Nursing 360 exam two voucher

A nurse is assisting with and amniotomy for a client who is an active labor. Which of the following actions should the nurse take

Assess the fetal heart rate before and after the procedure

A nurse is caring for a client who is in labor and received maperidine for pain one hour prior to entering the second stage of labor. Which of the following actions should the nurse take

Assess the newborn for respiratory depression

A nurse and the labor and delivery suite is planning care for a group of four clients. Which of the following client should the nurse he first?

1)A client who is an active labor and has late to celebrations on the fetal heart monitor strip 2) A client who is in transition and screaming and disturbing other clients 3) A client who has epidural analgesia and is reporting breakthrough pain 4) A client who has received an oxytocin infusion and is experiencing contractions every two minutes lasting 60 seconds A client who is an active labor and has late to celebrations on the fetal heart monitor strip

A nurse is performing a non-stress test on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following or sponsorship the nurse provide

1)This test to determine if you are likely to deliver within the next week 2) this test will help determine if your baby is healthy 3) this test can see how your baby responds when you have contractions 4) this test will determine if your babies lungs are mature This test will help determine if your baby is healthy

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as a priority

480 mL urine output in 24 hours, blood pressure 144/92, 2+ Adema of the feet, 1+ protein in urine Answer: 480 mL of urine output in 24 hours

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to use this medication

Active genital herpes Because the newborn can acquire the infection wow passing through the birth canal. A cesarean birth is recommended for clients that have this.

While caring for a client who is an active labor a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take

Apply oxygen at 10 L per minute via non-rebreather facemask

A nurse is caring for a client who was in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take

Apply pressure to the client sacral area during contractions

A nurse is planning care for a client who is pregnant and is RH negative. In which of the following situation should the nurse administer RH (D) immune globulin

At 28 weeks gestation because this consists of passive antibodies against the Rh factor which will destroy any fetal red blood cells in the maternal circulation and block maternal antibody production.

A nurse is caring for a client who is at 39 weeks gestation and in active labor. Which of the following actions should the nurse include in the plan of care

Check the cervix prior to analgesic administration.If administer too close to the time of delivery the analgesic could cause respiratory depression in the newborn

A nurse is caring for a client who is experiencing preterm labor. Which of the following medication should the nurse anticipate administering to enhance fetal lung maturation

Betamethasone

The nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medication to the nurse have available at the clients bedside

Calcium gluconate

A nurse is caring for a client to us at 39 weeks gestation and shows manifestations of labor. Which of the following findings will alert the nurse that the client is in true labor

Changes in cervical dilatation or effacement

The nurse is providing care to a client who is in labor. A fetal heart tracing she was early decelerations. Which of the following actions should the nurse take

Continue to monitor the fetal heart tracings

A nurse receives a report for a client who is in labor and does experiencing contractions that are four minutes apart. Which of the following patterns should the nurse expect on the field monitor tracing

Contractions that last for 60 seconds each with a 3 Minute to rest between contractions

A nurse is teaching a client with preeclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects of the nurse include in the teaching

Feeling of warmth

A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the clients contractions?

Evaluating the time from the beginning of a contraction to the beginning of the next contraction

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects?

Fetal asphyxia because this medication may cause tachysystole which can lead to uteroplacental in sufficiency. In adequate oxygen transferred to the placenta will result in fetal asphyxia

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect

Fetal gastrointestinal anomaly, because gastrointestinal malformations and neurological disorders are expected findings for a fetus in polyhydramnios

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider

Fetal heart rate baseline of 90 bpm, maternal temperature of 100°, uterine relaxation for one minute, uterine contractions increasing in intensity Answer: fetal heart rate baseline of 90 bpm

A nurse is teaching a client I bought a non-stress test. Which of the following statements by the client indicates an understanding of the teaching

I should press the button on the hand held marker when my baby moves because this assesses feed her well-being.

A nurse is caring for a client to a schedule to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform

Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure because it can prevent hypotension

A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella nonimmune is positive for group a beta-hemolytic Streptococcus and has a blood type of O negative.Which of the following actions should the nurse take?

Instruct the client to obtain a rubella immunization after delivery

A nurse is caring for a client who is in preterm labor and has a new prescription for nifedipine. The client states she is concerned because her father takes nifedipine for his angina pectoris. The nurse explained that nifedipine works for clients who are pregnant Through which of the following mechanisms?

It inhibits uterine contractions by blocking the entry of calcium into uterine sells

The nurse is caring for a client in latent stage of labor who is reporting pain level of 4 on a scale of 1 to 10. Which of the following actions should the nurse take

Lead the client in relaxation breathing techniques

A nurse is planning care for a client it was scheduled to have prostaglandin E2 gel inserted For cervical ripening. Which of the following actions should the nurse take

Maintain the client in a side lying position for 30 minutes after insertion because it allows the gel to stay in contact with the cervix.

A nurse is caring for a client to us at 34 weeks gestation and has a prescription for terbutaline in for preterm labor. Which of the following statements by the client is the priority

My ankles are swollen at the end of the day, I can feel the baby kicking my ribs and it is very uncomfortable, I'm growing more and more worried every day, my heart feels like it's racing Answer: my heart feels like it's racing

A nurse is caring for a client who is at 28 weeks gestation and is experiencing preterm labor. Which of the following medication should the nurse plan to administer

Nifedipine because it is a tocolytic medication that is administered to stop preterm labor

A nurse is caring for a client at 36 weeks gestation who has preeclampsia. Which of the following findings should the nurse identify as a priority

One plus protein urea, blood pressure 140/98, non-reactive nonstress test, fundal height 33 cm Answer: non-reactive non-stress test

A nurse is caring for a client who is receiving oxytocin to induce labor. Which of the following actions should the nurse take

Perform continuous fetal heart rate monitoring, measure maternal temperature every hour, evaluate the maternal contraction pattern every hour, check blood pressure every five minutes Answer: perform continuous fetal heart rate monitoring

A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes are reassuring fetal heart rate tracing from the external fetal monitor. Which of the following actions should the nurse performed

Prepare equipment needed for newborn resuscitation, endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort decreased muscle tone and bradycardia

A nurse is caring for a client who has oligohydramnios. Which of the following feel anomalies should the nurse expect

Renal agenesis because when there is a amniotic fluid volume less than 300 mL this could cause a renal system dysfunction leading to the absence of fetal kidneys.

A nurse is caring for a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a category one feel hurt tracing. Which of the following actions should the nurse take?

Reposition the client in a side lying position and continue to monitor because a category one fetal heart rate tracing is an expected findings. This should optimize uteroplacental perfusion. You'd want to monitor the tracing for another 10 minutes.

A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting three minutes each. What action should the nurse take

Stop the oxytocin infusion

While assessing a client who is in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings should the nurse anticipates with a bladder distention

The bladder fluctuates with palpation because the bladder is suprapubic, round, bulging, and dull to percussion and fluctuates like a balloon filled with water. The uterus is usually displays to the right, boggy, and located well above the umbilicus.

A nurse is caring for a client to add pelvic measurements recorded by the provider. The client asks since my pelvis is gynecoid will I be able to deliver vaginally which of the following responses should the nurse make?

The shape of your pelvis is ideal for vaginal childbirth

A nurse is assisting with the care of a client in labor. Her cervix is dilated to 9 cm and she has strong contractions every two minutes that last 75 seconds. The nurse should recognize that this client is in which of the following faces or stages of labor

Transition phase of the first stage

A nurse is caring for a client in labor who cervix is dilated to 9 cm. She is experiencing strong contractions every two minutes lasting 75 seconds. The nurse should recognize that the client is in which of the following faces or stages of labor?

Transition phase of the first stage

A nurse is caring for a client who is an active labor whose membranes have ruptured. The fetal monitoring tracing reveals late decelerations. Which of the following actions should the nurse take first?

Turn the client onto her left side, palpate the clients uterus, administer oxygen to the client, increase the clients IV fluids Answer: turn the client onto her left side

A nurse is assessing a client at 35 weeks gestation who is receiving magnesium sulfate via continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report the provider

Urinary output 20 mL per hour, respiratory rate 16, blood pressure 150/96, deep tendon reflexes 2+ Answer: urinary output 20 mL per hour

A nurse is assessing a client who is receiving magnesium sulfate as a treatment for preeclampsia. Which of the following clinical findings is the nurse is priority

Urinary output 40 ml in two hours, respirations 16, reflexes are 2+, fetal heart rate is 158 Answer: urinary output 400 ML in two hours because this excrete the magnesium very quickly. Magnesium sulfate should be discontinued if the hourly output is less than 30 mL per hour.

A nurse is caring for a client at 37 weeks gestation who is undergoing a non-stress test. The fetal heart rate is 130 bpm without accels for the past 10 minutes. Which of the following actions should the nurse take

Use Vibra acoustic stimulation on the clients abdomen for three seconds because this will elicit fetal activity.

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate what is the bleeding is caused by placenta previa or an abruptio placenta

Uterine tone

A nurse is caring for a client at 39 weeks gestation it was an active labor. The nurse observes late decelerations in the fetal heart rate. Which of the following findings should the nurse identify as the cause of late decelerations

Uteroplacental insufficiency

The nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior. Based on this information which of the following fetal position should the nurse document in the medical record

Vertex

A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses to the nurse provide

We need to observe your baby more closely

A nurse is providing education to the client to us at 34 weeks of gestation about a non-stress test. Which of the following pieces of information Should the nurse include?

You might have to drink orange juice during the test because in nonstress test monitors for a celebrations of the fetal heart rate over a 20 minute period. The parent might be asked to drink orange juice to stimulate fetal movement.

A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which of the following statements should the nurse make

an epidural given too early can prolong labor;The medication depresses the central nervous system extending the time needed for the cervix to dilate and effaced.

A nurse is caring for a client in labor who has an epidural for pain relief. Which of the following is a complication of the epidural block

hypotension

A nurse is preparing to administer oxytocin to a client who is at at 41 weeks gestation and is experiencing ineffective labor. Which of the following actions should the nurse plan to take

increase the dose of Oxytocin to obtain uterine contractions that occur every 2-3 minutes Because effective uterine contractions should occur every 2 to 3 minutes.