Test 3

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform fi rst? 1. Offer the client the bedpan. 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push

2

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows average short-term and long-term variability with a baseline of 142 beats per minute (bpm). What should the nurse do? 1. Provide caring labor support. 2. Administer oxygen via face mask. 3. Change the client's position. 4. Speed up the client's intravenous.

1

When during the latent phase of labor should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? Select all that apply. 1. After vaginal examinations. 2. Before administration of analgesics. 3. Periodically at the end of a contraction. 4. Every ten minutes. 5. Before ambulating

1, 2, 3, 5

A woman has just arrived at the labor and delivery suite. To report the client's status to her primary healthcare practitioner, which of the following assessments should the nurse perform? Select all that apply. 1. Fetal heart rate. 2. Contraction pattern. 3. Urinalysis. 4. Vital signs. 5. Biophysical profile

1, 2, and 4 - FHR, VS & contraction pattern should be assessed before reporting client status to HCP

The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate? 1. Sacral promontory. 2. Ischial spines. 3. Cervix. 4. Symphysis pubis

2- station is assessed by palpating the ischial spines

A nurse is caring for a client who will undergo medical management for an ectopic pregnancy. Which treatment would the nurse anticipate a. laparotomy b. methotrexate c. folic acid d. Plan B pill

b

The nurse receives report on 4 first trimester pregnant clients. which client should the nurse assess first? a. client with hydatidiform mole reporting dark brown vaginal discharge b. client with hyperemesis gravidarum reporting excessive vomiting and weight loss c. client with suspected ectopic pregnancy reporting abdominal and shoulder pain d. client with threatened miscarriage who says I am a Jehovah's witness

c

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position.

1

A client enters the labor and delivery suite stating that she thinks she is in labor. Which of the following information about the woman should the nurse note from the woman's prenatal record before proceeding with the physical assessment? Select all that apply. 1. Weight gain. 2. Ethnicity and religion. 3. Age. 4. Type of insurance. 5. Gravidity and parity.

1, 2, 3, 5 - weight gain should be checked, ethnicity and religion are important factors before physical assessment, age should be noted, gravidity and parity should be noted before assessment

The childbirth education nurse is evaluating the learning of four women, 38 to 40 weeks' gestation, regarding when they should go to the hospital. The nurse determines that the teaching was successful when a client makes which of the following statements? Select all that apply. 1. The client who says, "If I feel a pain in my back and lower abdomen every 5 minutes." 2. The client who says, "When I feel a gush of clear fluid from my vagina." 3. The client who says, "When I go to the bathroom and see the mucous plug on the toilet tissue." 4. The client who says, "If I ever notice a greenish discharge from my vagina." 5. The client who says, "When I have felt cramping in my abdomen for 4 hours or more."

1, 2, 4

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1. Bulging perineum. 2. Increased bloody show. 3. Spontaneous rupture of the membranes. 4. Uncontrollable urge to push. 5. Inability to breathe through contractions.

1, 2, 4- as fetal head descends through fully dilated cervix, the perineum begins to bulge, the bloody show increases and the laboring woman usually feels a strong urge to push

The nurse knows that which of the following responses is the primary rationale for the inclusion of the information taught in childbirth education classes? 1. Mothers who are performing breathing exercises during labor refrain from yelling. 2. Breathing and relaxation exercises are less exhausting than crying and moaning. 3. Knowledge learned at childbirth education classes helps to break the fear-tension- pain cycle. 4. Childbirth education classes help to promote positive maternal-newborn bonding.

3

A woman has decided to hire a doula to work with her during labor and delivery. Which of the following actions would be appropriate for the nurse to delegate to the doula? Select all that apply. 1. Give the woman a back rub. 2. Assist the woman with her breathing. 3. Assess the fetal heart rate. 4. Check the woman's blood pressure. 5. Regulate the woman's intravenous infusion rate.

1,2

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1. Inform the mother that the rate is normal. 2. Reassess in 5 minutes to verify the results. 3. Immediately report the rate to the healthcare practitioner. 4. Place the client on her left side and apply oxygen by face mask

1- normal range is 110 to 160

The nurse is caring for a nulliparous client who attended Lamaze childbirth education classes. Which of the following techniques should the nurse include in her plan of care? Select all that apply. 1. Hypnotic suggestion. 2. Rhythmic chanting. 3. Muscle relaxation. 4. Pelvic rocking. 5. Abdominal massage

3, 4, 5

The Lamaze childbirth educator is teaching a class of pregnant couples the breathing technique that is most appropriate during the second stage of labor. Which of the following techniques did the nurse teach the women to do? 1. Alternately pant and blow. 2. Take rhythmic, shallow breaths. 3. Push down with an open glottis. 4. Do slow chest breathing

3- all other options are during stage 1

A client is complaining of severe back labor. Which of the following nursing interventions would be most effective? 1. Assist mother with childbirth breathing. 2. Encourage mother to have an epidural. 3. Provide direct sacral pressure. 4. Move the woman to a hydrotherapy tub

3- counteraction to pressure being exerted by fetal head

The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions? 1. Mentum anterior. 2. Sacrum posterior. 3. Occiput posterior. 4. Scapula anterior

3- when in occiput posterior mother complains of severe back pain

A client who is 7 cm dilated and 100% effaced is breathing at a rate of 50 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers and some light-headedness. Which of the following actions should the nurse take at this time? 1. Assess the blood pressure. 2. Have the woman breathe into a bag. 3. Turn the woman onto her side. 4. Check the fetal heart rate.

2- signs of hyperventilation

A client is in the second stage of labor. She falls asleep immediately after a contraction. Which of the following actions should the nurse perform at this time? 1. Awaken the woman and remind her to push. 2. Cover the woman's perineum with a sheet. 3. Assess the woman's blood pressure and pulse. 4. Administer oxygen to the woman via face mask

2

In addition to breathing with contractions, the nurse should encourage women in the first stage of labor to perform which of the following therapeutic actions? 1. Lying in the lithotomy position. 2. Performing effleurage. 3. Practicing Kegel exercises. 4. Pushing with each contraction.

2

The nurse is assessing a client who states, "I think I'm in labor." Which of the following findings would positively confirm the client's belief? 1. She is contracting q 5 min × 60 sec. 2. Her cervix has dilated from 2 to 4 cm. 3. Her membranes have ruptured. 4. The fetal head is engaged.

2

A client in labor, G2 P1001, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During the past 10 minutes she has become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment of the situation? 1. The client had poor childbirth education prior to labor. 2. The client is exhibiting an expected behavior for labor. 3. The client is becoming hypoxic and hypercapnic. 4. The client needs her alpha-fetoprotein levels checked.

2 - woman is showing expected signs of active phase of labor

A nurse is teaching childbirth education classes to a group of pregnant teens. Which of the following strategies would promote learning by the young women? 1. Avoiding the discussion of uncomfortable procedures like vaginal examinations and blood tests. 2. Focusing the discussion on baby care rather than on labor and delivery. 3. Utilizing visual aids like movies and posters during the classes. 4. Having the classes at a location other than high school to reduce their embarrassment

3

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2. Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3

A nurse is teaching a class of pregnant couples the most therapeutic Lamaze breathing technique for the latent phase of labor. Which of the following techniques did the nurse teach? 1. Alternately panting and blowing. 2. Rapid, deep breathing. 3. Grunting and pushing with contractions. 4. Slow chest breathing.

4

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to the hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1. "The contractions are 5 to 20 minutes apart." 2. "I saw a pink discharge on the toilet tissue when I went to the bathroom." 3. "I have had cramping for the past 3 or 4 hours." 4. "The contractions are about a minute long and I am unable to talk through them."

4

The nurse documents in a laboring woman's chart that the fetal heart is being "assessed via intermittent auscultation." To be consistent with this statement, the nurse, using a Doppler electrode, should assess the fetal heart at which of the following times? 1. After every contraction. 2. For 10 minutes every half hour. 3. Only during the peak of contractions. 4. For 1 minute immediately after contractions.

4

Upon examination, a nurse notes that a woman is 10 cm dilated, 100% effaced, and −3 station. Which of the following actions should the nurse perform during the next contraction? 1. Encourage the woman to push. 2. Provide fi rm fundal pressure. 3. Move the client into a squat. 4. Monitor for signs of rectal pressure

4

A woman who states that she "thinks" she is in labor enters the labor suite. Which of the following assessments will provide the nurse with the most valuable information regarding the client's labor status? 1. Leopold maneuvers. 2. Fundal contractility. 3. Fetal heart assessment. 4. Vaginal examination.

4 - will provide the best information about labor

One hour ago, a multipara was examined with the following results: 8 cm, 50% effaced, and +1 station. She is now pushing with contractions and the fetal head is seen at the vaginal introitus. The nurse concludes that the client is now: 1. 9 cm dilated, 70% effaced, and +2 station. 2. 9 cm dilated, 80% effaced, and +3 station. 3. 10 cm dilated, 90% effaced, and +4 station. 4. 10 cm dilated, 100% effaced, and +5 station.

4- cervix is dilated fully and effaced and the baby is low enough to be seen through vaginal introitus

A woman, G2 P0101, 5 cm dilated, and 30% effaced, is doing fi rst-level Lamaze breathing with contractions. The nurse detects that the woman's shoulder and face muscles are beginning to tense during the contractions. Which of the following interventions should the nurse perform fi rst? 1. Encourage the woman to have an epidural. 2. Encourage the woman to accept intravenous analgesia. 3. Encourage the woman to change her position. 4. Encourage the woman to perform the next level breathing

4- this woman is in active phase of labor, the first phase breathing is probably no longer effective. Encouraging her to shift to the next level is appropriate at this time

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV infusion. the nurse should monitor the client for which of the following manifestations as a sign of magnesium sulfate toxicity? SATA a. Respiratory rate less than 12 bpm b. excessive urinary output c. hyper reflexive deep tendon reflexes d. decrease level of consciousness e. flushing and sweating

A, D

A health care provider is caring for a client diagnosed with abruptio placente. which findings should the nurse identify as risk factors for this condition? SATA a. fetal rump position b. maternal hypertension c. cocaine use d. advanced maternal age e. cigarette smoking

b, c, d, e

A nurse in an antepartum clinic is providing teaching to a pt who is at 38 wk of gestation & has a new prescription for dinoprostone gel. Which of the following statements should the nurse include? A. This med promotes softening of the cervix B. This med is used to treat preeclampsia C. This med promotes relaxation of the uterine muscles D. This med is used to treat cervical insufficiency

a

A nurse is caring for a client having contractions every eight minutes that are 30 to 40 seconds in duration. the clients cervixes 2 cm dilated, 50% effaced and the fetus is at a -2 station with a FHR have 140 bpm. which of the following stages & phases of Labor is this client experiencing? A. first stage latent phase B. first stage active phase C. first stage transition phase D. second stage of Labor

a

A nurse is caring for a client who is at 32 weeks of gestation and has placenta previa. the nurse notes that the client is actively bleeding. which of the following medications should the nurse expect a provider to prescribe a. Betamethasone b. Indomethacin c. Nifedipine d. Methylergonovine

a

The nurse is caring for a client at 30 weeks gestation who is hospitalized for preeclampsia. after reviewing the client's chart and performing an initial assessment, the nurse notes several abnormal findings. which finding should the nurse discuss with the health care provider immediately? a. dark red vaginal bleeding b. edema of the hands and face c. elevated liver enzymes d. urine output of 150 mL in four hours

a

Which of the following response would the nurse expect to see from a pt who is in the latent phase of labor? A. Contractions q 5 - 10 min B. Contractions lasting 1 -2 min C. Cervical dilation of 6 - 7 cm D. Cervical effacement of 80%

a

A nurse is caring for a pt in labor & delivery who is receiving oxytocin after prolonged labor. Intervention is necessary when which assessment finding is noted? A. 6 contractions in 10 min B. Temp of 99.8 C. Cervical dilation from 5 to 6 cm in 1 hours D. FHR of 150 with moderate variability & no late decelerations

a more than 5 in a 10 minute period -- tachysystole

A 31 year old client is brought to the emergency room after suffering an ectopic pregnancy. based on the nurses understanding of this condition the nurse knows to look for which signs or symptoms on this client? SATA a. dark red vaginal bleeding b. right sided shoulder pain c. abdominal pain d. abdominal petechiae e.a firm board like abdomen

a, b, c

A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. the client received no prenatal care in reports being about 7 to 8 months. which action should the nurse anticipate? SATA a. blood draw for type & screen b. electronic fetal monitoring c. initiation of two large bore IV catheters d. pad counts to assess bleeding e. vaginal examination for cervical dilation

a, b, c, d

A woman is to receive methotrexate IM for an ectopic pregnancy. the nurse should teach the woman about which of the following common side effects of the therapy? SATA a. nausea and vomiting b. abdominal pain c. fatigue d. Lightheadedness e.breast tenderness

a, b, c, d

A client at 38 weeks gestation is brought to the emergency department after a motor vehicle crash. she reports severe, continuous abdominal pain. the nurse notes frequent urine contractions and mild, dark vaginal bleeding. what action should the nurse take? SATA a. anticipate emergence cesarean birth b. apply continuous external fetal monitoring c. assess routine vital signs every four hours d. draw blood for type and cross match e. initiate IV access with a 22 gauge catheter

a, b, d

Which of the following increases the risk for postpartum hemorrhage? SATA a. pregnancy induced hypertension b. placental abruption c. first birth d. fetal demise e. pre term delivery

a, b, d postpartum hemorrhage can be a potentially life threatening complication that develops after delivery of a baby. risk factors that increase the risk of postpartum hemorrhage are pregnancy induced hypertension, problems with the placenta such as placenta previa or placental abruption, etc infection, obesity, prolong labor and assisted delivery

A nurse is caring for a client who has postpartum hemorrhage after a normal vaginal delivery. assessment of vital signs reveals a drop in blood pressure with tachycardia. which of the following may have increased the risk of the client's condition? SATA a. Magnesium b. heart disease c. large for gestational age neonate d. excessive uterine contractility e. thrombophlebitis

a, c

The nurse is preparing to discharge a client following a first trimester miscarriage. which of the following statements should the nurse include in discharge teaching for the patient and partner? SATA a. attending a support group with other people who had a pregnancy loss can be helpful b. genetic counseling is recommended for couples after their first miscarriage c. one of the most important things you can do right now is communicate with your partner d. The grieving period only lasts about six months following a miscarriage e.trying to conceive again can help you cope by giving you something to look forward to

a, c

A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. a diagnosis of placenta previa was confirmed by ultrasound. what should the nurse tell the client to anticipate? SATA a. additional ultrasound around 36 weeks gestation b. clearance for sexual activity if bleeding stops c. discharge home if bleeding stops & fetal status is reassuring d. scheduled cesarean birth before onset of Labor e. weekly vaginal exams to assess for cervical change

a, c, d

A nurse is educating clients on the symptoms of ectopic pregnancy. which of the following symptoms should be included in the education? SATA a. Amenorrhea b. quickening c. positive pregnancy test d. fatigue e. spotting

a, c, d, e

a 12 week gravid patient presents in the emergency department with abdominal cramps and dark red bleeding. which of the following signs and symptoms should the nurse assess for this client? SATA a. tachycardia b. referred shoulder pain c. headache d. fetal heart dysrhythmias e.hypertension

a, c, d, e

select all the patients below who are risk for developing placenta previa a. 37 year old woman who is pregnant with her seventh child b. 28 year old pregnant female with chronic hypertension c. 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen d. 20 year old pregnant female who is a cocaine user

a, d

A pt who is being evaluated for suspected ectopic pregnancy reports sudden onset, severe, right lower abdominal pain & dizziness. Which additional assessment findings will the nurse anticipate if the pt is experiencing a ruptured ectopic pregnancy? SATA a. Blood pressure 82/64 mm Hg b. crackles on auscultation c. distended jugular veins d. pulse 120 e.shoulder pain

a, d, e

select all the signs and symptoms associated with placenta previa a. painless bright red bleeding b. concealed bleeding c. hard tender uterus d. normal fetal heart rate e. abnormal fetal position f. rigid abdomen

a, d, e

A 34 year old client who has missed two menstrual periods comes to the emergency room with cramping and vaginal bleeding. Which statement by the nurse is appropriate when the client is diagnosed with an incomplete abortion? SATA a. I am so sorry this must be difficult for you b. the HCP will clean out your womb with a D&C c. did you really want to be pregnant now d. you'll still be able to have children after this is over e.would you like to speak with a hospital chaplain or counselor

a, e

A 28 year old female who is 33 weeks pregnant with her second child has uncontrolled hypertension. which risk factor below found in the patient's health history places her at risk for abruptio placentae a. childhood polio b. preeclampsia c. C-section d. her age

b

A client at 24 weeks gestation arrives with painless bright red vaginal bleeding. which of the following conditions does the nurse suspect in this client a. abruptio placentae b. placenta previa c. premature rupture membranes d. rupture of the uterus

b

A client who just learned she has an ectopic pregnancy in her fallopian tube wants to know if she can continue with the pregnancy. what is the best response by the nurse? a. an ectopic pregnancy is not compatible with life so it has to be removed b. the pregnancy could rupture your fallopian tube so it cannot continue c. you can wait a little longer and see if the embryo moves out of the tube d.we need to remove the fallopian tube, you will no longer be able to get pregnant, I am very sorry

b

A female client presents to the emergency room with severe right sided abdominal pain and right shoulder pain. the urine pregnancy test is positive. what is the best next action by the nurse a. draw blood to confirm the pregnancy b. notify the HCP and request an ultrasound c. request a 12 lead EKG and cardiac enzymes d.administer 4 milligrams of morphine IV push

b

A nurse is caring for a client who is 40 weeks of gestation and reports having a large gush of fluid from the vagina while walking from the bathroom. which of the following actions should the nurse take first? A. examine the amniotic fluid for meconium B. check the fetal heart rate C. drive the client and make them comfortable E. apply a tocotransducer

b

A nurse is caring for multigravida pt in the process of delivery. The fetal head meets resistance as it descends along the soft tissues of the pelvis, muscles of the pelvic floor & cervix. What intervention does the nurse anticipate? A. Assist the obstetrician to prepare for emergency c section B. Assist the obstetrician to proceed with vaginal delivery C. Admin prescribed med to relax the uterus D. Reposition the pt on her side

b

A nurse is completing an admission assessment for a client who is 39 weeks of gestation and reports fluid leaking from the vagina for two days. which of the following conditions is the client at risk for developing? A. cord prolapse B. infection C. postpartum hemorrhage D. hydramnios

b

A patient who is 25 weeks pregnant has partial placenta previa. as a nurse you're educating the patient about the condition and self-care. which statement by the patient requires you to educate the patient a. I will avoid sexual intercourse & douching throughout the rest of the pregnancy b. I may start to experience dark red bleeding with pain c. I will have another ultrasound at 32 weeks to reassure the placenta's location d. my uterus should be soft and nontender

b

The client in early pregnancy comes to the ED with pian in her right pelvic area, the tentative diagnosis is ectopic pregnancy. For which additional signs and symptoms of ectopic pregnancy should the nurse assess this client? a. Excessive NV b. Referred shoulder pain c. Breast tenderness & amenorrhea d.Elevated blood pressure & proteinuria

b

The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. which client statement indicates an understanding of teaching? A. I need to be on bed rest for the duration of my pregnancy B. I will notify my HCP if I start having low back aches C. pelvic pressure is to be expected after cerclage placement D. this requires will be removed once my baby is at 28 weeks

b

Which nursing action should take priority when caring for a woman with a suspected ectopic pregnancy a. administer oxygen b. monitor vital signs c. attain surgical consent d.provide emotional support

b

a nurse is caring for a client who is in labor with cervical dilation at 5 cm. which of the following findings on the assessment requires intervention by the nurse? A. contraction intensity of 45 mm Hg B. duration of contraction of 100 seconds C. frequency of contractions every four minutes D. resting uterine tone of 10 mm Hg

b

a woman with a diagnosis of ectopic pregnancy is to receive medical interventions rather than a surgical interruption. which of the following intramuscular medications would the nurse expect to administer a. Decadron (dexamethasone) b. Amethopterin (methotrexate) c. Pergonal (menotropin) d.Prometrium (progesterone)

b

The graduate nurse and supervising nurse are preparing to follow up with a client who had a spontaneous abortion at six weeks gestation at home. which of the following statements by the graduate nurse are appropriate? SATA a. although the client is RH negative it is unnecessary to administer RH immune globulin due to the clients early gestational age b. I will reinforce teaching with the client about abstaining from sexual intercourse for two weeks c. the client should call the HCP for foul smelling vaginal discharge, heavy vaginal bleeding or severe pain d. the client should continue prenatal vitamins with iron and take ibuprofen as needed for pain e. she maintained perineal hygiene the client should soak nightly in a bathtub and used soap

b, c, d

A pregnant client is brought to the emergency department by ambulance after her water broke. she is screaming and bearing down with every contraction. which of the following assessment questions are essential to ask in preparation for the birth if possible newborn resuscitation? SATA A. did you receive the influenza vaccine during pregnancy B. do you take any medications or illicit drugs C. how many babies are you expecting D. what color was the fluid when your water broke E. when is your due date

b, c, d, e

A nurse is caring for a pt who delivered a baby 8 hr ago. When assessing the pts fundus, the nurse notes that it feels boggy & soft. Which interventions are most appropriate? SATA A. Elevate the pts legs B. Firmly massage the fundus C. Encourage the pt to void D. Apply compression stockings E. Admin methergine per HCP order

b, c, e

A nurse is providing care for a client who has marginal abruptio placentae. which of the following findings are risk factors for developing the condition? SATA a. fetal position b. blunt abdominal trauma c. cocaine use d. maternal age e. cigarette smoking

b, c, e

a 36 year old woman who is 38 weeks pregnant reports having dark red bleeding. the patient experienced abruptio placentae with her last pregnancy at 29 weeks. what other signs and symptoms can present with abruptio placenta? SATA a. decrease in fundal height b. hard abdomen c. fetal distress d. abnormal fetal position e. tender uterus

b, c, e

A pt at 39 wks gestation is in active labor & is currently receiving an IV infusion of oxytocin. What should the nurse do when frequent late decelerations are noted on the fetal monitor? SATA A. Assist the pt into the hands knees position B. Discontinue oxytocin infusion C. Perform the Kleihauer-Betke test D. Admin oxygen with a nonrebreather face mask E. Notify the HCP

b, d, e

A pt is 39 wks gestation is in active labor & is currently receiving an IV infusion of oxytocin. What should the nurse do when frequent late decelerations are noted on the fetal monitor? SATA A. Assist the pt into the hands knees position B. Discontinue oxytocin infusion C. Perform the kleihauer-betke test D. Admin oxygen with nonrebreather face mask E. Notify HCP

b, d, e

your patient who is 34 weeks pregnant diagnosed with total placenta previa. the patient is A positive. what nursing intervention below will you include in the patients care? SATA a. routine vaginal examination b. monitoring vital signs c. administer RhoGAM per MD order d. assess internal fetal monitoring e. placing patient on sideline position f. monitoring pad count g. monitoring CBC and clotting levels

b, e, f, g

A 42 yo pregnant pt has been told that she is at risk of preterm labor bc of her age & health history. Which info from the nurse is correct regarding prevention of preterm labor A. Avoid regular low impact exercise as activity can stimulate uterine contractions B. Increase protein intake to support uterine muscle & decrease carb intake C. Do not lift heavy bags of groceries or young children which requires use of abd muscles D. If experiencing contractions avoid eating or drinking anything & contact the HCP

c

A neighbor who is a nurse is called on to assist with an emergency home birth. What should the nurse do to help to expel the placenta? A. Put the pressure on the fundus B. Ask the mother to bear down C. Have the mother breast feed the newborn D. Place gentle pressure on the cord

c

A nurse at an antepartum clinic is caring for a client who is at four months of gestation. the client reports continued nausea, vomiting and scant, prune colored discharge. the client has experienced no weight loss and has a fundal height larger than expected. which of the following complications should the nurse suspect? a. hyperemesis gravidarum b. threatened abortion c. hydatidiform mole d. preterm labor

c

A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The clients partner asked about the purpose of the IV fluids. which of the following statements should the nurse make? A. it is needed to promote increased urine output B. it is needed to counteract respiratory depression C. it is needed to counteract hypotension D. it is needed to prevent oligohydramnios

c

A nurse is caring for a client post-op for removal of an ectopic pregnancy. the client has A negative blood type and reports receiving Rhogam with her last pregnancy. she asked if she needs to receive it again. what is the best response by the nurse a. you don't need it because the embryo didn't have a blood type yet b. there is no need for Rogan because he won't be delivering the baby c. we will administer rho gam before you get discharged d.the surgeon was able to remove all the contents so you don't need to get rho gam

c

A nurse is caring for a client who is in active labor, irritable and reports the urge to have a bowel movement. the client vomit and states I've had enough I can't do this anymore. which of the following stages of labor is is the client experiencing? A. second stage B. fourth stage C. transition phase D. Latent phase

c

A nurse is caring for a client who is in labor and is considering applying a scalp electrode to the baby for internal fetal monitoring. which condition is a contraindication for use of a scalp electrode a. fetus more than 37 weeks gestation b. the need for an episiotomy c. placenta previa d. maternal diagnosis of diabetes

c

A nurse is caring for a client who is in labor. the anesthesiologist has just administered a pudenal block. Which of the following is correct regarding a pudendal block? A. a pudendal block may class side effects of respiratory depression and hypotension B. APRA dental block is one of the first drugs administered for pain control during labor C. a pudendal block anesthetizes the premium, vulva & rectum D. a pudendal block is only used in emergency situations

c

A nurse is caring for a pt at 28 wk gestation who has a new prescription for dinoprostone (Cervidil). Which of the following is the most appropriate nursing intervention? A. Provide instructions about the med B. Recheck VS & maternal hx for medical problems before administration of the drug C. Call the HCP D. Determine the correct dose & route of admin

c

A nurse is caring for a woman who is receiving oxytocin to induce labor. The nurse must observe the pt carefully for signs of which of the following? A. Hypoglycemia B. Nerve pain C. Uterine tetany D. Bloody show

c

A woman, who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows that the placenta is located at the edge of the cervical opening. As the nurse you know that which statement is FALSE about this finding: a. This is known as marginal placenta previa b. the placenta may move upward as the pregnancy progresses and needs to be reevaluated with another ultrasound at about 32 weeks gestation c. the patient will need to have a C-section and cannot deliver vaginally d. the woman should report any bleeding immediately to the doctor

c

The graduate nurse is assisting the nurse preceptor to provide education to a client diagnosed with molar pregnancy. which statement by the graduate nurse requires the precepting nurse to intervene a. a uterine evacuation procedure is a typical treatment for removing the abnormal tissue b. we can provide you with resources for coping with perinatal loss if needed c. you may start trying to conceive again as soon as you and your partner feel ready d. you will need Rh immune globulin following a molar pregnancy because you have a Rh negative blood type

c

Which statement is true regarding abruptio placentae a. this condition occurs due to an abnormal attachment to the placenta in the uterus near or over the cervical opening b. a marginal abruptio placentae occurs when the placenta is located near the edge of the cervical opening c. nursing interventions for this condition includes measuring the fundal height d. fetal distress is not common in this condition as it is a placenta previa

c

a woman has been diagnosed with a ruptured ectopic pregnancy. which of the following signs and symptoms is characteristic of this pregnancy a. dark brown rectal bleeding b. severe nausea and vomiting c. sharp unilateral pain d.marked hyperthermia

c

A nurse is caring for a client who has received epidural anesthesia during labor. immediately after the epidural is administered the nurse notes decreased beat to beat variability and late decelerations on the fetal heart monitor. which of the following intervention should the nurse implement? SATA A. increase the oxytocin drip B. put the client in Trendelenburg position C. turn the client on left side D. increase IV fluid rate E. have anesthesia turn up the epidural

c, d

A client calls a provider's office and reports having contractions for two hours that increased with activity and did not decrease with rest and hydration. the client denies leaking of vaginal fluid but did notice blood when wiping after voiding. which of the following manifestations is a client experiencing? A. Braxton Hicks contractions B. rupture of membranes C. fetal dissent D. true contractions

d

A nurse is assessing a client who is in labor and received an epidural anesthesia block for pain relief. which of the following manifestations should the nurse identify as an adverse effect of the epidural block? A. Vomiting B. Tachycardia C. flank pain D. hypotension

d

A nurse is caring for a 25 year old client who has just had a spontaneous first trimester abortion. which of the following comments by the nurse is appropriate a. you can try again very soon b. it is probably better this way c. at least you weren't very far along d.I'm here to talk to you if you would like

d

A nurse is caring for a client who is using pattern breathing during labor. the client reports numbness and tingling of the fingers. which of the following actions should the nurse take? A. administer oxygen via nasal cannula at 2 L/min B. apply a warm blanket C. assist the client to a sideline position D. place an oxygen mask over the client's nose and mouth

d

A pregnant client at 39 weeks gestation is brought to the emergency department in stable condition following a motor vehicle collision. The client is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50/ which action should the nurse take first a. administer normal saline fluid bolus b. ask about any prenatal complications c. initiate fetal heart rate monitoring d. tilt the backboard to one side

d

A woman eight weeks pregnant admitted to the obstetric unit with a diagnosis of threatened abortion. which of the following tests would help to determine whether the woman is carrying a viable or nonviable pregnancy a. luteinizing hormone level b. endometrial biopsy c. hysterosalpingogram d.serum progesterone levels

d

An anesthesiologist is providing pain medication for a client who is in labor. he injects medication that provides a local anesthetic for pain relief to the vulva, the perineum, and the lower aspect of the vagina. which of the following best describes this type of pain control? A. Intrathecal anesthesia B. patient controlled epidural C. sphenopalatine nerve block D. pudendal nerve block

d

The laboring client reports feeling the need to have a bowel movement and begins vomiting. the nurse notes of the client's legs are trembling. what cervical examination finding with the nurse expect this client to have? A. 2 cm dilated 50% effaced, -2 station B. 6 cm dilated 70% effaced, -1 station C. 7 cm dilated 80% effaced, 0 station D. 8 cm dilated 100% effaced, +1 station

d

a 25 year old client is admitted with the following history: 12 weeks pregnant vaginal bleeding, no fetal heartbeat seen on ultrasound. the nurse would expect the doctor to write in order to prepare the client for which of the following a. cervical cerclage b. amniocentesis c. non stress test d.dilation & curettage

d

the nurse is caring for a client who has just been admitted to the hospital to rule out ectopic pregnancy. which of the following orders is the most important for the nurse to perform a. take the clients temperature b. document the time of the client's last meal c. obtain urine for your analysis and culture d.assess for complaint of dizziness and weakness

d