3

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which nursing actions are appropriate during oxytocin infusion? Select all that apply. 1. Administering IV oxytocin via the distal port 2. Assessing uterine contraction pattern 3. Auscultating fetal heart rate intermittently 4. Monitoring intake and output 5. Placing the IV oxytocin on an electronic infusion pump

245

A client at 30 weeks gestation is hospitalized for preeclampsia. Which assessment finding requires priority intervention? 1. Elevated liver enzymes [17%] 2. Lower abdominal pain and vaginal bleeding [45%] 3. Swelling of the hands, feet, and face [19%] 4. Urine output of 25 mL/hr [17%]

2

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? 1. Frequent vomiting since birth [18%] 2. Tiny blood streaks in the vomit [24%] 3. Vomit that is green [28%] 4. Vomiting through the nose [28%]

3

The health care provider is preparing to place a fetal scalp electrode to monitor the fetus of a laboring client. Which of the following assessment findings should the nurse communicate to the health care provider immediately? 1. Cervix is 3 cm dilated [0%] 2. Fetal presenting part is engaged [6%] 3. Fetus is in the breech position [66%] 4. Hepatitis B surface antigen test is positive [26%]

4

The nurse is caring for a full-term newborn following vaginal delivery. Which nursing interventions should be implemented? Select all that apply. 1. Always wear gloves when handling the newborn before bathing 2. Cover the newborn to maintain a body temperature of 97.5-99 F (36.4-37.2 C) 3. During the initial bath, remove as much vernix caseosa as possible 4. Give a single dose of vitamin K intramuscularly 5. Suction the pharynx first, then the nasal passages

1245

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply. 1. "Do you feel like the contractions are getting stronger?" 2. "Does anything you do make the pain better?" 3. "Have you lost your mucous plug?" 4. "How frequent are the contractions?" 5. "Where do you feel the contraction pain most?"

1245

Exhibit A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal heart rate is 140/min and the strip is shown in the exhibit. What is the nurse's best course of action? Click on the exhibit button for additional information. 1. Apply oxygen 10 L/min face mask [9%] 2. Continue to monitor the client [52%] 3. Discontinue oxytocin infusion [31%] 4. Notify the health care provider (HCP) [6%]

2

A client gives birth within an hour of arriving at the labor and delivery unit, and delivers the placenta 5 minutes later. During assessment, the nurse notes that the client's uterus is boggy and midline. Which action should the nurse take first? 1. Administer IV oxytocin [1%] 2. Insert in and out catheter [2%] 3. Monitor amount of lochia [3%] 4. Perform fundal massage [92%]

4

A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action? 1. Administer prescribed IV meperidine for pain relief [0%] 2. Encourage client to bear down with spontaneous urges to push [12%] 3. Place client in the lithotomy position in preparation for birth [35%] 4. Provide encouragement and coaching in breathing techniques [51%]

4

A diabetic woman has a precipitous delivery in the emergency department. Which initial neonate assessment finding is the priority and requires a nursing response? 1. Apgar score of 7 at 1 minute [9%] 2. Apical heart rate of 160/min [1%] 3. Circumoral duskiness [22%] 4. Jitteriness [65%]

4

A laboring client reports feeling the need to have a bowel movement and begins vomiting. The nurse notes that the client's legs are trembling. What cervical examination finding would the nurse most expect this client to have? 1. 2 cm dilated, 50% effaced, −2 station [4%] 2. 6 cm dilated, 70% effaced, −1 station [8%] 3. 7 cm dilated, 80% effaced, 0 station [16%] 4. 8 cm dilated, 100% effaced, +1 station [69%]

4

The nurse is evaluating a parent's understanding of post-circumcision care for a newborn. Circumcision was performed using the clamp method. Which statement by the parent demonstrates a need for further teaching? 1. "Bleeding should be no larger than the size of a quarter." [15%] 2. "I should apply petroleum jelly to the glans at diaper changes." [19%] 3. "My baby should have 4-6 wet diapers in 24 hours." [17%] 4. "Yellow exudate on the glans penis indicates infection." [47%]

4

When making assignments in the labor and delivery unit, the charge nurse should assign the most experienced newborn admit nurse to attend to the birth of which client? 1. Client with diet-controlled gestational diabetes [2%] 2. Client with mild preeclampsia and blood pressure averaging 140/90 mm Hg [12%] 3. Client with premature rupture of membranes 6 hours ago at 37 weeks gestation [9%] 4. Client with spontaneous rupture of membranes with greenish amniotic fluid [75%]

4

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds [60%] 2. Contraction frequency of every 3 minutes [15%] 3. Contraction intensity of 45 mm Hg [8%] 4. Uterine resting tone of 10 mm Hg [15%]

1

Which meal should the nurse recommend for a pregnant client at 13 weeks gestation? 1. Baked chicken, turnip greens, peanut butter cookie, and grape juice [62%] 2. Baked swordfish, fries, baked apples, and fat-free milk [4%] 3. Chilled ham and cheese sandwich, broccoli, orange slices, and water [18%] 4. Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water [14%]

1

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia [76%] 2. Fetal tachycardia with moderate variability [20%] 3. Increased anxiety and discomfort with contractions [1%] 4. Painful, strong contractions every 3-4 minutes [2%]

1

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client? 1. Administration of prophylactic antibiotics [46%] 2. Assessment of uterine contraction frequency [20%] 3. Collection of a clean-catch urine specimen [10%] 4. Vaginal examination to assess cervical dilation [21%]

1

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counterpressure to the client's sacrum during contractions [46%] 2. Encouraging the client to remain in bed during early labor [0%] 3. Positioning the client on the left side with pillows for support [49%] 4. Requesting that the nurse anesthetist administer epidural anesthesia [3%]

1

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? Select all that apply. 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

1245

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene? 1. Documenting a positive nitrazine test result when the test strip turns blue [5%] 2. Donning nonsterile gloves and using soluble gel for vaginal examination [62%] 3. Palpating the client's abdomen before applying external fetal monitors [10%] 4. Providing the client with a variety of clear liquids to drink [21%]

2

Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? Select all that apply. 1. Avoid discussing the adoption details until after the birth 2. Encourage the birth mother to hold the newborn 3. Notify other staff who may interact with the client of the adoption plan 4. Offer the birth mother a chance to say goodbye to the newborn 5. Use phrases that illustrate adoption as a decision of love, not abandonment

2345

A nurse is preparing to administer oxytocin to induce labor in a client. The nurse recognizes that the oxytocin infusion can lead to which of the following? 1. Decreased postpartum hemorrhage [19%] 2. Delayed milk production [4%] 3. Fetal distress and cesarean birth [67%] 4. High risk of placenta previa [9%]

3

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting, and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take? 1. Apply gloves and assess perineal area [55%] 2. Initiate large-bore IV access [6%] 3. Notify anesthesia provider of client's request for epidural [2%] 4. Obtain fetal heart tones via Doppler [35%]

4

A pregnant client comes to the labor and delivery unit stating the water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure [14%] 2. Perform Leopold maneuvers [11%] 3. Perform the McRoberts maneuver [20%] 4. Position the client on hands and knees [52%]

4

Exhibit A client at 38 weeks gestation is in labor and receiving an oxytocin infusion. The continuous fetal heart rate (FHR) monitor displays the strip shown in the exhibit. Which action by the nurse is most appropriate? Click on the exhibit button for additional information. 1. Discontinue oxytocin infusion [33%] 2. Place client in the side-lying position [45%] 3. Provide oxygen 10 L/min via face mask [7%] 4. Review medication administration record [13%]

4

A pregnant client has labor induced with oxytocin infusion. The nurse assesses that the client has had 6 contractions in the past 10 minutes with a resting tone of 25 mm Hg. Fetal heart rate tracing shows a change in the baseline rate from 145/min to 170/min and minimal variability. What is the nurse's order of priority action? All options must be used.

right

During the first prenatal assessment, the client reports the last normal menstrual period starting on March 1 and ending on March 5, but also slight spotting on March 23. The client had unprotected intercourse on March 15. Using Naegele's rule, what is the estimated date of birth? 1. December 8 [57%] 2. December 12 [22%] 3. December 22 [13%] 4. December 30 [6%]

1

The nurse is admitting a pregnant client who is experiencing intense "back labor." The nurse suspects the fetus is in which position? 1. [40%] 2. [15%] 3. [7%] 4. [37%]

1

A pregnant client arrives in the emergency department by ambulance, reporting that her "water broke" at home. She is screaming and bearing down with every contraction. What questions are essential to ask in preparation for the birth and possible neonatal resuscitation? Select all that apply. 1. "How many babies are you expecting?" 2. "What color was the fluid when your water broke?" 3. "What drugs did you take in the last 4 hours?" 4. "When is your due date?" 5. "Who is your health care provider?"

1234

Exhibit A nurse is evaluating the external fetal monitoring strip of a laboring primigravida at 36 weeks gestation. Which nursing interventions should the nurse implement? Click on the exhibit button for additional information. Select all that apply. 1. Administer supplemental oxygen by mask 2. Increase the intravenous (IV) fluid rate 3. Prepare the client for an amnioinfusion 4. Reposition the client to the supine position 5. Stop the client's oxytocin infusion

125

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply. 1. Avoid intake of dairy products 2. Consume a low-fat diet 3. Drink large amounts of fluids with meals 4. Eat several small meals a day 5. Lie down on the left side after meals

24

A client at 34 weeks gestation reports constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which recommendations should the nurse make for this client? Select all that apply. 1. Decreased daily dairy intake 2. Increased fruit and vegetable intake 3. Moderate-intensity regular exercise 4. One laxative twice daily for a week 5. Two cups of hot coffee each morning

23

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. 1. Angle bottle up and toward cleft 2. Burping the infant often 3. Feeding in an upright position 4. Feeding slowly over 45 minutes or more 5. Using a specialty bottle or nipple

235

A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? Select all that apply. 1. Cervical softening on examination 2. Fetal heart tones detected by Doppler device 3. Positive serum human chorionic gonadotropin test 4. Report of fetal movement felt by client 5. Visualization of fetus by ultrasound

25

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia [21%] 2. Hydrotherapy [29%] 3. IV narcotics [15%] 4. Pudendal nerve block [32%]

3

A nurse is assessing a newborn with an infection due to Candida albicans. Which assessment data support this diagnosis? 1. Diffuse skin rash that resembles flea bites [2%] 2. Small, white cysts on the hard palate [6%] 3. Vesicles on the skin surrounding the lips [2%] 4. White, adherent patches on the tongue and palate [88%]

4

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations [16%] 2. Inversion of the uterus [16%] 3. Uterine atony [27%] 4. Vaginal hematoma [40%]

4

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply. 1. Contractions that increase in frequency 2. Contractions that lessen after resting 3. Increased blood-tinged, mucoid vaginal discharge 4. Pain in lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation

145

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply. 1. Ask the parents if they would like to help bathe the infant 2. Discourage the parents from naming the infant 3. Discuss the importance of organ donation with the parents 4. Encourage the parents and family members to hold the infant 5. Offer to obtain handprints, footprints, and photographs of the infant

145

The charge nurse should intervene if the new graduate nurse performs which action when caring for a jaundiced newborn being treated with phototherapy? 1. Allowing the parents to feed the newborn [2%] 2. Applying a shirt while the newborn is exposed to phototherapy [88%] 3. Assessing the temperature of the incubator while the newborn is inside [5%] 4. Covering the newborn's eyes with protective shields [3%]

2

A nurse is caring for a postpartum client who has chosen to exclusively formula feed her newborn for medical reasons and is experiencing breast engorgement. What should the nurse teach regarding relief of breast engorgement? 1. Apply heat frequently to both breasts for 15-20 minutes [6%] 2. Manually express milk several times a day [18%] 3. Massage breasts from the base to the nipple 3 or 4 times a day [3%] 4. Use chilled, fresh cabbage leaves on breasts throughout the day [71%]

4

A nurse is caring for a postpartum client who is being discharged with her newborn. Which discharge instruction should the nurse teach the client regarding newborn safety? 1. Avoid using blanket rolls to position the infant in the car seat [41%] 2. Place the baby in bed in the prone position while sleeping [10%] 3. Place the infant's car seat in the back seat facing forward [10%] 4. Use an infant sleep sack when the newborn is in the crib [37%]

4

The nurse providing culturally competent care to a group of new mothers will give further teaching concerning breastfeeding to which of the following clients? 1. A mother of African descent who desires to breastfeed for 2 years [10%] 2. A mother of Arab descent who wishes to bottle-feed while in the hospital [11%] 3. A mother of European-Caucasian descent who wishes to breastfeed immediately after birth [2%] 4. A mother of Hispanic descent who refuses to offer colostrum to the newborn [75%]

4

The obstetric nurse is reviewing phone messages. Which client should the nurse call first? 1. Client at 18 weeks gestation taking ceftriaxone and reporting mild diarrhea [10%] 2. Client at 22 weeks gestation with twins who is taking acetaminophen twice a day [23%] 3. Client at 28 weeks gestation taking metronidazole and reporting dark-colored urine [27%] 4. Client at 32 weeks gestation taking ibuprofen for moderate back pain [38%]

4

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place. Answer: (mL) 7

7

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? 1. Bishop score of 10 [54%] 2. Firm and posterior cervix [11%] 3. History of precipitous labor [5%] 4. Reactive nonstress test [28%]

1

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication [21%] 2. Give the medication slowly during the peak of the next contraction [50%] 3. Hold until contractions are occurring at least every 4 minutes for an hour [19%] 4. Withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication [9%]

2

The nurse is caring for a client who is in active labor at 39 weeks gestation and receiving a continuous intravenous (IV) infusion of oxytocin. The nurse notes frequent and persistent late decelerations on the fetal monitor. What actions should the nurse take? Select all that apply. 1. Administer oxygen via a nonrebreather face mask 2. Change the maternal position to the lateral side 3. Discontinue oxytocin infusion 4. Notify the health care provider (HCP) 5. Perform a nitrazine test

1234

A client at 41 weeks gestation is admitted to the labor and delivery unit for labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate? Select all that apply. 1. Assessing the fetal heart rate before and after the procedure 2. Checking the client's temperature every 2 hours 3. Informing the client she will feel a sharp pain during the procedure 4. Keeping the client in a supine position after the procedure 5. Noting the characteristics of the amniotic fluid

125

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? Select all that apply. 1. Additional ultrasound around 36 weeks gestation 2. Clearance for sexual activity if bleeding stops 3. Discharge home if bleeding stops and fetal status is reassuring 4. Scheduled cesarean birth before onset of labor 5. Weekly vaginal examinations to assess for cervical change

134

A nurse is caring for a client who is breastfeeding and has been diagnosed with mastitis of the right breast. Which instructions should be included in the teaching? Select all that apply. 1. Increase oral fluid intake 2. Cease breastfeeding from right breast 3. Reduce frequency of feeds to every 8 hours in right breast 4. Take ibuprofen as needed for pain 5. Use underwire bra 24 hours a day for support

14

Exhibit A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken first? Click on the exhibit button for additional information. 1. Administer IV fluid bolus [3%] 2. Assess for umbilical cord prolapse [46%] 3. Notify the health care provider [11%] 4. Reposition client to alternate side [37%]

2

Exhibit The nurse reviews the external fetal monitoring tracing of a client receiving an oxytocin infusion for augmentation of labor. The obstetric provider asks to increase the infusion rate. Which action by the nurse is most appropriate at this time? Click on the exhibit button for additional information. 1. Increase the rate of oxytocin infusion as requested by the provider [24%] 2. Inform the provider that the oxytocin rate should not be increased at this time [38%] 3. Request that the charge nurse speak with the obstetric provider [3%] 4. Request to leave the rate unchanged, as the contraction pattern is adequate [33%]

2

The labor and delivery nurse assesses a laboring client who had rupture of membranes 4 hours ago and is 8 cm dilated, 100% effaced, and −1 station. Which additional assessment finding should the nurse report to the health care provider? 1. Copious blood-tinged cervical mucus [5%] 2. Green-tinged amniotic fluid [84%] 3. Lower backache unrelieved by epidural [7%] 4. Temperature of 99.9 F (37.7 C) [2%]

2

The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action? 1. Document fetal presentation as breech [10%] 2. Document fetal presentation as cephalic [64%] 3. Elevate the fetal presenting part away from the prolapsed cord [11%] 4. Request that the health care provider confirm fetal presentation [12%]

2

A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching? 1. "I can expect the cord to turn black in a few days." [13%] 2. "I should let the cord fall off by itself, in about 1-2 weeks." [2%] 3. "I should use a cotton swab to gently apply alcohol to the cord." [79%] 4. "I will fold the diaper below the cord to allow the cord to dry." [3%]

3

Exhibit The nurse reviews the laboratory results of a laboring client who is requesting epidural anesthesia. Which value is the priority to report to the anesthesia provider prior to epidural placement? Click on the exhibit button for additional information. 1. Blood type and Rh [7%] 2. Hemoglobin [9%] 3. Platelet count [70%] 4. White blood cell count [12%]

3

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider? 1. Clean the perineal area [1%] 2. Gently pull on the cord [4%] 3. Keep the infant warm [57%] 4. Massage the fundus [36%]

3

Four clients in labor are requesting pain medication from the nurse. Which client can safely receive an opioid agonist-antagonist analgesic intravenous (IV) push at this time? 1. Gravida 1, 2 cm dilated, 50% effaced, contractions 7-10 minutes apart, crying [47%] 2. Gravida 1, 6 cm dilated, 75% effaced, contractions 2-4 minutes apart, has history of heroin use [10%] 3. Gravida 2, 5 cm dilated, 100% effaced, contractions 3-4 minutes apart, moaning and shaking [31%] 4. Gravida 4, 10 cm dilated, 100% effaced, contractions 2-3 minutes apart, wants to push [11%]

3

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? 1. Complete hourly pain assessments using a numeric pain scale [38%] 2. Document that the client appears to be experiencing minimal pain [1%] 3. Monitor for nonverbal signs of ineffective coping with labor [57%] 4. Recognize that the client's stoicism is ineffective coping with labor [2%]

3

The nurse in the operating room is preparing for an emergency dilation and curettage post vaginal delivery for placenta accreta. What information is most important when reviewing this client's chart? 1. Client has been NPO and has no metal on the body [2%] 2. Client has stable vital signs and has signed consent [29%] 3. Client has type and crossmatch on file and at least 2 patent large-bore IV sites [58%] 4. Client is on oxygen and has a patent IV site [9%]

3

The nurse performs the first Apgar assessment of a newborn at 1 minute of life. The baby is completely blue, with a heart rate of 110/min and is emitting a weak cry. The baby is actively moving and grimaces when the nares are suctioned. What is this baby's Apgar score? 1. 4 [17%] 2. 5 [29%] 3. 6 [33%] 4. 7 [20%]

3

What is an appropriate nursing intervention after the birth of a newborn with anencephaly? 1. Instruct the parents that visitors should be restricted [4%] 2. Provide information to the parents about genetic counseling [8%] 3. Refer the parents to a perinatal loss support group [10%] 4. Wrap the newborn in warm blankets for the parents to hold [77%]

4