OB NCLEX
A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client?
"An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."
The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day?
500
The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?
A fever on and off is expected
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?
A mother who had 10 vaginal exams, mother with a history of it, a mother who has had prolonged ROM
The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What should be the nurse's response?
"Prolactin stimulates the secretion of milk, which is called lactogenesis."
A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose?
"The exercises will help strengthen the pelvic floor in preparation for delivery." "The exercises will help strengthen the muscles that support the bladder and urethra."
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?
"The vaginal discharge may be bothersome, but is a normal occurrence."
The nurse is teaching anew mother how to care for her newborn. The mother expresses she is fearful and is reluctant to handle the newborn. What interventions should occur?
Acknowledge the clients apprehension, assist the client with giving baths to allow her to become at ease
The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?
Adolescent experiencing emergency c-section for fetal distress
The client asks the causes of breast changes during pregnancy, what are the best responses?
Breast changes occur because of estrogen and progesterone secretion and blood vessels beneath the skin often appear blue, intertwining network, especially in a primigravida
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor?
Cervix is fully dilated and spontaneous urge to push occurs
The nurse at a well-baby clinic is assessing the motor development of a 24-month-old child. On the basis of the age of the child, the nurse expects to note what as the highest-level developmental milestone?
Child opens a door by turning the handle
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?
Client with lochia that is red and foul smelling
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?
Contact the HCP
The nurse employed in a fertility clinic is providing information to a couple considering in vitro fertilization. The nurse's explanation should most appropriately include which information?
Fertilized ovum is transferred into the woman's uterus, mild spotting or cramping may occur after egg removal, a medication protocol for follicle development will be prescribed.
Which statements indicate the student has an understanding of quickening?
Fetal movement that is felt by the mother, Typically experienced by multigravida mothers around 16-18 weeks
The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time?
Fetus is about 42-48 cm long, L/S ratio is greater than 2:1
During a woman's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What should be the nurse's next intervention?
Document findings
A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration?
Establish a toileting schedule
The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention?
Provide pain relief measures
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?
Tachycardia, fetal hypoxia, metabolic acidemia, congential anomalies
The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication?
flushing, depressed respirations, extreme muscle weakness
The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness?
Compression of the vena cava
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?
Promotes that it implants at the top portion of the uterus
The priority for the client who has been laboring for 1 hour is:
Rest between contractions
The nurse is providing medication instructions to a client with multiple sclerosis receiving baclofen. Which information should the nurse include in the instructions?
Watch for urinary retention
The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of first trimester pregnancy signs. Which signs should the nurse anticipate as being present during this time frame?
Hegar's, Goodell's, Chadwick's
The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?
Hypotonic
The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss?
Increased pulse rate
The instructor asks a nursing student to identify the phases of the ovarian cycle. Which phases identified by the nursing student indicate an understanding of the ovarian cycle?
Luteal, follicular, ovulatory
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 face anymore. I always look like I have been crying."
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?
"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 plan on having bottled water available in the refrigerator so I can get additional fluids easily."
What are the highest expected G&D of a 9 month old?
Able to say mama and dada, pull self up to a standing position using furniture, able to pick up small pieces of food
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 umbilical vein to the inferior vena cava
The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. How should the nurse respond?
It is presence of tissue outside the uterus that resembles the endometrium, also known as dysmenorrhea and causes lower abdominal discomfort, major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia
A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit?
Monitor Fetal movement
Which is the priority nursing action for the client with an ectopic pregnancy?
Monitoring pulse and BP
A preadolescent client asks the nurse about the onset of puberty. The nurse describes which changes as indicating puberty?
Mood swings, pubic hair growth, breast development, height increases
The nurse is interviewing a middle-aged woman with a history of fibrocystic disorder of the breasts. Which statements made by the client indicate a need for further teaching?
My symptoms will decrease just before menstruatiion and taking oral contraceptives now will increase my symptoms
The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result?
Normal Findings
What symptoms might the client report with a vaginal infection from Candida?
Pain, itching, vaginal discharge
The nurse is monitoring a client with current dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?
Passage of meconium
Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother?
Peanut butter and jelly sandwich with milk
The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction?
The mother requests that the nurse feed the newborn because she is feeling fatigued.
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 and a loss of variability. What is the priority action?
Turn onto her side and administer 2-4 L/NC
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 and a loss of variability. What is the initial nursing action?
Turn the client on her side and administer 8-10 L per face mask
A pregnant client is receiving oxytocin for the induction of labor. The nurse should immediately discontinue the oxytocin infusion if which is noted in the client?
Uterine hyperstimulation
The nursing student is asked to discuss information related to the uterus with female high school students. Which statements by the nursing student are accurate?
Uterus is a pelvic organ, uterus weighs about 2.2 pounds during pregnancy, uterus weighs about 2 ounces normally, uterus has 3 layers
The client is wondering about how to prevent varicose vain during pregnancy, which statement indicates further education?
I should wear knee-high hose, and no longer than 8 hours
A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy?
Increased efficiency of contractions,The need for increased maternal blood pressure monitoring,The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
Mother at 29 weeks with GDM, what information should you give her?
Schedule a BPP right away, plan for weekly nonstress tests at 32 weeks, obtain counseling with a dietitian
A client has decided to formula feed her infant. What instructions should the nurse give?
Wear a supportive bra for 72 hours