N105T Exam 2

A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse make?

"You must be feeling very scared"

A nurse is reinforcing teaching about Kegel exercises with a client who is in the third trimester of the client indicates an understanding of the teachings?

"these exercises will help my pelvic muscles stretch when I give birth"

A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend?

Cluster the newborn's care activities.

A nurse is collecting data from a newborn immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect?

Dry cracked skin

A nurse is assisting with the care of a client who is in labor. Immediately after delivery of a newborn, which of the following actions should the nurse take first?

Dry the newborn

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Heart rate 110/min

A nurse is caring for a client who is 36 hr postpartum and has a distended bladder. The client reports saturating four perineal pads in the past hour. Which of the following actions should the nurse take? (select all that apply)

Palpate the fundus for location and tone Check the client's blood pressure and pulse Administer intravenous infusion of 0.9% sodium chloride Look under the client's buttocks

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

Pelvic pain

A nurse in a prenatal clinic is determining a client's estimated date of delivery using Naegele's rule. The first day of her last menstrual period was May 4. Which of the following dates should the nurse tell the client is her estimated date of delivery?

February 11

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

Fetal position is persistent occiput posterior

A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

Excessive uterine enlargement

A nurse is assisting with the care of a client who is pregnant and in the labor and delivery unit. The nurse is contacting the provider regarding the client's status. Which of the following findings should the nurse include in the report? Select the 4 findings that the nurse should report.

Gestational age Vaginal examination Uterine contractions Maternal report of pain

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Place the client in a knee-chest or Trendelenburg position

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this findings as an indication of which of the following conditions?

Placenta previa

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

Position the client on her side

The client is at the greatest risk developing ___________ due to ____________.

Postpartum hemorrhage; Hydramnios

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Precipitous birth

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

Prepare for cesarean birth

A nurse is reviewing laboratory results from a client who is at 28 weeks of gestation diabetes. The nurse notes that blood glucose levels taken 1 hr following a meal range from 145 mg/dL to 162 mg/dL over the past week. Which of the following actions should the nurse take?

Reinforce instruction about insulin administration

A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones?

Right upper Quadrant

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

Umbilical cord compression

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

Umbilical cord compression

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse included?

"Given too soon, epidural anesthesia can prolong labor."

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia. Which of the following responses should the nurse make?

"Lochia can pool in the vagina while you lie in bed."

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?

"Take a deep, cleansing breath before and after each contraction."

A nurse is reinforcing teaching about fetal development with a group of women who are pregnant. Which of the following statements should the nurse include in the teaching?

"The baby's heartbeat is audible by a Doppler stethoscope at 12 weeks of pregnancy."

A nurse is preparing to administer dinoprostone gel to client who is pregnant. The client asks the nurse about the purpose of the medication. Which of the following responses should the nurse make?

Dinoprostone promotes softening of the cervix

A nurse is reinforcing teaching with a client who has genital herpes. Which of the following client statements should the nurse identify as understanding of the teaching?

"The lesions can spread to other areas of my body."

A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate?

"The primary consideration is what type of incision you had."

A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make?

"The purpose of this medication is to boost fetal lung maturity."

A nurse is caring for a client who has consented to an amniocentesis for genetic cell analysis. The client asks why she can't have the test before 14 weeks of gestation. Which of the following responses should the nurse make?

"There is not enough amniotic fluids until this time."

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

A large amount of bright red vaginal bleeding without pain

A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks of gestation and reports continuous abdominal pain and vaginal bleeding. The nurse should identify that the client is likely experiencing which of the following compilation?

Abruptio placentae

Complete the diagram by dragging from the choices below tp specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions Take: Place the newborn under a radiant warmer. Check the newborn's capillary blood glucose level Potential Condition: Hypoglycemia Parameters to monitor: Temperature Seizure activity

A nurse is caring for a client who is 2 days postpartum. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress

Actions to Take: Administer methylergonovine Initiate intravenous infusion of oxytocin Potential Condition: Subinvolution of Uterus Parameters to Monitors: Number of saturated perineal pads Hemoglobin and hematocrit

A nurse is assisting in the care of a client who is pregnant. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress

Actions to Take: Assist with initiation of magnesium sulfate infusion Administer antihypertensive medication Potential Condition: Preeclampsia with severe features Parameters to Monitor: Serum magnesium level Serum glucose level twice daily

A nurse is assisting with the care of a client who is in early labor with intact membranes and a temperature of 38.9 C (102 F). After notifying the provider, whichof the following actions should the nurse take?

Administer acetaminophen orally

A nurse is caring for a client who is at 34 weeks of gestation and has a suspected placenta previa. Which of the following actions should the nurse take?

Apply an external fetal monitor.

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Apply an ice pack to the perineum

A nurse is caring for a client who is at 38 weeks of gestation and has a score of 10 on her biophysical profile. Which of the following actions should the nurse take?

Assure the client that the score is within the expected range

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?

Cervical dilation

A nurse is caring for a client who is pregnant and reports constipation. Which of the following recommendations should the nurse make?

Increased cellulose and fluid in the diet

A nurse in a prenatal clinic is caring for a client who is at 12 weeks of gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

Increased progesterone production causes decreased motility of smooth muscle.

A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

Lecithin/sphingomyelin (L/S) ration of 2:1

A nurse in a prenatal client is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding, without contractions, that started spontaneously. She is in no distress and states that she can "feel the baby moving." The client should undergo an ultrasound to determine which of the following findings?

Location of the placenta

A nurse is reinforcing teaching with a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse recognizes that which of the following is the most common risk factor for a placental abruption?

Maternal hypertension

The newborn has the greatest risk for developing__________ due to ____________.

Meconium aspiration syndrome Amniotic fluid

A nurse is caring for a client who is at 32 weeks of gestation and is in labor. Which of the following medications is contraindicated for this client?

Misoprostol

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

Newborn hypoglycemia

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

The client is Rh negative and the newborn is Rh positive

A nurse is a caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?

The newborn's temperature control mechanism is immature

A nurse is caring for a client who is at 28 weeks of gestation and has received terbutaline. Which of the following findings should the nurse expect?

Weakened uterine contractions

A nurse is reinforcing teaching with a client who is at 6 weeks of gestation. The client tells the nurse that she smokes one pack of cigarettes per day. The nurse should instruct the client that her newborn is at increased risk for which of the following clinical manifestations?

Low birth weight

A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent which of the following ?

Porstpartum Hemorrhage

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination?

Profound bleeding

A nurse is assisting with the care of a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Respiratory rate of 16/min

A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?

Suction the newborn's mouth with a bulb syringe

A nurse is assisting with the care of a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to Take: flex the client's legs against the abdomen Apply suprapubic pressure Potential Condition: shoulder dystocia A nurse Parameters to Monitor: Neonate's upper extremities Maternal perineum

A nurse on a labor and delivery unit is assisting in the care of a client who is at 39 weeks of gestation and is in the first stage of labor. Complete the diagram by dragging from the choices below to specify what complication the client is most likely experiencing, 2 actions the nurse should take to address that complication, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to take: Turn client to left side Administer oxygen at 10 L/min via nonrebreather face mask Potential Complication: Variable fetal heart rate decelerations Parameters to Monitor: Fetal heart rate baseline Fetal heart rate variability

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breast soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7 C (100 F), pulse rate 88/min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Ask the client to empty her bladder.

A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

Assist the client to breathe into a paper bag

A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

Blurred vision

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Check for blood under the client's buttock

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Check the client's fundus

A nurse is caring for a client 2 hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

Check the consistency of the client's uterine fundus

A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

Check the fetal heart rate pattern

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

Clear the respiratory tract

A nurse is reinforcing teaching with a client about how to reduce the risk of giving birth to a newborn who has a neural tube defect. Which of the following instructions should the nurse include in the teachings?

Eat foods fortified with folic acid

A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?

Facial edema

A nurse is reinforcing teaching about a biophysical profile with a client who is at 40 weeks of gestation. The nurse should explain that this profile focuses on which of the following parameter? (Select all that apply)

Fetal breathing Fetal motion Amniotic fluid volume

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

Fetal heart rate 100/min for a 10-min period

A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response?

Have the client pant during the next few contractions.

A nurse is collecting data from a client who is 3 hr postpartum. The nurse notes that the client's fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Whish of the following actions should the nurse take?

Have the client urinate

A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings?

Headache

A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. Incomplete abortion is the initial diagnosis. Which of the following actions should the nurse contribute to the client's plan of care?

Determine the amount and type of vaginal bleeding

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate effectivess of this medication?

Fundal consistency

A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take?

Obtain blood glucose by heel stick.

A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

The test predicts fetal well-being in the third trimester

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?

Vastus lateralis