maternity

2/6 The nurse considers the client's cues and determines more information is needed. Which two (2) follow-up questions would be appropriate for the nurse to ask the client?

"Do you understand English?" "What language do you speak and understand?"

5/6 The interpreter has arrived and the nurse is able to begin a cultural assessment on the client and partner. The client and partner appear relieved to have someone who speaks their language. The nurse would like to learn more about the client's views on childbirth. Which four (4) questions should the nurse ask to learn more about the client's belief system?

"How do you view childbirth?" "Do you have a treatment plan?" "Do you have any concerns about being in the hospital and/or childbirth?" "Is there anything we can do to make you more comfortable during childbirth?"

A nurse is caring for a client in the 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching?

"I can lie in any comfortable position, but I should stay off my back."

After the nurse instructs a pregnant client about swimming and bathing during pregnancy, which client statement indicates the need for additional teaching?

"I can relax in a hot tub for about 20 minutes."

An obstetric ultrasound reveals that the client's fetus has spina bifida. The parent is concerned about raising a child with a congenital abnormality and starts to cry. Which response by the nurse is best?

"I know this must be overwhelming. I'm here to sit with you and support you."

6/6 The nurse is speaking to the client and partner using the hospital interpreter. Complete the following sentence(s) by choosing from the lists of options. The nurse knows the client is now able to understand when they make the statement

"I would like to have more privacy during the birthing process."

A client who has been treated for infertility is now pregnant. During a routine ultrasound at 8 weeks' gestation, the client learns that five fetuses are visualized. The client's spouse is concerned that five infants will not survive and that the client may not be able to handle the stress of the pregnancy, so they ask the nurse about selective reduction. What is the nurse's best response?

"It has been used to decrease the possibility of complications."

A client who tells the nurse that they would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful?

"It's important to take my temperature at about the same time every morning before arising."

A client hospitalized for preterm labor tells the nurse a family member blames them for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse?

"Let's talk about how preterm labor occurs to help you understand what causes it."

When the nurse instructs a pregnant client with a history of varicose veins about strategies to promote comfort, which client statement indicates that the teaching has been successful?

"Lying down with my feet elevated should help."

The nurse instructs the client about the procedures that will be performed on the neonate immediately after birth to prevent meconium aspiration. The nurse determines that the instructions have been effective when the client states that which procedure will be done to the baby?

"Suctioning will be needed if the baby is floppy."

Which statement by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?"

"This usually disappears after birth."

The prenatal client wants to know why the nurse is asking about their use of herbal supplements. What is the nurse's best response?

"Understanding the full picture of what herbal supplements you use to manage your health will help us better provide coordinated and safe care."

The nurse is caring for a client who is gravida 2 para 1 and in active labor. The client asks the nurse if this labor is expected to be different from the first. What response by the nurse is most accurate?

"Usually it takes about half as long as your first labor."

A nurse in a prenatal clinic is assessing a client who is 28 weeks' pregnant. Which findings lead the nurse to suspect that the client has mild preeclampsia?

1+ protein, blood pressure 142/92 mmHg

A laboring client with preeclampsia is prescribed magnesium sulfate 2g per hour intravenous (IV) piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using one decimal place.

50 ml/hr

A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which rate would cause the nurse to intervene?

60-79 beats per minute

The nurse is caring for an adult female client who arrived at the emergency department with left sided abdominal and back pain. Today, 1400 Client is tearful. States that they have had abdominal discomfort on the left side of the umbilicus and back for 24 hours. Pain level reported as 5 out of 10. Client is diaphoretic, nauseated, abdomen soft, positive bowel sounds. Last bowel movement was 2 days ago.Vital signs: 98.8°F (37.1°C), heart rate 120 beats/min, respiration 24 breaths/min, blood pressure 162/88 mm HgLast menstrual period 6 weeks ago. Client denies pregnancy stating that they have an intrauterine device implanted to prevent pregnancy.

Actions to Take Administer methotrexate. Begin intravenous therapy. Possible Conditions Ectopic pregnancy Parameters to monitor Abdominal pain Serum hCG level

A nurse in a telemetry unit is providing care to a 36-year-old female client who is at 28 weeks' gestation. Client was admitted to the telemetry unit after experiencing increasing shortness of breath and fatigue over the past 2 days. Client reports that shortness of breath occurs especially when trying to lie flat or with exertion. Client thought it was related to their pregnancy; client is at 28 weeks' gestation with their first child. Today the client experienced palpitations, dizziness, and some chest discomfort. Then, they passed out for a few seconds. Their spouse drove them to the emergency department (ED). Client's chest pain had subsided by the time they arrived at the ED. A 12-lead electrocardiogram (ECG) and cardiac enzymes were obtained and a myocardial infarction was ruled out but some abnormalities of the left ventricle were noted on the ECG. Client was admitted to the telemetry unit for further observat

Actions to Take Request a prescription for a beta blocker medication. Prepare the client for echocardiography. Potential Conditions hypertrophic cardiomyopathy Parameters to Monitor lung sounds vital signs

An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's parent states that the adolescent child "has to bite the bullet, just like I did." What should the nurse do to make sure the client's request is honored?

Ask the client in a nonthreatening way if they wish to have an epidural, and then speak with the health care provider.

A laboring client is experiencing increased pain and asks the nurse when they can have an epidural. Which would be a priority intervention by the nurse to establish whether the client can have an epidural?

Assess cervical dilation.

Two hours ago, a multigravid client was admitted in active labor with the cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on their lips, and extreme irritability. What should the nurse do first?

Assess the client's cervical dilation and station.

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first?

Assess the fetal heart rate (FHR) for 1 full minute.

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission?

Assess the imminence of birth.

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-Ib (4.08-Kg) neonate. Labor was unusually long and required oxytocin augmentation. The nurse who's caring for the client should stay alert for uterine

Atony

A 26-year-old primigravida visiting the prenatal clinic for their regular visit at 34 weeks' gestation tells the nurse that they take mineral oil for occasional constipation. What should the nurse should instruct the client to do?

Avoid taking mineral oil because it interferes with the absorption of fat-soluble vitamins.

A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color?

Blue

While assessing a multigravid client at 10 weeks' gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this as what finding?

Chadwick's sign

A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?

Change the client's position

The nurse is facilitating a childbirth education class with a group of parents. On the first day of class, the nurse finds that none of the clients is a first-time parent. Which of the following would be a teaching strategy to best assist the clients?

Complete a needs assessment about what the parents are interested in learning.

A client who had a Papanicolaou (Pap) test 2 months ago and is now beginning oral contraceptives tells the nurse that their menstrual flow has decreased since taking the oral contraceptives. What should the nurse tell the client to do?

Continue to take the oral contraceptives because decreased menstrual flow is normal.

The health care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding?

Contractions cease

The nurse has administered promethazine intravenously to a client in active labor. The drug has had the desired effect when the nurse notes which finding?

Decreased nausea and vomiting

A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that they want to breast-feed the neonate?

Discourage breast-feeding because HIV can be transmitted through breast milk.

Which instruction should a nurse give to a client who's 26 weeks pregnant and reports of constipation?

Encourage the client to increase the intake of roughage and to drink at least six glasses of water per day.

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when they say they will need to do which action?

Hold their breath throughout the length of the contraction.

6/6 The nurse reassesses the client after the postpartum hemorrhage protocol was initiated. Complete the following sentence by choosing from the list of options. The nurse reports that the clients condition has ____ with next step being to ____

Improved Continue to monitor peripads and fundus

A nurse is caring for laboring G2P1 client who is at 39 weeks gestation. Based on the most current findings, the nurse should take which four (4) nursing actions?

Instruct the client to stop pushing. Call for help. Push client's thighs to the abdomen to flex and abduct the hips. Apply suprapubic pressure.

5/6 The nurse is initiating the postpartum hemorrhage protocol. Which two (2) orders would the nurse complete immediately?

Massage fundus. Administer misoprostol.

A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority?

Massage the uterus

4/6 Select the orders that the nurse should include in the plan of care.

Nursing orders Intake and output Massage fundus Weigh peripads Oxygen to keep 02 saturation over 92% Laboratory orders Type and cross match blood Hemoglobin and hematocrit Medication orders Misoprostol Colloid fluids

1/6 The client is a gravida 3, now para 3. Transferred from the labor and delivery unit following a vaginal birth. Client required stitches for a 2nd degree perineal tear. Edema noted around perineal area. Fundus boggy, midline, 2 cm above umbilicus. Client has saturated 1 pad/hour since delivery. An orange sized blood clot is also on the pad. States, "I feel funny, somewhat tingly." Select four (4) assessment findings which need immediate follow-up by the nurse.

Pad saturation Client statement Boggy fundus Orange-sized blood clot

A primigravida states, "I think my water just broke." What should the nurse do? Select all that apply.

Perform a nitrazine test to confirm that the membranes are ruptured. Monitor the fetal heart rate and pattern. Assess maternal temperature.

The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" The client's last vaginal examination was 1 hour ago and showed the client was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client?

Perform a vaginal examination to determine if the client is fully dilated.

A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take?

Place the client on their left side and start supplemental oxygen, as ordered.

The nurse is caring for a pregnant client. The nurse notes hypotension and a non-reassuring fetal heart tracing. Which action would the nurse include in the client's plan of care?

Position the client on their left side.

When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal system?

Pulmonary

A client at 22 weeks' gestation has right upper quadrant pain radiating to their back. The client rates the pain as 9 on a scale of 0 to 10 and says that it has occurred two times in the last week for about 4 hours at a time. The client does not associate the pain with food. Which nursing measure is the highest priority for this client?

Refer the client to their health care provider for evaluation and treatment of the pain.

A nurse notices repetitive late decelerations on the fetal heart monitor. What are the best initial actions by the nurse?

Reposition the client, apply oxygen, and increase IV fluids.

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol?

Stop the visitor, and ask for identification.

A client's partner tells the nurse that they will remain in the waiting room while the client is in labor. The client's sibling has been chosen to be the birth companion. Which of the following responses from the nurse would be most appropriate?

Tell the partner that they will receive updates of the client's progress and be called as soon as the baby is born.

A client is seeking infertility treatment after attempting pregnancy for 2 years. Of the data from the client's history, which has the greatest impact on infertility?

The client is a gymnast weighing 105 lb (47.6 kg).

A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity?

The intact membranes

The client and their partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence?

The national standards of practice were met when providing care.

The community nurse works with the family to answer their questions on infant care. The nurse would like to maintain therapeutic boundaries within the therapeutic relationship. Which of the following is the best way to maintain boundaries?

The nurse does not disclose their home address or accept the invitation to stay for lunch.

3/6 Complete the following sentence by choosing from the list of options. The client is most likely experiencing a postpartum hemorrhage caused by

Uterine atony

2/6 For each assessment finding, click to indicate if the finding is consistent with a postpartum hemorrhage related to uterine atony, a pelvic hematoma, or a laceration of the genital tract.

Uterine atony Boggy fundus Saturation of 1 pad/hr. pulse oximeter, 90-% decreasing blood pressure client statement of feeling tingly An orange size blood clot Pelvic hematoma pulse oximeter, 90-% decreasing blood pressure client statement of feeling tingly Laceration of the genital tract pulse oximeter, 90-% decreasing blood pressure client statement of feeling tingly

The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage?

a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy

A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, what would the nurse most expect to find?

a history of pelvic inflammatory disease

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the health care provider should be notified?

an increased sense of rectal pressure

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point?

at about the level of the client's umbilicus

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

beginning of one contraction to the beginning of the next contraction

A client is in the last trimester of pregnancy. The nurse should instruct the client to notify the primary health care provider immediately of:

blurred vision.

A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that their lower back aches when they arrive home from work. The nurse should suggest that the client perform which exercise?

blurred vision.

The fetus of a multigravid client at 38 weeks' gestation is determined to be in a frank breech presentation. The nurse describes this presentation to the client as which fetal part coming in contact with the cervix?

buttocks

The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean birth?

client at 38 weeks' gestation with active herpes lesions

A client is 37 weeks gestation and is experiencing preeclampsia. The health care provider has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the client-nurse assignment before the morning shift begins. Which factors should be the primary factor in the decision surrounding who should care for this client?

complexity of care requirements

A 24-year-old client admitted to the hospital is suspected of having an ectopic pregnancy. On admission, which factor would be most important to assess?

date of last menstrual period

A 19-year-old unmarried college student who is approximately 8 weeks pregnant asks the nurse, "If I have an abortion in the next 2 or 3 weeks, how will it be done?" The nurse instructs the client that at this gestational age, an abortion is usually performed by which technique?

dilatation and curettage

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. The nurse notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?

early decelerations

A client in labor asks the nurse about Reiki, an alternative therapy that they have heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of

energy from light touch.

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if any of the clients have which finding?

evidence of spontaneous rupture of the membranes

A nurse recognizes that labor is divided into how many stages?

four

When evaluating a pregnant client's fundal height, the nurse should measure in which way?

from the symphysis pubis notch to the highest level of the fundus

An antenatal primigravid client has just been informed they are carrying twins. The plan of care includes educating the client concerning factors that put the client at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when they indicate carrying twins puts the client at risk for which complication?

group B streptococcus

A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply.

interpretation of the fetal monitor strip analgesia or anesthesia being used prior birth history support persons with the client

3/6 0500The client is admitted from triage with rupture of membranes in early labor. The nurse is performing an admission assessment and going over the labor process. While doing so, the nurse notices that the client nods frequently and the responses are not always appropriate. The client also frequently looks to their partner before answering and has a heavy accent. 0515The nurse asks the client what their native language is and if they understand English. The client states "Chinese and only a little bit." The nurse asks the same of the partner and they just shake their head in a negative manner. The nurse needs to finish the admission assessment and make sure the client is comfortable and understands the labor process. Complete the following sentence(s) by choosing from the lists of options.

language barrier communicate appropriately with the client

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?

maternal hypotension

A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. Because the client's fallopian tube has not yet ruptured, the nurse anticipates that which medication may be prescribed?

methotrexate

The health care provider prescribes a maternal blood test for alpha-fetoprotein for a nulligravid client at 16 weeks' gestation. When developing the teaching plan, the nurse bases the explanations on the understanding that this test is used to detect which condition?

neural tube defects

A primigravida, currently about 8 weeks' gestation, and their spouse ask when they should begin the preparation for birth classes that discuss maternal nutrition during pregnancy. Which time would be most appropriate for the nurse to suggest that they begin the classes?

now during the first trimester of pregnancy

A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that their lower back aches when arriving home from work. The nurse should suggest that the client perform which exercise?

pelvic tilts

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem?

respiratory distress syndrome

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:

review the unit's procedure manual.

1/6 Click to highlight the findings that will require follow up. The client is admitted from triage with rupture of membranes in early labor. The nurse is performing an admission assessment and going over the labor process. While doing so, the nurse notices that the client nods frequently and the responses are not always appropriate. The client also frequently looks to their partner before answering and has a heavy accent.

rupture of membranes client nods frequently and the responses are not always appropriate. client also frequently looks to their partner before answering

A client is 41 weeks gestation and is admitted to the hospital in true labor. The client has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15

4/6 While waiting for the interpreter, the nurse notices, the client putting on clothes over the hospital gown and covering up with the blanket whenever someone knocks on the door to come in the room. Complete the following sentence(s) by choosing from the lists of options. The nurse should first contact the Select...the charge nurse the hospital interpreter the provider Select... in order to

the hospital interpreter communicate appropriately with the client

A client who is in the third trimester presents at the labor and delivery triage area with a history of a fall. The client has bruising on their back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to

the social worker on call.

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates the client. Which assessment finding may indicate the need for cesarean birth?

umbilical cord prolapse

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings may signify:

umbilical cord prolapse.

A client at 36 weeks' gestation with type 1 diabetes has an abnormal biophysical profile and is scheduled for a contraction stress test. After explaining the purpose of the test, the nurse determines that the client understands the instruction when they state that the test is done to detect which problem?

uteroplacental sufficiency