Maternity NCLEX Practice

The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding? Fundus is at the appropriate level. Fundus is larger than expected height. Fundus is smaller than expected height. Growth pattern indicates intrauterine growth restriction (IUGR).

Fundus is at the appropriate level

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? "Iron supplements will give me diarrhea." "Meat does not provide iron and should be avoided." "The iron is best absorbed if taken on an empty stomach." "On the days that I eat green leafy vegetables or calf liver, I can omit taking the iron supplement."

The iron is best absorbed if taken on an empty stomach

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? "You will need to bottle-feed your newborn." "You will need to feed your newborn by nasogastric tube feeding." "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

You will need to bottle-feed your newborn

The nurse is monitoring a newborn born to a client who abuses alcohol. Which finding should the nurse expect to note when assessing this newborn? Flaccidity Irritability Poor feeding Minimal response to stimuli

Irritability

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

21001

A pregnant client reports that she has noticed a thin, colorless vaginal drainage. Which information should the nurse provide to the client?

It is normal

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Naegele's rule, which expected date of delivery should the nurse document in the client's chart? July 12, 2021 July 26, 2021 August 12, 2021 August 26, 2021

July 26, 2021

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? Offer only 1 breast at each feeding. Massage distended areas as the infant nurses. Express and discard milk from the affected breast at the first signs of mastitis. Cleanse the nipples with a mild antibacterial soap before and after infant feedings.

Massage distended areas as the infant nurses

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. Ballottement Chadwick's sign Uterine enlargement Positive pregnancy test Fetal heart rate detected by a nonelectronic device Outline of fetus via radiography or ultrasonography

Ballottement Chadwick's sign Uterine enlargement Positive pregnancy test

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? "I will place my baby's crib close to the door." "Some health care personnel won't have name badges." "I will ask the nurse to attend to my infant if I am napping and my husband is not here." "It's okay to allow the nurse assistant to carry my newborn to the nursery."

I will ask the nurse to attend to my infant if I am napping and my husband is not here

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? "I will drink 8 oz of water with each meal." "I will eat 3 servings of cracked wheat bread each day." "I will eat 2 saltine crackers before I get up each morning." "I will eat fresh fruits and vegetables for snacks and for dessert each day."

I will eat fresh fruits and vegetables for snacks and for dessert each day

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. Early labor Amniotomy Tachycardia Fetal hypoxia Metabolic acidemia Congenital anomalies

Tachycardia Fetal Hypoxia Metabolic Acidemia Congenital Anomalies

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate. Which is the initial nursing action? Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.

Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min

The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? Milk Potatoes Cantaloupe Whole-grain cereal

Whole-grain cereal

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at most risk for development of postpartum thromboembolic disorders? A 39-year-old woman who reports that she smokes A 24-year-old woman with a thin frame who is a vegetarian A 30-year-old woman in her fourth pregnancy who is normal weight A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have not caused any adverse effects

A 39-year-old woman who reports that she smokes

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?

Encourage the client to take pain medication as prescribed

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? Warming the crib pad Closing the doors to the room Drying the infant with a warm blanket Turning on the overhead radiant warmer

Drying the infant with a warm blanket

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. Massaging the uterus Pushing gently on the uterus Assisting the woman to urinate Rechecking the uterus in 1 hour Checking for a distended bladder Calling the delivery room to schedule an abdominal hysterectomy

Massaging the uterus Assisting the woman to urinate Checking for a distended bladder

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A primiparous client who delivered 4 hours ago A multiparous client who delivered 6 hours ago A multiparous client who delivered a large baby after oxytocin induction A primiparous client who delivered 6 hours ago and had epidural anesthesia

A multiparous client who delivered a large baby after oxytocin induction

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? Notify the primary health care provider (PHCP). Continue monitoring the fetal heart rate. Encourage the client to continue pushing with each contraction. Instruct the client's coach to continue to encourage breathing techniques.

Notify the PHCP

An initial assessment of a large for gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? Palpate the clavicles for a fracture. Auscultate the heart for a cardiac defect. Blanch the skin for evidence of jaundice. Perform Ortolani's maneuver for hip dysplasia.

Palpate the clavicles for a fracture

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? Monitoring the vital signs Palpating the uterine fundus Auscultating the bowel sounds Assessing the amount of drainage on the peripad

Palpating the uterine fundus

The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn. Which actions should the nurse take? Select all that apply. Pat the baby dry gently. Use shampoo to wash the scalp and hair. Support the newborn's body during the bath. Make sure that the room temperature is 75º F (23.9º C). Cleanse one body area at a time keeping other body areas covered.

Pat the baby dry gently Support the newborn's body during bath Make sure that the room temp is 75 Cleanse one body area at a time keeping other body areas covered

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? Monitor fetal heart rate continuously. Monitor maternal vital signs frequently. Perform a vaginal examination every shift. Administer an antibiotic per PHCP prescription and per agency protocol.

Perform a vaginal examination every shift

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? Stimulate the labor process. Prevent dehydration and hypoxemia. Avoid the necessity of a cesarean section. Eliminate the need for analgesic administration.

Prevent dehydration and hypoxemia

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? Provide pain relief measures. Prepare the client for an amniotomy. Promote ambulation every 30 minutes. Monitor the oxytocin infusion closely.

Provide pain relief measures

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? Ambulation Rest between contractions Change positions frequently Consume oral food and fluids

Rest between contractions

The nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur? She will feel some pain during the procedure. She will be placed in a supine left side-lying position. She will feel some pressure when the vaginal probe is moved. She will need to drink 2 quarts of water to attain a full bladder.

She will feel some pressure when the vaginal probe is moved

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis? Monitoring the urine for blood Monitoring the urinary output pattern Testing for contractures of the extremities Stimulating for reflex responses in the extremities

Stimulating for reflex responses in the extremities

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? Encourage the mother to breast-feed soon after birth. Support the mother in her reaction to the newborn infant. Tell the mother that it is important to hold the newborn infant. Document a complete account of the mother's reaction on the birth record.

Support the mother in her reaction to the newborn infant

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? The appearance of the fetal external genitalia The beginning of differentiation in the fetal groin The fetal testes are descended into the scrotal sac The internal differences in males and females become apparent

The appearance of the fetal external genitalia

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks' gestation because of which factor? The appearance of the fetal external genitalia The beginning of differentiation in the fetal groin The fetal testes are descended into the scrotal sac The internal differences in males and females become apparent

The appearance of the fetal external genitalia

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation? The client is hemorrhaging. The client needs to increase oral fluids. The client is experiencing normal lochia discharge. The client's primary health care provider (PHCP) needs to be notified of the finding.

The client is experiencing normal lochia discharge

The nurse is preparing to provide instructions to a new mother regarding cord care for a newborn infant. Which instructions would the nurse provide? Select all that apply. "The cord needs to be kept clean and dry." "Always use peroxide undiluted to clean the cord." "Cord care needs to be done once daily before bedtime." "You need to do cord care until the cord dries up and falls off." "You need to fold the diaper above the cord to prevent infection."

The cord needs to be kept clean and dry You need to do cord care until the cord dries up and falls off

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? "Your type of pelvis has a narrow pubic arch." "Your type of pelvis is the most favorable for labor and birth." "Your type of pelvis is a wide pelvis, but it has a short diameter." "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

Your type of pelvis is the most favorable for labor and birth

The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was, and the client reports February 14, 2021. Using Naegele's rule, the nurse determines that what is the estimated date of delivery? Fill in the blank. Record your answer using 6 digits (mmddyy).

112121

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the sex of the fetus can be determined as early as which week? 6 8 12 20

12

A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? "The test is a procedure that will require an informed consent to be signed." "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." "The test is done to see if the baby can handle the stress of labor, and medicine is given to make the uterus contract." "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen."

A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate? Massage the fundus. Cover the client with a warm blanket. Place the client in Trendelenburg's position. Contact the primary health care provider (PHCP).

Cover the client with a warm blanket

Which is considered a normal finding in a newborn less than 12 hours old?

Bluish discoloration of hands and feet

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Change in vital signs

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up

The client with lochia that is red and has a foul smelling odor

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

A primigravida with abruption placenta A gravida 2 who has just been diagnosed with dead fetus syndrome A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. Age 54 Body mass index of 28 Previous difficulty with fertility Administration of oxytocin for induction Potassium level of 3.6 mEq/L (3.6 mmol/L)

Age 54 BMI 28 Previous difficulty with fertility

The nurse is preparing to administer an injection of vitamin K to a newborn and provides the mother with information about the injection. Which information should the nurse provide? "It's a single injection given by the intravenous route." "The injection is given after birth and then again one month later." "The injection is extremely important to prevent bleeding in your baby." "It's fine if you want to refuse giving it to your baby. Once your baby starts on baby food vitamin K deficiency will be replaced."

The injection is extremely important to prevent bleeding in your baby

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? The mother requests that the window be closed before feeding. The mother holds the newborn properly during feeding and burping. The mother tests the temperature of the formula before initiating feeding. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding

A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure? "Ova and sperm are collected and allowed to incubate." "A fertilized ovum is transferred into the woman's uterus." "The procedure is a method of medically assisted reproduction." "The procedure is performed using artificial insemination of sperm instilled through the vagina."

The procedure is performed using artificial insemination of sperm instilled through the vagina

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? "What can I do for you?" "Now you have an angel in heaven." "Don't worry, there is nothing you could have done to prevent this from happening." "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

What can I do for you?

The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? "Most children do not receive the vaccine until they are 5 years of age." "You are still susceptible to rubella, so your toddler should receive the vaccine." "It is not advised for children of pregnant women to be vaccinated during their mother's pregnancy." "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."

Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations? Episodic, late decelerations that indicate uteroplacental insufficiency Periodic, early decelerations that indicate fetal head compression Periodic, variable decelerations that indicate cord compression Episodic, early decelerations that may be a result of maternal hypotension

Periodic, early decelerations that indicate fetal head compression

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

You will need to bottle-feed your newborn

The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? Wrap the tape measure around the infant's head, and measure just below the eyebrows. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. Place the tape measure under the infant's head at the base of the skull and wrap around to the front just below the eyes. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.

Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows

The nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding, the nurse should prepare for which appropriate nursing action? Administering oxygen via face mask Placing the mother in a supine position Increasing the rate of the intravenous (IV) oxytocin infusion Documenting the findings and continuing to monitor the fetal patterns

Administering oxygen via face mask

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. The nurse should tell the client that which exercise is safest? Walking Scuba diving Low-impact gymnastics Bicycling with the legs in the air

Walking

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. Allows for fetal movement Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus Can be used to measure fetal kidney function Prevents large particles such as bacteria from passing to the fetus Provides an exchange of nutrients and waste products between the mother and the fetus

Allow for fetal movement Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus Can be used to measure fetal kidney function

The nurse determines the apical heart rate of a 2-day-old newborn to be 140 beats/minute. Which intervention is most appropriate related to this finding? Reassess the heart rate in 15 minutes. Contact the primary health care provider (PHCP). Document the finding in the electronic health record. Attach the newborn to a cardiac monitor to obtain additional data.

Document the finding in the electronic health record

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. Proteinuria Hypertension Low-grade fever Generalized edema Increased pulse rate Increased respiratory rate

Proteinuria Hypertension

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make?

Between 16-20 weeks

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? Prepare the client for a cesarean delivery. Monitor the FHR every 30 minutes. Encourage an upright or side-lying maternal position. Increase the rate of the oxytocin infusion every 10 minutes.

Encourage an upright or side-lying maternal position

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? "We want to attend a support group." "We never want to try to have a baby again." "We are going to try to adopt a child immediately." "We are okay, and we are going to try to have another baby immediately."

We want to attend a support group

A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased? Increased urinary output A fetal heart rate of 180 beats/min Three contractions occurring in a 10-minute period Adequate resting tone of the uterus palpated between contractions

A fetal heart rate of 180 bpm

The nurse is preparing to care for 4 assigned clients. Which client is at most risk for hemorrhage? A primiparous client who delivered 4 hours ago A multiparous client who delivered 6 hours ago A multiparous client who delivered a large baby after oxytocin induction A primiparous client who delivered 6 hours ago and had epidural anesthesia

A multiparous clinet who delivered a large baby after oxytocin induction

The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply. Soft uterus Abdominal pain Nontender uterus Firm uterus by palpation Painless vaginal bleeding

Abdominal pain Firm uterus by palpation

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? Length of 19 inches Abnormal palmar creases Birth weight of 6 lb, 14 oz (3120 g) Head circumference appropriate for gestational age

Abnormal palmar creases

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and also notes that this is the client's first child. Which nursing interventions are most appropriate in assisting the promotion of mother-infant interaction and bonding? Select all that apply. Accepting the client's feelings Acknowledging the client's apprehension Assisting the client with giving the baths to allow her to become more at ease Leaving the infant with the client so that she will be required to provide the care Taking the newborn back to the nursery to provide rest periods for the new mother

Accept Acknowledge Assisting

The nurse is assisting the primary health care provider to perform Leopold's maneuvers on a pregnant client. Which action should the nurse perform before the procedure?

Ask the client to urinate

The nurse is preparing to instruct a client on how to bathe a newborn. Which statement should the nurse include in the instruction? "Begin with the eyes and face." "Begin with the feet and work upward." "Do the back side first, and then the front side." "Start with the chest, move to the face, and then finish the rest of the body."

Begin with the eyes and face

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps? "Bend your foot toward your body while flexing the knee when the cramps occur." "Bend your foot toward your body while extending the knee when the cramps occur." "Point your foot away from your body while flexing the knee when the cramps occur." "Point your foot away from your body while extending the knee when the cramps occur."

Bend your foot toward your body while extending the knee when the cramps occur

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? Ambulating Breast-feeding Taking sitz baths Increasing activity after arriving home

Breast-feeding

A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's firstaction?

Call the primary health care provider to obtain a prescription for intravenous antibiotic prophylaxis

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved? Pink mucous membranes Increased vaginal secretions Complaints of daily headaches and fatigue Complaints of increased frequency of voiding

Complaints of daily headaches and fatigue

The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?

Continue to monitor the client

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. Cyanosis Tachypnea Hypotension Retractions Audible grunts Presence of a barrel chest

Cyanosis Tachypnea Retractions Audible grunts

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?

Delivery of the fetus

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action? Document the finding. Check the mother's heart rate. Notify the obstetrician (OB). Tell the client that the fetal heart rate is normal.

Notify the OB

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? Document the findings. Notify the obstetrician (OB). Reassess the client in 2 hours. Encourage increased oral intake of fluids.

Notify the OB

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic exam

The nurse is providing instructions about taking iron supplements to a pregnant client. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which drink? Tea Milk Coffee Orange juice

Orange Juice

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? "The medication will affect you and your pain level only when given during a contraction." "The medication will provide optimal relief when it is given while your pain level is highest." "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." "You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication

During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? "Diet and insulin needs change during pregnancy." "I will plan my diet based on the results of urine glucose testing." "I will need to eat 600 more calories every day because I am pregnant." "I can continue with the same diet as before pregnancy, as long as it is well balanced."

Diet and insulin needs change during pregnancy

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? Apply gentle pressure. Reinforce the dressing. Document the findings. Contact the primary health care provider (PHCP).

Document the findings

The nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food should the nurse encourage the client to consume because it is highest in folic acid? Rice Cheese Chicken Dried beans

Dried beans

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only 2 vessels. How should the nurse interpret this finding?

Finding 2 vessels may indicate an increased risk for other congenital anomalies

The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the vital signs are within normal range if which set of vital signs is noted on assessment? Heart rate 90 beats/minute, respirations 46 breaths/minute Heart rate 120 beats/minute, respirations 68 breaths/minute Heart rate 130 beats/minute, respirations 46 breaths/minute Heart rate 180 beats/minute, respirations 56 breaths/minute

HR 130, RR 46

The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? Hematoma Hemorrhage Chronic hypertension Disseminated intravascular coagulation

Hemorrhage

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? "I don't like my figure anymore. My clothes are all too tight." "I don't like my breasts anymore. These silver lines are ugly." "I don't like my stomach anymore. That brown line is disgusting." "I don't like my face anymore. I always look like I have been crying."

I don't like my face anymore. I always look like I have been crying

The nurse is providing instructions regarding the treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? "I should avoid straining during bowel movements." "I can gently replace the hemorrhoids into the rectum." "I can apply ice packs to the hemorrhoids to reduce the swelling." "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? "I should apply my antiembolism stockings after breakfast." "I should avoid prolonged standing or sitting in 1 position." "I should perform regularly scheduled exercise such as walking." "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

I should apply my antiembolism stockings after breakfast

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? "I should avoid between-meal snacks." "I should lie down for an hour after eating." "I should use spices for cooking rather than using salt." "I should avoid eating foods that produce gas and fatty foods."

I should avoid eating foods that produce gas and fatty foods

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? Positive for HIV Indicates the presence of maternal infection Indicates that the newborn will develop acquired immunodeficiency syndrome (AIDS) later in life Positive for AIDS

Indicates the presence of maternal infection

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? Raise the head of the client's bed. Obtain hemoglobin and hematocrit levels. Instruct the client to request help when getting out of bed. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.

Instruct the client to request help when getting out of bed

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? Therapeutic abortion is required. Isoniazid plus rifampin will be required for 9 months. She will have to stay at home until treatment is completed. Medication will not be started until after delivery of the fetus.

Isoniazid plus rifampin will be required for 9 months

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply.

Keep Initiate Pad Avoid

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? Developmental delays because of excessive size Maintaining safety because of low blood glucose levels Choking because of impaired suck and swallow reflexes Elevated body temperature because of excess fat and glycogen

Maintaining safety because of low blood glucose levels

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? Maternal infection Gestational hypertension Gestational diabetes mellitus Consumption of recent high-sugar snack

Maternal infection

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?

Monitor the newborn's response to feedings and weight gain pattern

Which is the priority nursing action for the client with an ectopic pregnancy? Assessing urine for proteinuria Checking the electrolyte values Monitoring for signs of infection Monitoring the pulse and blood pressure

Monitoring the pulse and blood pressure

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? Maternal fatigue Coordinated uterine contractions Progressive changes in the cervix Persistent nonreassuring fetal heart rate

Persistent nonreassuring fetal heart rate

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likelyassociated with disseminated intravascular coagulation? Select all that apply.

Petechiae hematuria prolonged clotting oozing

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only 2 red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. Call bell Feeding pump Vital sign machine Phototherapy lights Intravenous (IV) pump

Phototherapy lights Intravenous (IV) pump

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. Breast-feeding needs to be stopped for 3 months. Pregnancy needs to be avoided for 1 to 3 months. The vaccine is administered by the subcutaneous route. Exposure to immunosuppressed individuals needs to be avoided. A hypersensitivity reaction can occur if the client has an allergy to eggs. The area of the injection needs to be covered with a sterile gauze for 1 week.

Pregnancy needs to be avoided for 1 to 3 months The vaccine is administered by the subcutaneous route Exposure to immunosuppressed individuals needs to be avoided A hypersensitivity reaction can occur if the client has an allergy to eggs

The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk?

Presence of cats

The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider (PHCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? Select all that apply. Protect defect from trauma. Protect sac or viscera with dry gauze. Maintain a thermoneutral environment. Feed newborn every 4 hours, 2 to 3 ounces (60 to 90 ml) of D5W. Assess for associated birth defects such as cleft palate.

Protect defect from trauma Maintain a thermoneutral environment Assess for associated birth defects such as cleft palate

Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply. Report a foul-smelling discharge. Take a warm sitz baths 3 times a day. Change the perineum pads 3 times a day. Use warm water to rinse the perineum after elimination. Wipe the perineum from front to back after voiding and defecation.

Report a foul-smelling discharge Take a warm sitz bath 3 times a day Use warm water to rinse the perineum after elimination Wipe the perineum from front to back after voiding and defecation

The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction? Increase daily calories to ensure weight gain. Maintain a supine position during rest periods. Restrict visitors who may have an active infection. Avoid becoming concerned about placing stress on the heart.

Restrict visitors who may have an active infection

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? Supine position with a wedge under the right hip Trendelenburg's position with the legs in stirrups Prone position with the legs separated and elevated Semi-Fowler's position with a pillow under the knees

Supine position with a wedge under the right hip

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. Which exercise should the nurse instruct the client to engage in? Swimming Water skiing Downhill skiing Aerobic exercising

Swimming

A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply. The breasts become stretched because of the weight gain. The increased metabolic rate causes the breasts to become larger. The breast changes occur because of the secretion of estrogen and progesterone. Cortisol secreted by the adrenal glands plays a role in increasing the size and appearance of the breasts. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida.

The breast changes occur because of the secretion of estrogen and progesterone Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)? Urinary output has increased. Dependent edema has resolved. Blood pressure reading is at the prenatal baseline. The client complains of a headache and blurred vision.

The client complains of headache and blurred vision

The nurse is monitoring the client for signs of postpartum depression. Which behavior indicates the need for further assessment related to this form of depression? The client is caring for the infant in a loving manner. The client demonstrates an interest in the surroundings. The client constantly complains of tiredness and fatigue. The client looks forward to visits from the father of the newborn.

The client constantly complains of tiredness and fatigue

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? The diet should include additional fluids. Prenatal vitamins should be discontinued. Soap should be used to cleanse the breasts. Birth control measures are unnecessary while breast-feeding.

The diet should include additional fluids

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply.

The ductus arteriosus allows blood to bypass fetal lungs One vein carried oxygenated blood form placenta to the fetus Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? "I will probably need my mother to help me with housekeeping." "Because I am so sore, I will nurse the baby while lying on my side." "My husband and I will not have intercourse until the stitches are healed." "The only medications I will take are prenatal vitamins and stool softeners."

The only medications I will take are prenatal vitamins and stool softeners

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Painless, bright red vaginal bleeding Increased uterine resting tone on fetal monitoring

Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Increased uterine resting tone on fetal monitoring

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? Variability Accelerations Early decelerations Variable decelerations

Variable decelerations

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? Avoid wearing a bra. Wash the breasts with warm water and keep them dry. Wear tight-fitting blouses or dresses to provide support. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion.

Wash breast with warm water

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide?

Washt the breasts with warm water

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." "You should not become pregnant for 2 to 3 months after administration of the vaccine." "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

You should not become pregnant for 2 to 3 months after administration of the vaccine

A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication? Placenta previa Polyhydramnios Abruptio placentae Gestational hypertension

Abruptio placentae

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? Elevate her legs. Remain on bed rest. Ambulate frequently. Apply warm, moist packs to the legs.

Ambulate frequently

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse should provide the client with which information? Glucose crosses the placenta Insulin crosses the placenta Increased caloric intake is needed Decreased caloric intake is required

Glucose crosses the placenta

The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement? "An increase in pulse rate occurs." "A decrease in blood volume occurs." "A decrease in cardiac output occurs." "The blood pressure increases by 20 mm Hg."

An increase in pulse rate occurs

The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area? Click on the image to indicate your answer.

4

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? A temperature of 100.4° F (38° C) An increase in the pulse rate from 88 to 102 beats per minute A blood pressure change from 130/88 to 124/80 mm Hg An increase in the respiratory rate from 18 to 22 breaths per minute

An increase in the pulse rate from 88 to 102 bpm

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL (238 mcmol/L). The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? Applying lotions to exposed newborn skin Assessing skin integrity and fluid status of the newborn Having minimal contact with the newborn to prevent stimulation Advising the mother to limit the newborn's oral intake during phototherapy

Assessing skin integrity and fluid status of the newborn

A primigravida asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 8 and 10 10 and 12 14 and 16 18 and 20

18 and 20

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? "If I experience any sweating during the night, I should call the primary health care provider." "If I have uterine cramping while breast-feeding, I should contact the primary health care provider." "If I'm still having vaginal drainage in a week, I should contact the primary health care provider." "If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider."

"If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider."

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply. A bulging anterior fontanel A depressed anterior fontanel A soft and flat anterior fontanel A triangular-shaped anterior fontanel A triangular-shaped posterior fontanel Size of posterior fontanel is 4 cm by 6 cm

A soft and flat anterior fontanel A triangular-shaped posterior fontanel

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? Increased urinary output A fetal heart rate of 90 beats/minute 3 contractions occurring within a 10-minute period Adequate resting tone of the uterus palpated between contractions

A fetal heart rate of 90 bpm

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. A primigravida with mild preeclampsia A primigravida who delivered a 10-lb infant 3 hours ago A gravida II who has just been diagnosed with dead fetus syndrome A gravida IV who delivered 8 hours ago and has lost 500 mL of blood A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

A gravida II who has just been diagnosed with dead fetus syndrome A primigravidy at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? A normal test result An abnormal test result A high risk for fetal demise The need for a cesarean section

A normal test result

The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis? Abdominal tenderness and chills Increased diuresis and appetite Maternal oral temperature of 100.2º F (37.9º C) Fundus 2 fingerbreadths below umbilicus, midline and firm

Abdominal tenderness and chills

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

Abnormal palmar increases

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? Administer oxygen via face mask. Place the mother in a supine position. Increase the rate of the oxytocin intravenous infusion. Document the findings and continue to monitor the fetal patterns.

Administer oxygen via face mask

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock? Complaints of abdominal cramping An increased pulse rate of 80 to 120 beats/min Complaints of feeling tired yet is feeling hungry An increase in the respiratory rate from 18 to 22 breaths/min

An increased pulse rate of 80 to 120 bpm

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? Strict bed rest is required after the procedure. Hospitalization is necessary for 24 hours after the procedure. An informed consent needs to be signed before the procedure. A fever is expected after the procedure because of the trauma to the abdomen.

An informed consent needs to be signed before the procedure

A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client? "The test is an invasive procedure and requires that you sign an informed consent." "The fetus is challenged by uterine contractions to obtain the necessary information." "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? Apply heat to the affected area. Take acetaminophen every 4 hours. Self-administer calcium carbonate tablets 3 times daily. Purchase a chewable antacid that contains calcium and take a tablet with each meal.

Apply heat to the affected area

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? Ask the client to turn on her side. Ask the client to urinate and empty her bladder. Massage the fundus gently before determining the level of the fundus. Ask the client to lie flat on her back, with her knees and legs flat and straight.

Ask the client to urinate and empty her bladder

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply.

Assess Check Assess Teach

A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which is the most appropriate nursing action? Instruct the client to avoid walking. Assess for signs of venous thrombosis. Instruct the client to elevate the legs throughout the day. Tell the client that this is normal during pregnancy.

Assess for signs of venous thrombosis

A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client? Administer her prepregnancy dose of metformin. Assess her blood glucose before administering any glucose-lowering medications. Administer 20 units of long-acting insulin, as sufficient time has elapsed since delivery. Keep NPO (nothing by mouth) for an additional 4 hours to allow the blood glucose to normalize.

Assess her blood glucose before administering any glucose-lowering medications

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? Reposition the laboring woman to knee-chest. Assess the vagina and cervix with a gloved hand. Notify the primary health care provider of the need for an amnioinfusion. Document the description of the fetal bradycardia in the nursing notes.

Assess the vagina and cervix with a gloved hand

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? At 1 minute after birth and 5 minutes after birth Immediately at birth, 3 minutes after birth, and 10 minutes after birth At 1 minute after birth, 5 minutes after birth, and 15 minutes after birth Immediately at birth, after the cord is cut, and after the mother delivers the placenta

At 1 minute after birth and 5 minutes after birth

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food should the nurse instruct the client to eat to supplement the dietary source of calcium?

Broccoli

The nurse checks the respirations of a newborn who was just delivered. The respiratory rate is 40 breaths/minute. Which intervention is most appropriate related to this finding? Provide oxygen (O2) via nasal cannula. Contact the primary health care provider (PHCP). Reassess the respiratory rate in 15 minutes. Document the findings in the electronic health record.

Document the findings in the electronic health record

The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? Consume a low-fiber diet. Drink 8 glasses of water per day. Use a Fleet enema when the episodes occur. Take a mild stool softener daily in the evening.

Drink 8 glasses of water per day

A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms? Eating a high-fat diet Increasing fluids with meals Eating a high-carbohydrate diet Eating dry crackers before arising

Eating dry crackers before arising

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? Prepare the client for a cesarean delivery. Monitor the FHR every 30 minutes. Encourage an upright or side-lying maternal position. Increase the rate of the oxytocin infusion every 10 minutes.

Encourage an upright and side-lying maternal position

The postpartum unit nurse is creating a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? Use a low-pitched voice to speak to the infant. Encourage the mother to hold the infant when the infant cries. Encourage the parents to allow the infant to sleep in the parental bed. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged.

Encourage the mother to hold the infant when the infant cries

The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? Encourage the parents to touch their newborn. Identify specific caregiving tasks that may be assumed by the parents. Explain the equipment that is used and how it functions to assist the newborn. Give the parents pamphlets that will help them understand their newborn's condition.

Encourage the parents to touch their newborn

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? Providing sitz baths Encouraging fluid intake Placing ice on the perineum Monitoring hemoglobin and hematocrit levels

Encouraging fluid intake

A just-delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism? Radiation Convection Conduction Evaporation

Evaporation

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? Hourly Every 15 minutes Every 30 minutes Before each contraction

Every 15 min

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? Enlargement of the breasts Complaints of feeling hot when the room is cool Periods of fetal movement followed by quiet periods Evidence of bleeding, such as in the gums, petechiae, and purpura

Evidence of bleeding, such as in the gums, petechiae, and purpura

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates an understanding of self-care for this diagnosis? "I need to eat fruits and vegetables only." "I will go to the laboratory daily for a glucose test." "I cannot exercise because of the negative effects on insulin production." "I will report signs of infection immediately to my primary health care provider."

I will report signs of infection immediately to my primary health care provider

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? Gently push the cord into the vagina. Place the client in Trendelenburg's position. Find the closest telephone and page the primary health care provider (PHCP) stat. Call the delivery room to notify the staff that the client will be transported immediately.

Place the client in Trendelenburg's position

The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action? Prepare the client for labor induction. Notify the primary health care provider (PHCP). Place the fetal heart monitor on the client in order to do a nonstress test (NST). Provide the client with information regarding warning signs and symptoms of pregnancy and discharge her to home.

Place the fetal heart monitor on the client in order to do a NST

A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information? The woman has the herpes simplex virus (HSV). The woman has contracted an airborne viral disease. The neonate will definitely develop this disease after birth. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test.

HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? Hematocrit 38% (0.38) Glucose 86 mg/dL (4.8 mmol/L) Hemoglobin 9 g/dL (90 mmol/L) White blood cell count 12,400 mm3 (12.4 × 109/L)

Hemoglobin 9 g/dL

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? Encourage ambulation hourly. Assess vital signs every 4 hours. Measure fundal height every 4 hours. Prepare an ice pack for application to the area.

Prepare an ice pack for application to the area

The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem? "I don't like dairy products." "I will continue drinking my afternoon milkshake." "I'm not used to eating so much food, but I will try." "I want to gain only 10 pounds because I want to have a small, petite baby."

I want to gain only 10 pounds because I want to have a small, petite baby

The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. Plan induction at 35 weeks. Plan amniocentesis at this time. Schedule a biophysical profile immediately. Plan for weekly nonstress tests at 32 weeks. Obtain nutritional counseling with a dietitian.

Plan for weekly nonstress tests at 32 weeks Obtain nutritional counseling with a dietitian

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? "I should retract the foreskin and clean the penis every time I change the diaper." "I need to retract the foreskin and clean the penis every time I give my infant a bath." "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction? "I need to take the antibiotics as prescribed." "I need to take warm sitz baths to promote healing." "I need to apply warm compresses to provide comfort." "I need to isolate the infant for 48 hours after beginning the antibiotics."

I need to isolate the infant for 48 hours after beginning the antibiotics

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? "I will record the number of movements or kicks." "I need to lie flat on my back to perform the procedure." "If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

I need to lie flat on my back to perform the procedure

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

I should avoid exercise

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? "I should increase my sodium intake during pregnancy." "I should lower my blood volume by limiting my fluids." "I should maintain a low-calorie diet to prevent any weight gain." "I should drink adequate fluids and increase my intake of high-fiber foods."

I should drink adequate fluids and increase my intake of high-fiber foods

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? "I should breast-feed every 2 to 3 hours." "I should change the breast pads frequently." "I should wash my hands well before breast-feeding." "I should wash my nipples daily with soap and water."

I should wash my nipples daily with soap and water

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. Back pain Heavy vaginal bleeding Increase in fundal height Hard, board-like abdomen Persistent abdominal pain Early deceleration on the fetal heart monitor

Increased fundal height Hard, board-like abdomen Persistent abdominal pain

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? "It promotes the fertilized ovum's chances of survival." "It promotes the fertilized ovum's exposure to estrogen and progesterone." "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

It promotes the fertilized ovum's normal implantation in the top portion of the uterus

The nurse is performing an initial assessment on a newborn. On assessment, which finding could be indicative of a congenital defect? Low-set ears Vernix caseosa A 5-cm anterior fontanel A heart rate of 130 beats per minute

Low-set ears

The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes? Select all that apply. Places the client at risk for dystocia Has an increased probability of cesarean section Is roomy and most conducive to a vaginal birth Places the client at high risk for precipitous labor Has a flat shape that may impede fetal descent Has an oval shape that will require cesarean section

Places the client at risk for dystocia Has an increased probability of c-section Has a flat shape that may impede fetal descent

A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicate a need for further teaching? Select all that apply.

The client is wearing knee high stockings The client is wearing sweatpants with snug elastic ankle bands

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? "Your newborn needs the medicine to develop immunity." "The medicine will protect your newborn from being jaundiced." "Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

Newborns are deficient in vitamin k

Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route?

Phytonadione Vitamin K

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? Protects the newborn's eyes from possible infections acquired while hospitalized. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

Prevents an infection called ophthalmia neonatorum from occuring after birth in a newborn born to a woman with an untreated gonococcal infection

A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? Immunization with rubella Retesting rubella titer during pregnancy Antibiotics to be taken throughout the pregnancy Counseling the mother regarding therapeutic abortion

Retesting rubella titer during pregnancy

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. Bed rest as a necessary preventive measure may be prescribed. Routine administration of subcutaneous heparin may be prescribed. An overbed lift may be necessary if the client requires a cesarean section. Less frequent cleansing of a cesarean incision, if present, may be prescribed. Thromboembolism stockings or sequential compression devices may be prescribed.

Routine administration of subcut heparin may be prescribed An overbed lift may be necessary if the client requires a c-section Thromboembolism stockings or sequential compression devices may be prescribed

The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the rooting reflex? Clap hands or slap the mattress. Stimulate the perioral cavity with a finger. Stimulate the ball of the infant's foot with firm pressure. Stimulate the pads of the infant's hands with firm pressure.

Stimulate the perioral cavity with a finger

The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first?

Stop Oxytocin

The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly? The client begins to wash the newborn by starting with the eyes and face. The client cleans the newborn's ears and then moves to the eyes and the face. The client washes the arms, chest, and back, followed by the neck, arms, and face. The client washes the newborn's entire body and then washes the eyes, face, and scalp.

The client begins to wash the newborn by starting with the eyes and face

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply. "The client would be independent." "The client initiates activities on her own." "The client participates in mothering tasks." "The client may complain of lack of sleep and fatigue." "The client is self-focused and talks to others about labor."

The client may complain of lack of sleep and fatigue The client is self-focused and talks to others about labor

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? The mother has cracked nipples and feeds the infant with a supplemental bottle. The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast. The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow

A pregnant client is diagnosed with tuberculosis. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis? Medication is not needed until after delivery. Tuberculosis is nothing to be concerned about. Tuberculosis cannot be transferred to the fetus. The newborn will be tested at birth and may be started on preventive therapy.

The newborn will be tested at birth and may be started on preventive therapy

A postpartum client develops a urinary tract infection. The nurse instructs the new mother on measures to take for treatment of the infection. Which statements, if made by the mother, would indicate a need for further instruction? Select all that apply. "I need to drink lots of fluids especially water every day." "The prescribed medication needs to be taken until I feel better." "Foods and fluids that will acidify the urine are best to consume." "I need to try to hold my urine as long as I can and urinate 3 to 4 times a day." "I may need to bring another urine sample to the lab after my treatment is complete."

The prescribed medication needs to be taken until I feel better I need to try to hold my urine as long as I can and urinate 3 to 4 times a day

The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply

Uterine infections Retained placental fragments from delivery

The rubella vaccine has been prescribed for a new mother. Which statements should the postpartum nurse make when providing information about the vaccine to the client? Select all that apply. "You will need a second vaccination at your 6-week postpartum visit." "You need this vaccine because you are not immune to the rubella virus." "You should avoid sexual intercourse for 2 weeks after the administration of the vaccine." "You should not become pregnant for 1 to 3 months after the administration of the vaccine." "You should avoid heat and extreme temperature changes for a week after the administration of the vaccine."

You need this vaccine because you are not immune to the rubella virus. You should not become pregnant for 1 to 3 months after the administration of the vaccine.

A postpartum care unit nurse is reviewing the records of 5 new mothers admitted to the unit. The nurse determines that which mother is most likely at risk for developing a puerperal infection? Select all that apply. A mother who had 10 vaginal exams during labor A mother with a history of previous puerperal infections A mother who gave birth vaginally to a 3200-gram infant A mother who experienced prolonged rupture of the membranes A mother who experienced the expected outcome with delivery of the placenta

A mother who had 10 vaginal exams during labor A mother with a history of previous puerperal infections A mother who experienced prolonged rupture of membranes

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? A private room across from the elevator A semiprivate room across from the nurses' station A private room 2 doors away from the nurses' station A semiprivate room with another client who enjoys watching television

A private room 2 doors away from the nurses' station

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? Notify the primary health care provider. Discontinue the infusion of oxytocin. Place oxygen on at 8 to 10 L/minute via face mask. Contact the client's primary support person(s) if not currently present.

Discontinue the infusion of oxytocin

The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? Document the findings. Contact the primary health care provider (PHCP). Apply an oxygen mask to the newborn infant. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.

Document the findings

The nurse is caring for a term newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL (2 mmol/L). Based on this information, which nursing action should be implemented? Administer an oral calcium channel blocker. Document the finding in the electronic health record. Contact the primary health care provider (PHCP) with the abnormal results. Prepare to insert an intravenous infusion containing parenteral calcium.

Document the findings in the electronic health record

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply. "I will be sure to wash my hands thoroughly and frequently." "I need to breast-feed, especially for the first 6 weeks postpartum." "My baby needs to receive all of the recommended vaccines at the regular schedule." "My baby has no symptoms so it is not likely that he has gotten the infection from me." "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

I need to breast-feed, especially for the first 6 weeks postpartum My baby has no symptoms so it is not likely that he has gotten the infection from me

The primary health care provider (PHCP) is assessing the client for the presence of ballottement. To make this determination, the PHCP should take which action? Auscultate for fetal heart sounds. Assess the cervix for compressibility. Palpate the abdomen for fetal movement. Initiate a gentle upward tap on the cervix.

Initiate a gentle upward tap on the cervix

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions? "Iron supplements may give me constipation." "All foods with protein lack iron and should be avoided." "The iron is best absorbed if taken at breakfast with some food." "My body has all of the iron it needs, and I don't need to take supplements."

Iron supplements may give me constipation

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? "It connects the pulmonary artery to the aorta." "It is an opening between the right and left atria." "It connects the umbilical vein to the inferior vena cava." "It connects the umbilical artery to the inferior vena cava."

It connects the umbilical vein to the inferior vena cava

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. It cushions and protects the baby. It maintains the temperature of the baby. It is the way the baby gets food and oxygen. It prevents all antibodies and viruses from passing to the baby. It provides an exchange of nutrients and waste products between the mother and developing fetus.

It is the way the baby gets food and oxygen It provides an exchange of nutrients and waste products between the mother and developing fetus

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? Elevate the client's legs. Massage the fundus until it is firm. Ask the client to turn on her left side. Push on the uterus to assist in expressing clots.

Massage the fundus until it is firm

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. Avoid stimulation. Decrease fluid intake. Expose all of the newborn's skin. Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.

Monitor skin temp Reposition the newborn q2hrs Cover the newborn's eyes with eye shields or patches

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low set. Which nursing action is most appropriate? Document the findings. Arrange for hearing testing. Notify the primary health care provider. Cover the ears with gauze pads.

Notify the primary healt care provider

Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother? Apple and orange Peanut butter and jelly sandwich and glass of 2% milk Hamburger with bun, French fries, and glass of skim milk 4-ounce (113 gm) grilled chicken breast, sweet potato, and 16-ounce milkshake

PB&J and glass of 2% milk

A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client? Costovertebral angle pain Pain, itching, and vaginal discharge Absence of any signs and symptoms Proteinuria, hematuria, edema, and hypertension

Pain, itching, and vaginal discharge

The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources for which primary reason? Reduce excessive maternal stress and fatigue. Help the mother prepare for labor and delivery. Avoid exposure to potential pathogens and resulting infections. Prepare the 18-month-old child for maternal separation during hospitalization.

Reduce excessive maternal stress and fatigue

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? Soft abdomen Uterine tenderness Absence of abdominal pain Painless, bright red vaginal bleeding

Uterine tenderness

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed if the breasts are not too sore. Take the prescribed antibiotics until the soreness subsides. Avoid decompression of the breasts by breast-feeding or breast pump.

Wear a supportive bra Rest during the acute phase Maintain a fluid intake of at least 3000 mL/day Continue to breast-feed if the breasts are not too sore

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. Uterine rigidity Uterine tenderness Severe abdominal pain Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age

Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? Bring the infant to the clinic. This is a normal occurrence and no further action is needed. Increase the number of times that the cord is cleaned per day. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

Bring the infant to the clinic

A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs? "My weight gain is not important." "I should avoid stressful situations." "I should rest by lying on my back." "There is no restriction on people who visit me."

I should avoid stressful situations

The nurse is preparing to care for a client in labor. The primary health care provider (PHCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse should ensure that which is implemented before the beginning of the infusion? An IV infusion of antibiotics Placing the client on complete bed rest Continuous electronic fetal monitoring Placing a code cart at the client's bedside

Continuous electronic fetal monitoring

The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that it is 37.3º C (99.2º F). Based on this finding, which nursing action is most appropriate? Document the temperature. Notify the primary health care provider. Retake the temperature by the rectal route. Inform the client that the temperature is elevated and antibiotics may be required.

Document the temp

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? Perform an abdominal scrub on the client. Prepare the delivery room for a vaginal delivery. Explain to the client why a cesarean delivery is necessary. Call the primary health care provider to obtain a prescription for an antiviral medication.

Explain to the client why a cesarean delivery is necessary

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? Hemoglobin of 11 g/dL (110 mmol/L) Fetal heart rate of 180 beats per minute Maternal pulse rate of 85 beats per minute White blood cell count of 12,000/mm3 (12 × 109/L)

Fetal heart rate of 180 bpm

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? "I need to urinate frequently throughout the day." "The prescribed medication must be taken until it is finished." "My fluid intake should be increased to at least 3000 mL daily." "Foods and fluids that will increase urine alkalinity should be consumed."

Foods and fluids that will incfease urine alkalinity should be consumed

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. "I should wear a bra that provides support." "Drinking alcohol can affect my milk supply." "The use of caffeine can decrease my milk supply." "I will start my estrogen birth control pills again as soon as I get home." "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

I should wear a bra that provides support Drinking alcohol can affect my milk supply The use of caffeine can decrease my milk supply I plan on having bottled water available in the refrigerator so I can get additional fluids easily

The nurse is describing cardiovascular system changes that occur during pregnancy to a client. Which findings are normal for a client in the second trimester? Select all that apply. Increase in pulse rate Increase in blood pressure Frequent bowel elimination Increase in red blood cell production Decrease in white blood cell production

Increase in pulse rate Increase in RBC production

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? Increased insulin Decreased insulin Increased caloric intake Decreased protein intake

Increased insulin

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? Providing comfort measures Monitoring the fetal heart rate Changing the client's position frequently Keeping the significant other informed of the progress of the labor

Monitoring the fetal heart rate

The nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? Selective placement of the infant Periodic well-baby examinations Phenylketonuria (PKU) testing at birth Administration of an antibiotic for an umbilical cord staphylococcal infection

Periodic well-baby examinations

Which oral medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate? Folic acid Phenytoin Bupropion Methyldopa

Phenytoin

Which are considered normal findings in a newborn less than 12 hours old? Select all that apply. Grunting respirations Presence of vernix caseosa Heart rate of 190 beats/minute Anterior fontanelle measuring 5 cm Bluish discoloration of hands and feet Yellow discoloration of the sclera and body

Presence of vernix caseosa Anterior fontanelle measuring 5 cm Bluish discoloration of hands and feet

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. The client has a history of intravenous drug use. The client has a significant other who is heterosexual. The client has a history of sexually transmitted infections. The client has had one sexual partner for the past 10 years. The client has a previous history of gestational diabetes mellitus.

The client has a history of IV drug use The client has a history of STI