?
The BPP is an ultrasound that measures breathing, body movement, tone, and amniotic fluid volume.
A pregnant woman at term is in the obstetrics unit for induction in the morning. Her membranes rupture, and the external fetal monitor shows deep variable decelerations. For what should the nurse immediately check the patient?
Umbilical cord prolapse
A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?
Your primary care provider will order safe doses of your medication."
1. The nurse assesses a 20-week gestational client at a routine prenatal visit. What will the nurse predict the fundal height to be on this client experiencing an uneventful pregnancy? (Ch-15; P-280; DL-15; B-Apply; CO-6) a. 12 cm b. 16 cm c. 20 cm d. 24 cm
a. 20 cm
1. The nurse is reviewing client data following a regular monthly appointment at 6 months' gestation. Which fundal height requires no further intervention? (Ch-15; P-280; DL-26; B-Apply; CO-6) a. 32 cm b. 30 cm c. 24 cm d. 18 cm
a. 24 cm
1. A woman is in her early second trimester of pregnancy. The nurse would instruct the woman to return for a follow-up visit every: (Ch-15; P-272; DL-28; B-Apply; CO-6) a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks
a. 4 weeks
1. The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters? (Ch-16; P-294-295; DL-24; B-Analyze; CO-1)
a. 8 to 10
A patient makes an appointment at the prenatal clinic because she thinks she might be pregnant. Which assessment is a probable sign of pregnancy? a. Amenorrhea b. Enlargement and darkening of areola c. Nausea and vomiting d. A positive pregnancy test
a. A positive pregnancy test
1. The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording? (Ch-16; P-306; DL-28; B-Analyze; CO-1) a. Acceleration of at least 15 bpm for 15 seconds b. Increase in variability by 27 bpm c. Deceleration followed by acceleration of 15 bpm d. Decrease in variability for 15 seconds
a. Acceleration of at least 15 bpm for 15 seconds
1. A client asks the nurse about cervical mucus changes that occur during the menstrual cycle. Which statement should the nurse expect to include in the client's teaching plan? (Ch-14; P-243; DL-20; B-Apply; CO-13) a. As ovulation approaches, cervical mucus is abundant and stretchable b. Cervical mucus disappears immediately after ovulation, resuming with menses c. About midway through the menstrual cycle, cervical mucus is clear and sticky d. During ovulation, the cervix remains dry with scant mucus secretion
a. As ovulation approaches, cervical mucus is abundant and stretchable
1. During which time is the nurse correct to document the end of the third stage of labor? (Ch-16; P-300; DL-19; B-Apply; CO-1) a. Following fetal birth b. At the time of placental delivery c. When pushing begins d. When the mother is moved to the postpartum unit
a. At the time of placental delivery
1. The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? (Ch-16; P-304; DL-29; B-Apply; CO-11) a. Administer oxygen b. Change the position of the client c. Increase her IV fluids d. Notify the primary care provider
a. Change the position of the client
1. A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next? (Ch-16; P-294; DL-27; B-Apply; CO-1) a. Perform a vaginal exam b. Check the fetal heart rate c. Notify the primary care provider immediately d. Change the linen saver pad
a. Check the fetal heart rate
1. A pregnant client in her second trimester is diagnosed with hyperemesis gravidarum. The nurse would monitor the client closely for which of the following? (Ch-15; P-270; DL-4; B-Apply; CO-6) a. Heartburn b. Diarrhea c. Dehydration d. Constipation
a. Dehydration
1. The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: (Ch-16; P-297; DL-29; B-Apply; CO-1) a. Internal rotation, flexion, descent, extension, external rotation, expulsion b. Descent, flexion, external rotation, extension, internal rotation, expulsion c. Internal rotation, flexion, descent, extension, external rotation, expulsion d. Descent, flexion, internal rotation, extension, external rotation, expulsion
a. Descent, flexion, internal rotation, extension, external rotation, expulsion
1. A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? (Ch-16; P-294; DL-27; B-Apply; CO-1) a. signs of infection b. fetal position c. FHR d. maternal comfort level
a. FHR
1. A nurse is conducting an in-service education program about the female reproductive cycle for a group of nurses working at a women's health clinic. When describing the phases of the endometrial cycle, the nurse would explain that the proliferative phase of the endometrial cycle corresponds to which phase in the ovarian cycle? (Ch-14; P-243; DL-34; B-Apply; CO-13) a. Secretory b. Follicular c. Ischemic d. Menstrual
a. Follicular
1. A nursing instructor is explaining the stages of fetal development to a group of nursing students. The instructor determines the session is successful after the students correctly choose which time period as representing the pre-embyonic stage? (Ch-15; P-256; DL-25; B-Apply; CO-10) a. Approximately 2 weeks after fertilization and to the end of the eighth week b. Approximately 9 weeks after fertilization and to birth c. Approximately 6 weeks after fertilization and to the end of 8 weeks d. From fertilization and to the end of the second week
a. From fertilization and to the end of the second week
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of a miscarriage within the first trimester. The nurse is correct to document the history as: a. G = 4, T = 2, P = 0, A = 0, L = 1 b. G = 3, T = 1, P = 0, A = 1, L = 1 c. G = 1, T = 1, P = 1, A = 0, L = 1 G = 2, T = 0, P = 0, A = 0, L =
a. G = 3, T = 1, P = 0, A = 1, L = 1
1. A nurse is classifying the pregnancy history of a woman who has had five pregnancies: three full-term, one preterm, and one abortion. How would the nurse document this information on the patient chart? (Ch-14; P-233; DL-31; B-Analyze; CO-1) a. G4 P3115 b. G5 P3115 c. G5 P1135 d. G5 P3114
a. G5 P3114
1. To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? (Ch-16; P-298; DL-24; B-Understand; CO-1) a. Lying supine with legs in lithotomy stirrups b. Squatting while holding her breath c. Head elevated, grasping knees, breathing out d. Lying on side, arms grasped on abdomen
a. Head elevated, grasping knees, breathing out
A nurse is assessing a female client. When obtaining the client's history, the client tells the nurse that her menstrual cycle is usually 30 days and that she expects her next menstruation on March 20. Based on the client's information and the nurse's understanding of the female reproductive cycle, the nurse would identify ovulation as most likely occurring at which time? a. March 1 b. March 13 c. March 6 d. March 27
a. March 6
1. A woman reports that her last menstrual period (LMP) occurred February 1, 2017. Using the Naegele rule, what would be her estimated date of delivery (EDD)? (Ch-15; P-277; DL-36; B-Apply; CO-13) a. October 1, 2018 b. November 8, 2018 c. October 1, 2017 d. November 8, 2017
a. November 8, 2017 count back 3 months and add 7 days
1. A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? (Ch-16; P-302; DL-24; B-Apply; CO-11) a. Palpate the mother's radial pulse at the same time b. Ask the woman to hold her breath while assessing the FHR c. Have the woman lie completely flat on her back while auscultating d. Instruct the woman to bend her knees and flex her hips
a. Palpate the mother's radial pulse at the same time
1. The five "Ps" of labor are: (Ch-16; P-284-291; DL-32; B-Remember; CO-1) a. Passageway, passenger, position, powers, psych b. Passenger, posture, position, presentation, psych c. Passenger, position, presentation, pushing, psych d. Passenger, position, powers, presentation, psych
a. Passageway, passenger, position, powers, psych
1. A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time? (Ch-16; P-297; DL-10; B-Apply; CO-1) a. Push with contractions and rest between them b. Hold the breath while pushing during contractions c. Begin pushing as soon as the cervix has dilated to 8 cm d. Pant while pushing
a. Push with contractions and rest between them
1. The nurse is assessing the read-out of the external fetal monitor and notes late decelerations. Which action should the nurse prioritize at this time? (Ch-16; P-304; DL-24; B-Apply; CO-11) a. Notify the health care provider b. Palpate for bladder fullness c. Do nothing, this is benign d. Reposition the client on either side
a. Reposition the client on either side
1. The nursing instructor is teaching students about normal changes of pregnancy. The instructor talks about diastasis recti. What is the instructor presenting? (Ch-15; P-265; DL-33; B-Apply; CO-1) a. Separation of the muscles of the abdominal wall b. Raising of the uterus into the abdomen c. Relaxation of the kidneys d. Movement of the bladder to the rear of the pelvis behind the uterus
a. Separation of the muscles of the abdominal wall
1. Untreated hyperemesis can lead to preterm birth. What is the cause of the preterm birth? (Ch-15; P-263; DL-29; B-Apply; CO-6) a. Ketonuria resulting in neurologic changes in the fetus b. Severe dehydration resulting in hypoperfusion of the placenta c. Poor nutrient intake resulting in poor fetal growth d. Class B drugs used to control the vomiting resulting in uterine contractions
a. Severe dehydration resulting in hypoperfusion of the placenta
1. The nurse midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell's sign. Which description illustrates this alteration? (Ch-15; P-265; DL-31; B-Apply; CO-1) a. The cervix looks blue or purple when examined b. The lower uterine segment softens c. The fundus enlarges d. The cervix softens
a. The cervix softens
1. A client is attempting to become pregnant and is using varied methods to identify ovulation. What assessment finding would most clearly suggest that the client is ovulating? (Ch-14; P-243; DL-34; B-Analyze; CO-13) a. Cervical mucus is absent b. The client menstruated eight days ago c. The client has clear, thin cervical mucus d. The client's progesterone levels are peaking
a. The client has clear, thin cervical mucus
1. The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize? (Ch-16; P-300; DL-28; B-Apply; CO-1) a. The client's vital signs b. The end of recovery c. The completion of the third stage of labor d. The transition phase
a. The completion of the third stage of labor
1. Which statement best expresses the role of the corpus luteum? (Ch-14; P-241; DL-20; B-Understand; CO-13) a. The corpus luteum promotes the increased production of estrogen before ovulation b. During the luteal phase, the corpus luteum secretes glycogen c. The corpus luteum secretes progesterone to promote the preparation of the endometrium for implantation d. Increasing amounts of cervical mucus are produced as a result of the luteinizing hormone produced by the corpus luteum
a. The corpus luteum secretes progesterone to promote the preparation of the endometrium for implantation
1. The nursing instructor is teaching a group of nursing students about the menstrual cycle. The instructor determines the session is successful when the students correctly choose which action as responsible for the increased thickness of the endometrium? (Ch-14; P-242; DL-33; B-Apply; CO-13) a. The level of the FSH b. The decreasing level of the progesterone c. The dropping level of LH d. The increasing level of estrogen
a. The increasing level of estrogen
1. A multigravid client has been in labor for several hours and is becoming anxious and distressed with the intensity of her frequent contractions. The nurse observes moderate bloody show and performs a vaginal examination to assess the progress of labor. The cervix is 9 cm dilated. The nurse knows that the client is in which phase of labor? (Ch-16; P-295; DL-36; B-Analyze; CO-1) a. Latent phase b. Transition phase c. Active phase d. Early phase
a. Transition phase
1. The nurse is explaining the phases of the uterine cycle to a client. What action during the proliferative phase of the uterine cycle should the nurse include in the teaching session with the client? (Ch-14; P-243; DL-34; B-Apply; CO-13) a. While the ovarian follicles are producing increased amounts of estrogen, the endometrium prepares for possible fertilization with pronounced growth b. If fertilization does not occur, the corpus luteum degenerates, and hormonal levels fall c. Withdrawal of hormones causes the endometrial cells to change, and menstruation begins d. An ovum matures and is released
a. While the ovarian follicles are producing increased amounts of estrogen, the endometrium prepares for possible fertilization with pronounced growth
A nurse is client teaching with a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority?
avoidance of infection
1. The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is: (Ch-15; P-254; DL-25; B-Apply; CO-13) a. January 30 b. December 30 c. December 16 d. November 23
b. December 30
When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which schedule would be most appropriate?
bi-monthly visits until 28 weeks, then weekly visits
While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:
caput succedaneum.
A nurse working in the newborn nursery hears an innocent murmur on auscultation of a 24-hour-old infant's chest. The nurse recognizes this as most likely the result of which condition?
delayed fetal shunt closure
The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from:
developing Rh sensitivity.
A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client?
diminished reflexes
The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize?
dyspnea, crackles, and irregular weak pulse
On an Apgar evaluation, how is reflex irritability tested?
flicking the soles of the feet and observing the response
A nurse is conducting an assessment of a woman who has experienced PROM. Which finding would lead the nurse to suspect infection as the cause of a client's PROM?
foul odor
The nurse would be alert for possible placental abruption during labor when assessment reveals which finding?
gestational hypertension
A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as:
hydatidiform mole.
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?
improves pelvic floor tone
A client is entering her 42nd week of gestation and is being prepared for induction of labor. The nurse recognizes that the fetus is at risk for which condition?
macrosomia
A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply.
nifedipine magnesium sulfate indomethacin
A postpartum client comes to the clinic for her 6-week postpartum check up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:
slit-like.
A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable abortion?
strong abdominal cramping
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:
taking-in, taking-hold, letting-go.
A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem?
temperature of 101° F (38.3° C)
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?
touching
A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention?
urine output of 20 mL/hour
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
uterine infection prolonged labor hydramnios