Test #2 Mat & Peds
The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize? A) Hand washing B) Complete the antibiotic course C) Proper perineal care D) Get plenty of sleep
Hand washing
The nurse is admitting a woman at 32 weeks' gestation in preterm labor. The nurse should question the order for magnesium sulfate after noting which assessment finding? A) Cervical dilation of 5 cm B) Strong, regular contractions C) Fetus in a breech presentation D) A spontaneous abortion in an earlier pregnancy
Strong, regular contractions
The nurse is reviewing discharge instructions with a young couple. The nurse determines they understand how to properly use prepared formula and will discard any leftover refrigerated formula after which time frame? A) 12 hours B) 24 hours C) 36 hours D) 48 hours
24 hours
The nurse is preparing a client for treatment to ripen her cervix in anticipation oflabor. When comparing the various options for the client, which one will thenurse point out provides an oral option? A) misoprostol B) prostaglandin E2 gel C) dinoprostone D) prostaglandin E2 vaginal inserts
misoprostol
The nurse is monitoring a client who has given birth and is now bonding with herinfant. Which finding should the nurse prioritize and report immediately forintervention? A) The mother is unable to void after 4 hours. B) Maternal tachycardia and falling blood pressure C) Placental separation 15 minutes after birth D) Dark red lochia
Maternal tachycardia and falling blood pressure
A newborn is diagnosed with the communicating type of congenital hydrocephalus. Which explanation should the nurse prioritize when preparing a teaching session for the parents? A) There is a decreased production of cerebrospinal fluid. B) There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord. C) There is an opening between the ventricles and the spinal cord that usually closes at birth. D) There is defective absorption of cerebrospinal fluid
There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord.
The nurse is preparing to assess a client who is 1 day postpartum. The nursepredicts the client's fundus will be at which location on assessment?A) At level of umbilicus B) 1 cm above the umbilicus C) 1 cm below the umbilicus D) At the symphysis pubis
1 cm below the umbilicus
The nurse is preparing a dietary care plan for a newborn who currently weighs 7lbs (3136 g). How many kcal per day will the nurse plan for to ensure the infant'senergy needs are met? A) 300 kcal B) 350 kcal C) 400 kcal D) 450 kcal
300 kcal
A primi gravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize? A) Tell the woman to stay home until her membranes rupture. B) Emphasize that food and fluid should stop or be light. C) Ask the woman to describe why she believes that she is in labor. D) Arrange for the woman to come to the hospital for labor evaluation.
Ask the woman to describe why she believes that she is in labor.
A client at 42 weeks' gestation presents for induction of labor. Which assessmentshould the nurse prioritize as the best indicator for the induction to proceed? A) Bishop score of 7 B) L/S ratio of 1.5 C) Cervical presence of fetal fibronectin D) Cervical length of 28 millimeters
Bishop score of 7
A 30-minute-old newborn starts crying in a high-pitched manner and cannot beconsoled by the mother. Which action should the nurse prioritize if jitteriness isalso noted and the infant is unable to breastfeed? A) Check blood glucose. B) Place child in a radiant warmer. C) Assess for pain source. D) Assess the baby's temperature
Check blood glucose.
The nurse is assessing a newborn's vital signs and notes the following: HR 138,RR 42, temperature 97.7oF (36.5oC), and blood pressure 78/40 mm Hg. Whichaction should the nurse prioritize? A) Report tachypnea. B) Recheck blood pressure in 15 minutes. C) Put warming blanket over infant. D) Document normal findings.
Document normal findings.
The nursing instructor is teaching a session on the birth process. During whichstage does the woman's cardiac output increase 80% above the pre-labor level? A) First stage B) Pushing C) Immediately after birth D) Transition stage
Immediately after birth
A group of nursing students are preparing a presentation which will illustrate various components of the birthing process. When presenting the pelvis, the students should point out that it is often referred to as which term? A) Passenger B) Passageway C) Powers D) Psyche
Passageway
The nursing instructor is conducting a discussion centered on the variousmethods used to describe an infant. The instructor determines the session issuccessful when the students correctly choose which as an indication ofgestational age? A) The weight, height, and length of the newborn at birth B) The length of time between fertilization of the egg and birth C) The age of the newborn who is born before 40 weeks D) The newborn according to their birth assessment
The length of time between fertilization of the egg and birth
The nurse is preparing a client for the administration of prostaglandin E2 to prepare for induction of labor. The nurse should explain this is administered via which route to the client? A) Rectal B) Venous C) Oral D) Vaginal
Vaginal
The nurse is preparing to assess the pulse on a newborn who has just arrived tothe nursery after being cleaned in the labor and birth suite and swaddled in ablanket. Which action should the nurse prioritize? A) Perform a 3-minute surgical-type scrub. B) Wear clean gloves. C) Use infection transmission precautions. D) Clean hands with a betadine scrub.
Wear clean gloves.
The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? A) Bathe the infant immediately after birth. B) Place the infant on the mother's abdomen after birth. C) Wrap the infant in a warm, dry blanket. D) Turn the temperature up in the birth room.
Wrap the infant in a warm, dry blanket.
The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process? A) The client has the baby without any analgesic or anesthetic. B) The health care provider decides the best pain relief for the mother and family. C) Client priorities and preferences are incorporated into the plan. D) The nurse suggests alternative methods of pain relief.
Client priorities and preferences are incorporated into the plan.
A client with limited prenatal care presents in labor and is requesting a VBAC. What is the nurse's response after verifying the client had a classical incision with the last cesarean delivery? A) "There is no reason to stop you at this point; we will admit you to the unit." B) "Based on your history, a vaginal delivery is not recommended, it might cause your uterus to rupture." C) "We can do a trial of monitored labor, but may have to do a cesarean anyway." D) "This will be up to your health care provider."
"Based on your history, a vaginal delivery is not recommended, it might cause your uterus to rupture."
The new mother has decided to formula-feed her infant and is unsure when to introduce soft foods. Which age should the nurse point out will be appropriate to introduce her infant to mashed fruit and vegetables? A) 4 to 6 months B) 6 to 8 months C) 8 to 10 months D) after 12 months
6 to 8 months
The nurse has been monitoring a multipara client for several hours. She cries outthat her contractions are getting harder and that she cannot do this. The nursenotes the client is very irritable, nauseated, annoyed, and doesn't want to be leftalone. Based on the assessment the nurse predicts the cervix to be dilated howmany centimeters? A) 0 to 2 B) 5 to 7 C) 3 to 4 D) 8 to 10
8 to 10
A client at 36 weeks' gestation presents to the OB unit reporting continuous, heavy vaginal discharge and pelvic pressure. Assessment reveals no signs of labor and positive Nitrazine test. The nurse prepares for which nursing intervention after admitting the client? A) Administering erythromycin IV B) Performing daily pelvic exams C) Administering IM corticosteroids D) Administering oxytocin
Administering erythromycin IV
The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately? A) Calf pain B) Pyrexia C) Edema D) Dyspnea
Calf pain
The nurse is teaching young parents discharge instructions. Which form of birth control should the nurse point out will be the best option for the breast-feeding mom who hopes to have more children later? A) Tubal ligation B) Birth control pill C) Mini-pill D) Condom
Condoms
The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be the most effective at this point? A) Effleurage of the abdomen during the contraction B) Conscious relaxation/guided imagery in low Fowler's C) Counter pressure against the sacrum D) Pant-blow (breaths and puffs breathing techniques)
Counter pressure against the sacrum
A multigravida client admitted in active labor has progressed well and the client and fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, 'The baby is coming!'? A) Time the contractions. B) Auscultate the fetal heart tones. C) Contact the primary care provider. D) Inspect the perineum.
Inspect the perineum.
The nurse is monitoring a client who is 3 hours postpartum. On assessment thenurse notes a temperature of 102.4°F. Which action should the nurse prioritize? A) Notify the RN; she will notify the provider. B) Administer an antipyretic. C) Assist the client in ambulation. D) Continue to monitor for another hour.
Notify the RN; she will notify the provider.
The nurses at a local free clinic are concerned there may be an increase in small-for-gestational age infants in the community. When collecting data to research the situation, the nurses will exclude infants above which category? A) The fourth percentile for gestational age B) The sixth percentile for gestational age C) The eighth percentile for gestational age D) The 10th percentile for gestational age
The 10th percentile for gestational age
The community health nurse is preparing a presentation which will illustrate thevarious forms of spina bifida for a health fair. Which explanation should thenurse use to explain spina bifida with meningocele? ) There is protrusion of the spinal cord and meninges, with nerve roots embedded. B) The spinal meninges protrude through the bony defect and form a cystic sac. C) There is no protrusion of the spinal cord, only soft-tissue inflammation occurs. D) There is a bony defect that occurs without soft-tissue involvement.
The spinal meninges protrude through the bony defect and form a cystic sac.
The nurse is assessing a 4-year-old male born with a heart condition who is brought in for a routine well-child visit by his parents. The parents report he is very curious, active, and very social; however, they often see him take breaks in his play by squatting for a few minutes or sitting on the sidelines at which time they insist he take a nap. Assessment reveals a child small for his age, mildly cyanotic, and tires easily. What is the best response to the parents when they ask the nurse for suggestions on how to encourage their son to take the naps they insist on but he doesn't want to take? A) "It's important to limit Stevie's physical exertion, so it is good to bring him inside when you think he needs to rest." B) "Children are often aware of their limitations, and because he has shown that he knows when he needs to take a break he should be encouraged to control his own activity level." C) "He might do well with a scheduled 15-minute break for every 30 minutes of active play." D) "He might not need to nap, but it would be sensible to call him in so that you can check his pulse if he squats or takes a rest."
"Children are often aware of their limitations, and because he has shown that he knows when he needs to take a break he should be encouraged to control his own activity level."
The nurse is preparing discharge instructions for a new mother who has beenlearning to breast-feed. Which response should the nurse prioritize when the mother questions her ability to produce enough milk for her infant? A) Take a daily multivitamin. B) Drink a lot of milk. C) "Drink a lot of fluids." D) Consume a minimum of 3000 calories per day.
"Drink a lot of fluids."
The nurse is working with an adult female who has PKU and desires to becomepregnant. The nurse notes on her assessment her current serum phenylalaninelevel is 10 mg/dL. Which instruction should the nurse prioritize for this client? A) "Think carefully about the decision. The child might be intellectually disabled since your PKU is inherited, especially if your levels stay high. B) "It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg." C) "It will be best if you cut back on vegetables and fruit before you become pregnant to get your serum phenylalanine level down under 8 mg." D) "The baby won't be able to breast-feed. You know breast-feeding is really the best way to care for a newborn."
"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."
The nurse is caring for a primipara with PROM who appears extremely anxiousand reveals that she is scared her birthing process will be extremely painfulbecause it will be 'dry'. Which is the best response from the nurse? A) "This is true but you can receive pain medication to help relieve this." B) "No birth is ever really dry, because amniotic fluid continues to be manufactured." C) "Don't think so far ahead; concentrate on the problem at hand." D) "Although the birth will be dry, it won't be painful."
"No birth is ever really dry, because amniotic fluid continues to be manufactured."
However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge teaching to address this issue? A) "You may have intercourse until next month with no fear of pregnancy." B) "Ovulation may return as soon as 3 weeks after birth." C) "You will not ovulate until your menstrual cycle returns." D) "Ovulation does not return for 6 months after birth."
"Ovulation may return as soon as 3 weeks after birth."
A primigravidia client at 38 weeks' gestation calls the clinic and reports, 'My baby is lower and it is more difficult to walk.' Which response should the nurse prioritize? A) "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." B) "This is not normal unless you are in active labor; come to the hospital and be checked." C) "That is something we expect with a second or third baby, but because it is yourfirst, you need to be checked." D) "The baby moved down into the pelvis; this means you will be in labor within 24hours, so wait for contractions then come to the hospital."
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."
The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss? A) "We need to do a more in-depth assessment." B) "This is a normal response." C) "How often are you feeding your baby?" D) "You may need to supplement breast-feedings for a while."
"This is a normal response."
The nurse is accepting a new mother and her term infant into the unit after delivery and notes the newborn is documented as low birth weight. How much does the nurse expect the newborn to weigh? A) 1450 grams B) 2000 grams C) 2550 grams D) 2950 grams
2000 grams
The nurse is assessing a newborn and notes that the size of the infant will necessitate classification as large for gestational age. When questioned by the mother as to what this means, the nurse should point out the infant is at which percentile? A) 86th percentile B) 88th percentile C) 90th percentile D) 92nd percentile
90th percentile
The nurse is caring for several postpartum clients and notes various warning signs that are concerning. Which client should the nurse suspect is developing endometritis? woman with diabetes, vaginal birth, HR 110, temperature 101.7° F (38.7° C) on the third postpartum day. The next day, appears ill; temperature now 102.9° F(39.3° C); WBC 31,500 cells/mm-3; negative blood cultures. B) A woman with a history of infection and smoking, temperature 101° F (38.3° C) on the fourth postpartum day; reports severe perineal pain; edges of the episiotomy have separated. C) An obese woman with temperature 100.4° F (38° C) at 12 hours after birth; lochiais moderate; negative vaginal cultures. D) A woman with PROM before birth; reports severe burning with urination, malaise and severe temperature spikes on the 7th postpartum day. WBC is 21,850 cells/mm-3; temperature 101° F (38.3° C); skin pale and clammy.
A woman with PROM before birth; reports severe burning with urination, malaise and severe temperature spikes on the 7th postpartum day. WBC is 21,850 cells/mm-3; temperature 101° F (38.3° C); skin pale and clammy.
The nurse has completed an assessment on a newborn and documents a score of17 for the physical maturity in the records. Which elements has the nurse prioritized for this assessment? Select all that apply. A) Skin B) Posture C) Breast buds D) Square window E) Plantar creases F) Lanugo
A) Skin C) Breast buds E) Plantar creases F) Lanugo
The nurse is assessing a laboring client and notes: 5 cm dilated, 80% effaced, zero station, contractions every 2 to 3 minutes, lasting 50 seconds, becoming increasingly uncomfortable, and apprehensive but appropriate and focused on breathing and relaxation. The nurse determines which nursing diagnosis is most appropriate for this client? A) Risk for altered tissue perfusion related to breathing techniques B) Impaired gas exchange related to prolonged contractions C) Acute pain related to uterine contractions D) Ineffective individual coping related to fear and anxiety
Acute pain related to uterine contractions
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize? A) "This is normal; give it a few days and then call back." B) "After birth it is easier to develop an infection in the urinary system; we need to see you today." C) "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." D) "It is common for women to have yeast problems; try an over the counter cream and let us know if this continues."
After birth it is easier to develop an infection in the urinary system; we need to seeyou today."
client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action? A) Complete bed rest B) Ambulation ad lib C) Bathroom privileges D) Up in chair TID
Ambulation ad lib
The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize? A) Assess return of sensory and motor functions to the lower extremities. B) Help the client get up and walk around immediately. C) Let the client rest and recover while keeping her legs slightly elevated. D) Make sure the client receives plenty of fluids.97.
Assess return of sensory and motor functions to the lower extremities
The nurse has just applied a sterile pressure dressing to an epidural site afterremoving the epidural catheter in a client who is now recovering from a standarddelivery. Which action should the nurse now prioritize? A) Assess return of sensory and motor functions to the lower extremities. B) Help the client get up and walk around immediately. C) Let the client rest and recover while keeping her legs slightly elevated. D) Make sure the client receives plenty of fluids.
Assess return of sensory and motor functions to the lower extremities.
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? A) Oxygen is exchanged in the lungs. B) Fluid is removed from the alveoli and replaced with air. C) Pressure changes occur and result in closure of the ductus arterios us. D) The oxygen in the blood decreases.
C) Pressure changes occur and result in closure of the ductus arterios us.
The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning? A) Making eye contact with the baby B) Breastfeeding the infant on demand C) Calling the baby "it" or "they" D) Asking for assistance changing a diaper
Calling the baby "it" or "they"
The nurse is preparing to assist a new mother to breast-feed for the first time. Which action should the nurse prioritize? A) Ensure privacy by closing the door or pulling the curtain. B) Assist the woman with holding the infant correctly. C) Assist the woman into a comfortable position. D) Check the newborn's and woman's ID bands to make sure they match.
Check the newborn's and woman's ID bands to make sure they match.
A client presents to the clinic with her 3-week-old infant complaining of general flu-like symptoms and a painful right breast. Assessment reveals temperature101o8F (38.8oC) and the right breast nipple with a hard area that is red and warm. Which instruction should the nurse prioritize for this client? A) Complete the 10-day antibiotic prescription even if she begins to feel better. B) Use NSAIDs, warm showers, and warm compresses to relieve discomfort. C) Breast-feed or otherwise empty her breasts at least every 3 hours. D) Increase her fluid intake to ensure that she will continue to produce adequate milk.
Complete the 10-day antibiotic prescription even if she begins to feel better.
nursing instructor is leading a group discussion on congenital hydrocephalus.The instructor determines the session is successful after the students correctlychoose which factor that determines the noncommunicating type? A) Decreased production of cerebrospinal fluid B) Obstruction that keeps CSF from passing between the ventricles and the spinal cord C) Opening between the ventricles and the spinal cord that usually closes at birth D) Defective absorption of cerebrospinal fluid
Defective absorption of cerebrospinal fluid
The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents? A) Suggest they rock the baby to sleep B) Encourage the mother to breastfeed C) Commend the parents for making the right choice D) Encourage the parents to pick up the baby
Encourage the parents to pick up the baby
A G4P4 client is recovering from dystocia for which oxytocin was administered to assist with the contractions. On assessment 24 hours later, the nurse notes moderate to heavy lochia with numerous large clots and the uterus in the midline, above the umbilicus, and boggy. Which action should the nurse prioritize? A) Ensure that her bladder is empty. B) Initiate fundal massage. C) Draw blood for H&H STAT. D) Encourage breast-feeding to stimulate uterine contractions.
Ensure that her bladder is empty
Initial measures to stop a client's bleeding have not proved successful, and she is being transferred to the ICU. Her family is frightened by the IV lines and the nasal cannula. The client's brother suddenly says to her partner, 'This is all your fault!' What is the best response by the nurse? A) Leave the room quietly; this is a family matter. B) Draw the brother aside and tell him that if he cannot control himself, he will have to leave. C) Explain the client's care, focus on signs of improvement, and acknowledge this is a difficult time. D) Tell them that the RN will be notified and will explain the client's treatment to them.
Explain the client's care, focus on signs of improvement, and acknowledge this is a difficult time.
A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize? A) Immediately call the RN or health care provider. B) Change and bathe the infant. C) Check all of the baby's vital signs before calling the doctor. D) Explain this is normal.
Explain this is normal.
The nurse is preparing pre- and postoperative instructions for a family whose 6-month-old infant is scheduled for an inital surgical repair of a cleft lip and palate. Which activity should the nurse prioritize in the instructions to the caregivers ofthis infant? A) Feed the infant with a drinking straw. B) Feed the infant with a rubber covered spoon. C) Train the infant to drink from a glass or cup. D) Let the infant become accustomed to being in elbow restraints.
Feed the infant with a rubber covered spoon.
The nurse is helping a mother prepare to breast-feed her newborn for the first time. Which position should the nurse point out will be most appropriate with her cesarean incision site? A) Football hold B) Side-lying position C) Cradle hold D) Whichever is most comfortable
Football hold
The nurse is caring for a pregnant woman who is struggling with controlling her gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus? A) Have a serious birth defect B) Grow to an unusually large size C) Suffer from symmetrical intrauterine growth restriction D) Suffer from asymmetrical intrauterine growth restriction
Grow to an unusually large size
The nurse is monitoring the EFM and notes the following: variable V-shaped decelerations in the FHR lasting about 30 seconds, accelerations of about 5 bpm before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize? A) Help the woman change positions. B) Discontinue supplemental oxygen. C) Position the woman on her side with a pillow under her left hip. D) Start an oxytocic infusion and decrease the rate of IV fluids.
Help the woman change positions.
The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition? A) Heroin withdrawal B) Hypoglycemia C) Hypoxia D) Hemolytic disease
Hemolytic disease
The nurse is performing an assessment for a client in the immediate postpartumperiod. Which assessment finding should the nurse prioritize? A) Infection B) Dehydration C) Hemorrhage D) Bladder distention
Hemorrhage
The nurse is assisting a primigravida woman make decisions and prepare for her baby. The nurse should point out that breast-feeding is not an option for this client based on which assessment finding? A) Breast implants B) Galactosemia C) Need to return to work quickly D) Human immunodeficiency virus infection
Human immunodeficiency virus infection
The nurse is preparing a client for an epidural block. Which intervention is apriority before the epidural anesthesia is started? A) Increase oral fluids B) IV fluid bolus C) Monitor temperature D) Monitor maternal apical pulse
IV fluid bolus
The infant born at 5 a.m. has moved to the transition phase and is progressing well. The nurse documents a HR 130, RR 42, axillary temperature 99.5oF(37.5oC), and blood pressure 60/40 at 6:45 a.m. When should the nurse plan to reassess the infant's vital signs? A) In 15 minutes B) In 30 minutes C) In 45 minutes D) In 60 minutes
In 30 minutes
The nurse caring for a newborn notes a distended abdomen approximately 24hours after birth. Which action should the nurse prioritize after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement? A) Attempt to take a rectal temperature. B) Inform the RN and/or primary care provider immediately C) Schedule radiography to diagnose the problem. D) Inform the parents that the infant might need surgery
Inform the RN and/or primary care provider immediately
The nursing instructor is leading a discussion on the physical changes to awoman's body after delivery of the baby. The instructor determines the session issuccessful after the students correctly point out which process results in thereturn of nonpregnant size and function of the female organs? A) Evolution B) Involution C) Decrement D) Progression
Involution
The nurse is weighing and measuring a term newborn. The nurse should question this baby is suffering from asymmetrical intrauterine growth restriction based on which assessment findings? A) Looks wasted and has poor skin turgor B) Is pale with loose, dry skin C) Has cracked and leathery skin D) Has very thin skin and has multiple visible veins
Is pale with loose, dry skin
A caregiver brings a 13-year-old male for a pre-high school checkup and report she has spent lots of time in the principal's office or serving detention during junior high, and questions if he is too immature to be in high school. The nurse's assessment reveals evident breasts, little underarm or chest hair, and a high-pitched voice. Which condition should the nurse suspect and discuss with the primary care provider? A) Turner syndrome B) Klinefelter syndrome C) Ambiguous genitalia D) Hypothyroidism
Klinefelter syndrome
The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document? A) Fatigue and dyspnea B) Delayed growth and development C) Loud, harsh murmur D) Bounding pulse
Loud, harsh murmur
The African American parents are spending time with their newborn after the nurse brings the baby back from the transition nursery. The parents are horrified to note that their infant's buttocks appears bruised and demand to know what happened. The nurse should explain this is related to which factor? A) Lanugo B) Vascular nevi C) Bruising D) Mongolian spots
Mongolian spots
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention? A) Hesitates to hold newborn, expressing disappointment with baby's appearance. B) Neglects to engage or provide care or show interest in infant. C) Tearful for several days, difficulty eating and sleeping D) Express doubt in ability to care for newborn..
Neglects to engage or provide care or show interest in infant
The nurse is conducting a prenatal class for a group of pregnant women and their partners. When illustrating the various potential complications that can necessitate a cesarean delivery, which primary reason should the nurse point out? A) Placenta previa B) Ruptured uterus C) Nonreassuring fetal status D) Preeclampsia
Nonreassuring fetal status
The multigravida client is moving into the transition phase and asks for anarcotic, stating she doesn't remember the pain being this bad before. Which response from the nurse will be best? A) "I will page the provider and ask for your pain medication." B) "You are so close to birth; don't you want to have natural birth?" C) Pain medication can affect the baby's breathing; let's try to focus and breathe." D) "Rather than use a narcotic, let's ask for a different type of pain medication."
Pain medication can affect the baby's breathing; let's try to focus and breathe."
client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending? A) Alert the team that internal fetal monitoring may be needed. B) Palpate the area just above the symphysis pubis. C) Institute effleurage and apply pressure to the client's lower back duringcontractions. D) Encourage the client to push.
Palpate the area just above the symphysis pubis
The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step? A) Position the newborn on side, and suction with a bulb syringe. B) Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. C) Position the newborn on side with head slightly below body; use a small suction catheter to clear nose. D) Position the newborn on side with head slightly below body; use a bulb syringe to clear nose
Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth.
a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? A) Postpartum blues B) Postpartum depression C) Postpartum psychosis D) Maladjustment
Postpartum psychosis
The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifiying the RN and primary care provider, which action should the LPNprioritize? A) Include a set of piper forceps when the table is prepped. B) Apply pressure to the woman's lower back with a fisted hand. C) Assist with Nitrazine and fern tests. D) Prepare to assist with external version.
Prepare to assist with external version.
he nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? A) Fencing B) Moro C) Tonic neck D) Rooting
Rooting
The nursing instructor is teaching a group of student nurses about the current use of episiotomies during the labor process. The instructor determines the session is successful when the students correctly choose which situation that may require the health care provider to perform an episiotomy? A) Persistent occiput anterior position B) VBAC delivery C) Shoulder dystocia D) Multifetal births
Shoulder dystocia
The nurse is preparing a client for an emergent cesarean delivery. Which action should the nurse prioritize? A) Sign informed consent. B) Prep her abdomen. C) Ensure that a urinary catheter is in place. D) Record EFM tracing
Sign informed consent.
At 0500 hrs, a client was started on oxytocin. The nurse notes on assessment theclient is dilated to 4 cm with contractions every 1 minute and increased signs ofPage 5 fetal distress. What action should the nurse prioritize after noting the time is now1200 hrs? A) Administer pain medication. B) Increase IV fluids. C) Stop the oxytocin infusion. D) Notify the health care provider.
Stop the oxytocin infusion.
The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize? A) Obtain a comprehensive obstetric history. B) Determine plans for labor and the newborn. C) Take blood pressure and determine if clonus or edema are present. D) Assess use of drugs, alcohol, and tobacco during pregnancy.
Take blood pressure and determine if clonus or edema are present.
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse? A) Advise her to take acetaminophen to ease symptoms. B) Ask primary care provider to prescribe an analgesic. C) Instruct to use a sitz bath while voiding. D)
Teach that adequate hydration helps clear the infection quicker.
A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying? A) Apologize and tell her that the photos will be destroyed immediately. B) Console her with the fact that she has other children. C) Tell her that the hospital will keep the photos for her in case she changes her mind D) Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.
Tell her that the hospital will keep the photos for her in case she changes her mind
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor? A) The contraction pains are 2 minutes apart and 1 minute in duration. B) The client reports back pain, and the cervix is effacing and dilating. C) The contraction pains have been present for 5 hours, and the patterns are regular. D) After walking for an hour, the contractions have not fully subsided.
The client reports back pain, and the cervix is effacing and dilating.
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and12:20 p.m. What can the nurse conclude from these findings? A) The client is in active labor. B) The duration of the contractions is every 5 minutes. C) The frequency of the contractions is every 5 minutes D) The client can be sent home.
The frequency of the contractions is every 5 minutes
The nurse is teaching new parents about their newborn who was born with respiratory distress syndrome (RDS). The nurse determines the teaching session is successful when the parents correctly choose which explanation as being the cause of their newborn's condition? A) The lungs are hyperextended due to increased load of work B) The infant has inherited allergies from the mother. C) The lungs are immature and deficient in surfactant. D) The mother has a history of asthma which interfered in lung development.
The lungs are immature and deficient in surfactant.
The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? A) Emotions are calm and happy. B) Frequency of contractions are 5 to 6 minutes. C) Fetus is at -1 station. D) The urge to push occurs
The urge to push occurs
The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients? A) Clean the woman's perineum with a Betadine scrub. B) Strictly follow universal precautions. C) Replace soiled drapes and linen as needed. D) Thoroughly wash the hands before and after client contact.
Thoroughly wash the hands before and after client contact.
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? A) Use a birthing ball and find a position of comfort. B) Stay low on her back to ease the back pain. C) Use the Valsalva maneuver for effective pushing. D) Ask for privacy, and have just the partner present
Use a birthing ball and find a position of comfort.
The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? A) Use a birthing ball and find a position of comfort. B) Stay low on her back to ease the back pain. C) Use the Valsalva maneuver for effective pushing. D) Ask for privacy, and have just the partner present.
Use a birthing ball and find a position of comfort.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? A) Uterine rupture B) Hypertonic uterus C) Placenta previa D) Umbilical cord compression
Uterine rupture
A woman at 39 weeks' gestation is brought to the emergency department in labor following blunt trauma from an vehicle accident. The labor has been progressing well after the epidural when suddenly the woman reports severe pain in her back and shoulders. Which potential situation should the nurse suspect? A) Fractured ribs B) Placental abruption C) Uterine rupture D) Dystocia
Uterine rupture
The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance? A) Lanugo B) Milia C) Vernix D) Amniotic fluid
Vernix
The parents of a 1-day-old newborn are concerned the infant is cold andshivering. Which action should the nurse prioritize to best prevent heat loss? A) Keep the newborn under the radiant heater when not with mom. B) Cover the newborn with several blankets while under the warmer. C) Warm all surfaces and objects that come in contact with the newborn. D) Bathe and wash the newborn when temperature is 97.5° F (36.4°
Warm all surfaces and objects that come in contact with the newborn.
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction? A) increase even if relaxing and taking a shower B) remain irregular with the same intensity C) subside when walking around and use the lateral position D) cause discomfort over the top of uterus
increase even if relaxing and taking a shower
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? A) Instill 0.5% ophthalmic silver nitrate. B) Instill 0.5% ophthalmic tetracycline. C) Instill 0.5% ophthalmic erythromycin. D) Watch for signs of eye irritation.
instill 0.5% ophthalmic erythromycin
