315 - Exam 1 (Prep U & Nearpod)
The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best? A. Take no extra measures; prepare for a standard labor. B. Anticipate this client is a one-to-one registered nursing assignment. C. Notify the client's support person that the labor is typically long. D. Prepare for vital signs and fetal monitoring hourly.
A
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also 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.
A
A client is assessed 5 hours after delivery. Temperature = 37.8 C. What is the most appropriate action? A. Encourage oral fluid intake B. No action needed C. Notify provider D. Administer acetaminophen with codiene prn
A
When assessing the newborn's umbilical cord, what should the nurse expect to find? A. two smaller arteries and one larger vein B. two smaller veins and one larger artery C. one smaller vein and two larger arteries D. one smaller artery and two larger veins
A
When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering
A
Patterned breathing techniques used in labor provide which benefits? Select all that apply. A. conscious relaxation B. distraction C. pain relief without special tools D. spirituality
A B C
The nurse is teaching infant security to a group of new nurses on a labor and delivery unit. Which characteristic fits the profile of the typical newborn abductor in the United States? A. Male B. 12 to 50 years of age C. Single D. Intends to sell the newborn
B
A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station? A. +4 B. +2 C. 0 D. -2
D
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.
D
The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the LPN, is completed first? A. Assess the fetal heart rate B. Assess the strength of contraction C. Assess if the bladder is distended D. Assess the client's psyche
C
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? A. respiratory rate of 50 breaths/minute B. acrocyanosis C. asymmetrical chest movement D. short periods of apnea (less than 15 seconds)
C
Which intervention would be least effective in caring for a woman who is in the transition phase of labor? A. having the client breathe with contractions B. providing one-to-one support C. encouraging the woman to ambulate D. urging her to focus on one contraction at a time
C
A nurse is educating a pregnant client about physical changes that can occur in pregnancy. Which conditions are associated with physical changes in pregnancy? Select all that apply. A. persistent cough B. Kussmaul respirations C. nasal stuffiness and sinus problems D.thoracic breathing instead of abdominal breathing E. swollen and tender gums
C D E
The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn? A. lack of subcutaneous fat B. continual kicking C. continual crying D. constriction of blood vessels
A
The nurse performs a nonstress test (NST) on a client at 36 weeks' gestation. What criteria does the nurse look for on the tracing to determine that the NST is reactive? A. Presence of 2 accelerations in 20 minutes B. Presence of 2 decelerations in 60 minutes C. Presence of 2 accelerations per hour D. Presence of 2 contractions during a 20 minute window
A
A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate? A. "This is likely just coincidence." B. "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." C. "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth." D. "You are older now and that can impact how your neonate adapts to the birth process." E. "Neonates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth."
B
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching? A. "Change the newborn's diaper every four hours while awake." B. "Place the newborn on the back to sleep and stomach to play." C. "Newborns can sleep on a couch to allow constant visual monitoring." D. "You need to give your newborn a bath everyday."
B
The nurse is documenting a non-pregnant client's obstetric history. The client informed the nurse she has 4 children living at home. She birthed one child at 34 weeks' gestation, one child at 37 weeks' gestation, one at 38 weeks' gestation, and one at 39 weeks' gestation. The client has had one abortion. Using the GTPAL format, how will the nurse document the client's obstetric history? A. G5, T2, P1, A1, L3 B. G4, T3, P0, A1, L3 C. G5, T2, P2, A1, L4 D. G4, T3, P1, A1, L4
C
The nurse is assessing a woman in labor. Which assessment finding is of highest concern? A. Pain = 10/10, radiating from back to front of pelvis with contractions B. R = 28 breaths/minute during contractions C. The client has not voided in 3 hours D. BP = 148/96 mmHg between contractions
D
The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal? A. decreased plasma fibrinogen levels B. increased blood coagulation time C. increased blood glucose levels D. increased white blood cell count
D
During which time is the nurse correct to document the end of the third stage of labor? A. Following fetal birth B. When pushing begins C. At the time of placental delivery D. When the mother is moved to the postpartum unit
C
How should the nurse record the obstetric history for a newly pregnant client who previously delivered two live infants at term and had one abortion at 12 weeks' gestation? A. Gravida 3, para 2 B. Gravida 3, para 3 C. Gravida 4, para 2 D. Gravida 4, para 3
C
A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because: A. Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth. B. Vitamin K aids in protein metabolism. Newborns have defective protein metabolism until 24 hours of life. C. Newborns are prone to hypoglycemia, and vitamin K helps maintain a steady blood glucose level. D. The mother was febrile at the time of birth and prophylactic vitamin K is necessary.
A
During which phase of labor would the nurse anticipate providing the most emotional support for the mother? A. Active phase of labor B. Final phase of labor C. Transition phase of labor D. Latent phase of labor
C
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.
B
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? A. Bloody fluid B. Clear to straw-colored fluid C. Greenish fluid D. Cloudy white fluid
B
A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent? A. First B. Second C. Third D. Fourth
C
A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? A. symmetrical chest movements B. periodic breathing C. respirations of 40 breaths/minute D. sternal retractions
D
A pregnant woman has come to the clinic for her first prenatal visit. The nurse informs the woman that the physician will do a pelvic examination at this time and that she should go empty her bladder. What is the primary reason the nurse instructs the patient to empty her bladder? A. A CBC might be needed. B. Urinating now might help to prevent an infection. C. The pregnant woman's bladder does not hold much urine, so this will prevent an accident. D. Urinating now will allow easier identification of organs.
D
A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize? A. Immediately report to the RN that the FHR shows tachycardia. B. Immediately report to the RN that the FHR shows no variability. C. Before reporting to the RN, determine the short term variability (STV). D. Before reporting to the RN, determine the uterine contraction pattern.
D
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long? A. the first 28 days B. the first 3 months C. the first 4 months D. the first 6 months
D
A gravid client is talking with the nurse about the excessive nausea and vomiting she has been experiencing throughout the day. She asks why this is happening to her and what she can do to reduce the nausea. What information should be included in the nurse's response? Select all that apply. A. The levels of estrogen normally seen in pregnancy are associated with nausea and vomiting. B. Limiting fluid intake during the morning and evening hours has been shown to reduce nausea in pregnancy. C. The changes in progesterone in pregnancy are associated with high levels of nausea in pregnancy. D. Ingesting small frequent meals in pregnancy is helpful to manage nausea. E. Eating a high carbohydrate snack before getting out of bed may be helpful.
D E
A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment? A. blood pressure B. pulse C. temperature D. respirations E. pain
A
To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern? A. 108 beats/minute B. 122 beats/minute C. 132 beats/minute D. 140 beats/minute
A
When examining a newborn female, the nurse notices a small pinkish discharge from the vaginal area. What should the nurse suspect? A. pseudomenstruation, a normal finding B. infection C. evidence of birth trauma D. impending hemorrhage from a congenital defect
A
A nurse is assisting a client who is in the first stage of labor. Which principle should the nurse keep in mind to help make this client's labor and birth as natural as possible? A. Women should be able to move about freely throughout labor. B. The support person's access to the client should be limited to prevent the client from becoming overwhelmed. C. Routine intravenous fluid should be implemented. D. A woman should be allowed to assume a supine position.
A
Which action is a priority when caring for a woman during the fourth stage of labor? A. assessing the uterine fundus B. offering fluids as indicated C. encouraging the woman to void D. assisting with perineal care
A
Which client is most likely to be in labor? A. The woman who reports her contractions were irregular and now are every 2 minutes B. The woman who reports 8/10 contractions on her due date C. The woman who reports that she has been walking aroudn and her contractions don't bother her as much D. The woman who reports her "water broke"
A
Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting? A. shoulders B. occiput C. brow D. buttocks
B
A client at 16 weeks' gestation is scheduled for prenatal testing. Which of the following would the nurse anticipate as the most likely screening test for congenital anomalies based on the current age of this pregnancy? A. Cardiocentesis. B. Amniocentesis. C. Nuchal translucency testing. D. Chorionic villi sampling.
B
A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage? A. regular contractions B. cervical dilation (dilatation) C. fetal movement through the birth canal D. placental separation
B
The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client? A. Massage therapy B. Continuous labor support C. Pharmacologic pain management D. Prenatal classes
B
When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? A. crowning B. effacement C. dilation (dilatation) D. molding
B
When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation? A. crowning B. effacement C.dilation (dilatation) D. molding
B
The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? A. Administer an oral dose of vitamin K to the newborn. B. Assume that the parents refused this medication for their infant. C. Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. D. Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn.
C
The woman who is 4 weeks postpartum should be instructed to contact her provider for which symptom? A. Scant non-odorous white vaginal drainage B. Discomfort with sexual intercourse C. Sore nipples with cracks D. Needing a daily nap while the newborn sleeps
C
What anatomic area should be examined when assessing Montgomery glands (Montgomery tubercles)? A. thorax B. abdomen C. breasts D. perineum
C
A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching? A. "The warmth and buoyancy of the water has a nice relaxing effect." B. "I can stay in the bath for as long as I feel comfortable." C. "My cervix should be dilated more than 5 cm before I try using this method." D. "The temperature of the water should be at least 105℉ (40.5℃)."
D
Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action? A. Suction the mouth and then the nose with a suction catheter. B. Place the newborn on its stomach with the head down and gently pat its back. C. Suction the nose first and then the mouth with a bulb syringe. D. Using a bulb syringe, suction the mouth then the nose.
D
The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth? A. -5 B. 0 C. +1 D. +4
D
When teaching possible differences in labor between the first labor experience and all other labors, which statement is most beneficial to assist a woman's psyche? A. "The labor process is typically shorter for subsequent pregnancies." B. "You can have input into the labor plan as you know what to expect." C. "The intensity of contractions are much greater throughout the labor." D. "You had a successful labor and vaginal delivery with your first pregnancy."
D
Which action will the nurse avoid when performing basic care for a newborn male? A. Inspecting the genital area for irritated skin B. Palpating if testes are descended into the scrotal sac C. Determining the location of the urethral opening D. Retracting the foreskin over the glans to assess for secretions
D
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? A. Apgar score B. blood sugar C. heart rate D. temperature
B
A nurse is explaining to a group of new parents about the various changes that occur as a newborn transitions to extrauterine life. The nurse determines that the teaching was successful when the group identifies which adaptation as most important? A. Closure of the fetal heart shunts. B. Immune system functioning. C. Stabilization of temperature. D. Initiation and continued respirations.
A
The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth? A. Head flexed forward so much that the chin touches the sternum B. Chin in moderately flexed military position C. Fetus in partial extension with brow presenting to birth canal D. Fetus in complete extension with back arched
A
Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor? A. decrease in vaginal secretions B. development of a membrane further closing the cervix C. rupture of amniotic membranes D. decrease in duration of contractions
C
Which cardinal movement allows the fetus to travel through the birth canal most efficiently? A. Extension B. External rotation C. Flexion D. Engagement
C
The nursing instructor is conducting a class exploring the care of the neonate right after birth. The instructor determines the class is successful when the students correctly choose the best reason to prevent cold stress? A. The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. B. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. C. It takes energy to keep warm, so the neonate has to remain in an extended position. D. If the neonate becomes cold stressed, it will eventually develop respiratory distress.
D
The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? A. The infant may sleep through the night around 2 months of age. B. Caregivers need to sleep while the baby is sleeping. C. Newborns usually sleep for 16 or more hours each day. D. Place the infant on the back when sleeping.
D
The nurse is weighing an infant and is ensuring that the scale is warmed and the procedure is performed as quickly as possible. Doing so allows the nurse to minimize the effects of heat loss by what method? A. Conduction B. Radiation C. Convection D. Evaporation
A
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart? A. Fetal heart rate in relation to contractions B. The station in which the fetus is located C. Maternal heart rate and blood pressure D. Maternal request for pain medication
A
A nurse is monitoring a client during the second stage of labor. Which finding in the mother should cause concern for the nurse? A. A rise in systolic blood pressure of 30 mm Hg with each contraction B. An increase in white blood cell count to 30,000 cells/mm3 C. An increase in body temperature to 99.6 °F (37.5℃) D. An increase in the specific gravity of urine to 1.030
A
Which documentation in the health record is most correct for the third stage of labor? A. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta. B. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus. C. Begins with the time of placental delivery and ends when the healthcare provider is satisfied that there are no placental fragments. D. Begins with the time of placental delivery and ends 48 hours later.
A
Which is the best place to perform a heel stick on a newborn? A. the fat pads on the lateral aspects of the foot B. the vascularized flat surface of the foot C. the front of the heel (the outer arch) D. the calcaneus
A
Which of the following is true regarding the newborn's fontanelles? A. The anterior fontanelle is diamond shaped and measures about 3.5 cm. The posterior fontanelle is triangular shaped and measures about 1 cm. B. The anterior fontanelle is triangular in shape and measures about 3.5 cm. The posterior fontanelle is diamond shaped and measures about 1 cm. C. The anterior fontanelle is diamond shaped and measures about 1 cm. The posterior fontanelle is triangular in shape and measures about 3.5 cm. D. The anterior fontanelle is triangular in shape and measures about 1 cm. The posterior fontanelle is diamond shaped and measures about 3.5 cm.
A
What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply. A. A washcloth B. Hexachlorophene soap C. Warm tub of water D. Thermometer E. Talc powder
A C D
The nurse is caring for a newborn who was delivered via a planned cesarean delivery. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor? A. Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide. B. Excessive fluid in its lungs, making respiratory adaptation more challenging. C. Fetal lungs are uninflated and full of amniotic fluid that must be absorbed. D. Much of the fetal lung fluid is squeezed out in cesarean delivery.
B
The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation? A. Admission time and time of fetal birth B. Complete cervical dilation (dilatation) and time of fetal birth C. Effacement time and time when contractions are regular D. Time of mucus plug expulsion and full cervical dilation
B
The nurse is monitoring a client and notes: contractions every 2 to 3 minutes, duration 45 to 60 seconds, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor? A. transition B. second C. third D. active
B
The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention? 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
B
The nurse understands that the maternal uterus should be at what location at 20 weeks' gestation? A. at the level of the symphysis pubis B. at the level of the umbilicus C. at the level near the bottom of the sternum D. three finger-breadths above the umbilicus
B
The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor? A. transition phase B. stage two C. latent phase D. stage three
C
The nurse has provided care to a client throughout labor and delivery and is comparing assessment findings with expected norms. When tracking the client's cardiac assessments, the nurse should predict that cardiac output will likely be the highest at which time? A. During active labor B. Second stage of labor C. Immediately after birth D. During transition
C
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? A. Fetal heart rate B. Possible maternal infection C. Meconium in the fluid D. Irregular contractions
C
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? A. Risk factors B. Maternal status C. Fetal status D. Maternal obstetrical history
C
The nurse is assisting a client in labor and delivery and notes the placenta is now delivered. Which documentation should the nurse prioritize? A. The client's vital signs B. The end of recovery C. The completion of the third stage of labor D. The transition phase
C
The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which? A. The client is fully effaced. B. The fetus is floating high in the pelvis. C. The fetus is in the true pelvis and engaged. D. The fetus has descended down the birth canal.
C
The nurse is educating the client at 12 weeks' gestation regarding the best types of exercise throughout pregnancy. Which activities should the nurse encourage? A. All activities that the client does in a prepregnant state B. Relaxing activities such as hot baths and jacuzzis C. High-impact movements enabling less time in the activity D. Stretching and breathing exercises such as yoga
D
The nurse is conducting a prenatal class for a group of primigravida clients. Which instruction will the nurse prioritize when teaching about breast care? A. Use hot water and a mild soap to keep the nipples clean. B. Wash the nipples with a deodorant soap to keep them clean and help toughen them. C. Use an antibacterial soap and cool water to keep the nipples clean. D. Wash the nipples with clean water only.
D
A neonate has been administered a prescribed dose of vitamin K. What outcome would most clearly indicate to the nurse that the medication has had the intended effect? A. The infant remains free of bleeding B. The infant's jaundice resolves C. The infant's hemoglobin level increases D. The infant remains free of infection
A
A nurse is assessing a female client in the labor admission unit. The client has been having contractions every 5 minutes for the past 6 hours. Which finding would the nurse use to determine if the client is experiencing true labor? A. The cervix has changes of effacement and dilation. B. The client has a history of giving birth to two infants. C. The contractions increase in duration and intensity. D. The client's membranes ruptured spontaneously.
A
A nurse is performing a physical assessment of a woman in labor. As part of her assessment, she examines the outer and inner surfaces of her lips. What is the best rationale for this assessment? A. Detection of herpes virus infection B. Detection of a respiratory infection C. Detection of anemia D. Detection of rales
A
A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation? A. frank B. full C. complete D. footling
A
A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? A. encouraging the woman to push when she has a strong desire to do so B. alleviating perineal discomfort with the application of ice packs C. palpating the woman's fundus for position and firmness D. completing the identification process of the newborn with the mother
A
A woman wearing hospital scrubs comes to the nursery and states "Mrs. Smith is ready for her baby. I will be glad to take the baby to her." What will the nursery nurse do next? A. Look at the woman's hospital identification badge. B. Determine which hospital unit the woman works on. C. Inform the woman she cannot transport the baby. D. Ask if the client actually sent the woman.
A
Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in: A. latent phase of the first stage. B. active phase of the first stage. C. pelvic phase of the second stage. D. early phase of the third stage.
A
Mrs. Timms is now in the transition phase of labor. One of the nurse's concerns is the possibility of an ineffective breathing pattern. If one of the goals was for the woman's breathing pattern to be effective, what outcome would you expect? A. Does not hyperventilate B. Uses accelerated breathing patterns continuously C. Refrains from using the pant-blow technique so she doesn't push D. Pants through each contraction as she pushes
A
On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? A. No interventions are needed. This will resolve on its own over the next several days. B. An ice pack should be placed on the edematous scalp. C. Have the mother massage the scalp twice daily to reduce the swelling. D. Place a snug cap on the newborn's head to compress the swelling.
A
Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? A. respiratory rate 45 breaths/minute, irregular B. costal breathing pattern C. nasal flaring, rate 65 breaths/minute D. crackles on auscultation
A
The Apgar score is based on which 5 parameters? A. heart rate, muscle tone, reflex irritability, respiratory effort, and color B. heart rate, breaths per minute, irritability, reflexes, and color C. heart rate, respiratory effort, temperature, tone, and color D. heart rate, breaths per minute, irritability, tone, and color
A
The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby? A. 1 cm below the ischial spine. B. 1 cm below the symphysis pubis. C. 1 cm above the ischial spine. D. 1 cm above the symphysis pubis.
A
The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor? A. "She is in active labor; she is progressing at this point and we will keep you posted." B. "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner." C. "She is still in early latent labor and has much too long to go to tell when she will give birth." D. "She is doing well and is in the second stage; it could be anytime now."
A
The nurse is assessing a 3-day-old infant. The infant's sclerae have a yellow tinge as does the infant's forehead and nose. What would the nurse do next? A. Obtain a transcutaneous bilirubin level. B. Draw blood for a metabolic panel. C. Prepare the infant for an exchange transfusion. D. Initiate phototherapy.
A
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize? A. Check the chart for the last void. B. Notify the health care provider about the mass. C. Ask the client if the mass has always been present. D. Assume this is part of the uterus.
A
The nurse is reinforcing health care provider education on the technique for an amniocentesis. Which piece of equipment will the nurse have ready? A. Ultrasound equipment B. Sterile field with scalpel C. 26-gauge spinal needle D. Sterile urine cup
A
Which statement is false regarding bathing the newborn? A. To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. B. Bathing should not be done until the newborn is thermally stable. C. While bathing the newborn, the nurse should wear gloves. D. Mild soap should be used on the body and hair but not on the face.
A
During a prenatal visit a pregnant client asks the nurse how to tell whether the contractions she is having are true contractions or Braxton Hicks contractions. Which description should the nurse mention as characteristic of true contractions? Select all that apply. A. begin irregularly but become regular and predictable B. felt first in lower back and sweep around to the abdomen in a wave C. increase in duration, frequency, and intensity D. begin and remain irregular E. felt first abdominally and remain confined to the abdomen and groin F. often disappear with ambulation or sleep
A B C
Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply. A. Monitor maternal and fetal vital statistics every hour. B. Report an elevated temperature over 38℃ (100.4℉). C. Answer questions and encourage verbalization of fears. D. Have a client remain on bed rest with bathroom privileges only. E. Position client on the left side throughout the labor process.
A B C
The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply. A. Nasal flaring B. Respiratory rate of 64 breaths per minute C. Bluish coloration of hands and feet D. Chest retractions E. Heart rate of 120 beats per minute
A B D
The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply. A. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. B. Don't leave the newborn unattended unless the mother is going to the bathroom. C. Know when the newborn is scheduled for any tests and how long the procedure will last. D. Do not remove the identification bands until the newborn is discharged from the hospital. E. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery.
A C D
The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. A. Warmer bed B. Glucose water C. Suction equipment D. Identification bands E. Ophthalmoscope
A C D
A client at 10 weeks' gestation is complaining of ptyalism over the past 2 weeks. What intervention would the nurse recommend to this client? Select all that apply. A. Chew gum. B. Use saline nasal spray. C. Wear a panty liner. D. Eat a large, protein rich meal in the evening. E. Suck on hard candies.
A E
A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take? A. Feed the newborn to provide more glucose. B. Place the newborn away from drafts and under a blanket. C. Begin the newborn on oxygen with BNC at 2L. D. Place a pillow under the newborn to raise the head of the bed.
B
A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse? A. "Newborns are given vitamin K to help with the digestion to help them absorb fat-soluble vitamins." B. "Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes." C. "Newborns are given vitamin K and erythromycin ointment to help prevent ophthalmia neonatorum." D. This vitamin substitutes for vitamin C for newborns to strengthen their immune systems."
B
A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate? A. "You probably took iron during your pregnancy and that is what causes this type of stool." B. "This is meconium stool and is normal for a newborn." C. "I'll take a sample and check it for possible bleeding." D. "This is unusual, and I need to report this to your pediatrician. "
B
A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a 4-year-old child who was delivered at 38 weeks' gestation and tells the nurse that she does have a history of spontaneous abortion (miscarriage) within the first trimester. The nurse is correct to document the history as: A. G = 4, T = 2, P = 0, A = 0, L = 1 B. G = 3, T = 1, P = 0, A = 1, L = 1 C. G = 1, T = 1, P = 1, A = 0, L = 1 D. G = 2, T = 0, P = 0, A = 0, L = 1
B
A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description? A. The cardiac murmur heard at birth disappears by 48 hours of age. B. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. C. Heart rate remains elevated after the first few moments of birth. D. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed.
B
A nurse is reviewing the obstetric history of a pregnant woman who has come to the clinic for a visit. The history reveals that the woman is "gravida 3, para 2." Which interpretation by the nurse would be appropriate? A. Three previous pregnancies and two live births B. Two previous pregnancies, two live births, and currently pregnant C. Two previous births and three miscarriages D. Three previous pregnancies and two live births
B
A nurse is taking a history during a client's first prenatal visit. Which assessment finding would alert the nurse to the need for further assessment? A. history of exercising twice a week B. history of diabetes for 4 years C. history of occasional use of OTC pain relievers D. maternal age of 28 years
B
A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response? A. "This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though." B. "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration." C. "The teeth will fall out within the first month, so don't worry about them." D. "The teeth will fall out when the newborn's baby teeth come in so this is a blessing."
B
A pregnant client tells the nurse that she has a 2-year-old child at home who was born at 38 weeks; she had a miscarriage at 9 weeks; and she gave birth to a set of twins at 34 weeks. Which documentation would be appropriate for the nurse? A. gravida 2, para 1 B. gravida 4, para 2 C. gravida 3, para 4 D. gravida 2, para 4
B
A pregnant woman comes to the clinic for a prenatal visit for her third pregnancy. She reveals she had a previous miscarriage at 12 weeks and her 3-year-old son was born at 32 weeks. How should the nurse document this woman's obstetric history? A. G3, T1, P0, A2, L1 B. G3, T0, P1, A1, L1 C. G2, T1, P2, A1, L2 D. G2, T0, P1, A1, L1
B
A primigravida has been in labor for 18 hours and is finally moving into the second stage and is anxious to begin pushing. Which assessment should be prioritize at this time? A. Evaluate maternal vital signs B. Ensure cervix fully dilated C. Evaluate fetal heart monitor D. Ensure empty urinary bladder
B
A woman calls the health care facility stating that she is in labor. The nurse would urge the client to come to the facility if the client reports which symptom? A. increased energy level with alternating strong and weak contractions B. moderately strong contractions every 4 minutes, lasting about 1 minute C. contractions noted in the front of abdomen that stop when she walks D. pink-tinged vaginal secretions and irregular contractions lasting about 30 seconds
B
According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement? A. Drowsy B. Quiet alert C. Active alert D. Active attentive
B
Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor? A. Braxton Hicks contractions get closer together with activity. B. Braxton Hicks contractions usually decrease in intensity with walking. C. Braxton Hicks contractions do not last long enough to be true labor. D. Braxton Hicks contractions cause "ripening" of the cervix.
B
Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism? A. evaporation B. convection C. conduction D. radiation
B
The client states that the first day of her last menstrual period is March 23. The nurse is most correct to calculate using Naegele rule that the estimated date of delivery is: A. January 30 B. December 30 C. December 16 D. November 23
B
The infant is in the quite-state. Which is the most appropriate nursing action? A. Administer aquamephyton B. Encourage breastfeeding C. Swaddle the infant, place in bassinet D. Teach parents about car seat safety
B
The newborn's APGAR scores are 8 and 9. Which nursing action is appropriate based on the APGAR score? A. Swaddle the newborn B. Assist with breastfeeding C. Assess the temperature D. Administer ophthalmic erythromycin
B
The nurse discovers a new prescription for Rho(D) immune globulin for a client who is about to undergo a diagnostic procedure. The nurse will administer the Rho(D) immune globulin after which procedure? A. contraction stress test B. amniocentesis C. nonstress test D. biophysical profile
B
The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? A. Low temperature and hypertonia B. Jitteriness and irritability C. Hypotonia and fever D. Frequent activity and jitteriness
B
The nurse is assessing a primipara's fundal height at 36 weeks' gestation and notes the fundus is now located at the xiphoid process of the sternum. The client asks if this is normal. Which response to the client would be best? A. "By this time, the fundus should drop down lower because the baby is moving towards the pelvic inlet." B. "At 36 weeks' gestation, the fundus is in the normal expected location." C. "To be honest, the fundus should be lower since you have gained minimal weight." D. "Just get prepared, the fundus might actually get a little higher until a few days before you go into labor."
B
The nurse is assessing the latest laboratory results of a pregnant client who is at 17 weeks' gestation. The nurse should prepare to teach the client about which possible defects after noting the maternal serum alpha-fetoprotein level is above normal? A. fetal hypoxia B. open spinal defects C. Down syndrome D. maternal hypertension
B
The nurse receives a call from a concerned client, who is 39 weeks' gestation, indicating the woman has "blood-tinged mucus seeping from the vagina." What does the nurse understand about this? A. The woman should rest on her left side and drink water. B. This is known as "bloody show" and is a normal finding at this time. C. The woman has likely been overly active, and should be evaluated for complications. D. This is known as Braxton Hicks contractions and is not a concern at this time.
B
The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting? A. Return right away. B. Watch it and report if heavy increase in bleeding. C. The bleeding, called Chadwick sign, is a normal part of pregnancy. D. The cervical mucus plug may have been expelled.
B
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? A. Conduction B. Convection C. Radiation D. Evaporation
B
Which assessment finding is of concern in a woman who had a spontaneous vaginal delivery 4 hours ago? A. Temperature = 37.4 C B. Blood pressure = 148/92 mmHg C. Heart rate = 56 beats/minute D. Lochia rubra, moderate amount
B
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? A. Have the client lightly push to meet the need. B. Have the client pant and blow through the contraction. C. Have the client divert the energy to squeezing a hand. D. Assist the client to a Fowler position.
B
While triaging messages from the answering machine from clients with the following symptoms, which client would obtain the first visit of the day? A. The client at 37 weeks' gestation experiencing shortness of breath B. The client at 11 weeks' gestation experiencing abdominal cramping C. The client at 24 weeks' gestation experiencing frequent heartburn D. The client at 6 weeks' gestation experiencing nausea and vomiting
B
Why is the first prenatal visit usually the longest prenatal visit? A. Laboratory tests are performed. B. Baseline data is collected. C. A pelvic exam with Papanicolaou test is performed. D. Extensive client teaching is done.
B
Which clients have a risk factor for uterine atony? (Select all that apply) A. Mother who delivered first baby with average length labor B. Mother with prolonged labor and pushing C. Mother who is breastfeeding frequently D. Mother who is delivering a large for gestational age baby E. Mother who is delivering her 4th child F. Mother who is delivering a preterm newborn
B D E
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus? A. LOA B. LOP C. ROA D. ROP
C
A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks' gestation, a 2-year-old son born at 39 weeks' gestation, and a spontaneous abortion (miscarriage) 1 year ago at 6 weeks' gestation. Using the GTPAL method, the nurse would document her obstetric history as: A. 3 2 1 0 3. B. 3 1 2 2 3. C. 4 1 1 1 3. D. 4 2 1 3 1.
C
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? A. Rocking and talking to the infant B. Swaddling the infant before returning to the crib C. Feeding the infant more formula whenever she begins to fuss D. Gently patting or stroking the infant's back
C
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse? A. Heart Rate B. Respiratory Rate C. Blood Pressure D. Temperature
C
A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating? A. boggy, soft uterus B. uterus becoming discoid shaped C. sudden gush of dark blood from the vagina D. shortening of the umbilical cord
C
A woman is 20 weeks pregnant. The nurse would expect to palpate the fundus at which location? A. symphysis pubis B. between the symphysis and umbilicus C. at the umbilicus D. just below the ensiform cartilage
C
A woman is in the first stage of labor. The nurse would encourage her to assume which position to facilitate the progress of labor? A. supine B. lithotomy C. upright D. knee-chest
C
An adolescent at 8 weeks' gestation is at her first prenatal visit. During the health history interview, the nurse asks the client, "Are you afraid of anyone?" What is the nurse assessing with this question? A. mood B. mental status C. intimate partner violence D. social history
C
Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station? A. -2 B. -1 C. 0 D. +1
C
By the time a woman is 36 weeks' gestation, where would the nurse expect to find the uterus? A. at the umbilicus B. halfway between the umbilicus and bottom edge of the ribcage C. near the bottom of the sternum D. under the edge of the ribcage
C
The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex? A. Moro B. Tonic neck C. Rooting D. Sucking
C
The nurse has been monitoring the progression of labor for a primipara. At which time is the nurse most correct to prepare for delivery? A. When the health care provider arrives B. When the client begins pushing C. When the fetus is crowning D. When full dilation (dilatation) is reached
C
The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? A. The client states that she is having heavy bleeding. B. When ambulating the client to the bathroom, a gush of red blood was noted. C. The client has saturated three sanitary napkins in the past 4 hours. D. The client has lost 100cc of blood from what I approximate on her clothing.
C
The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? A. Using a 21-gauge needle B. Injecting 1cc of medication C. Injecting the medication into the vastus lateralis D. Injecting at a 45-degree angle
C
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.
C
The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows: A. internal rotation, descent, extension, flexion, external rotation, expulsion B. descent, flexion, external rotation, extension, internal rotation, expulsion C. descent, flexion, internal rotation, extension, external rotation, expulsion D. internal rotation, flexion, descent, extension, external rotation, expulsion
C
When documenting the fetus is at "zero station", the nurse knows this is where in relation to the pelvic structure? A. Pelvic inlet B. Pelvic outlet C. Ischial spines D. Pelvic crest
C
Which assessment finding is most important as labor progresses? A. The client is remaining in control of emotions. B. Labor is completed within 18 hours. C. The uterus relaxes completely between contractions. D. The pulse and respirations rise with the work of labor.
C
Which measurements were most likely obtained from a normal newborn delivered at 38 weeks to a healthy mother with no maternal complications? A. Weight = 2000 g, length = 17 inches, head circumference = 32 cm, and chest circumference = 30 B. Weight = 2500 g, length = 18 inches, head circumference = 32 cm, and chest circumference = 30 cm C. Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm D. Weight = 4500 g, length = 22 inches, head circumference = 36 cm, and chest circumference = 34 cm
C
Which nursing action has a negative effect on fetal descent? A. Laying the client on the left side B. Using a tap water enema C. Administering narcotic pain medication D. Walking the client in the hall
C
Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? A. "Physiologic jaundice usually begins in the first week after birth." B. "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." C. "Breastfed babies need supplements of glucose water to help lower bilirubin levels." D. "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."
C
A nurse is assessing a pregnant client. Which of the following would the nurse document as an abnormal finding in a pregnancy? A. Lordosis B. Pedal edema C. Linea nigra D. Visual changes
D
The client may spend the latent phase of the first stage of labor at home unless which occurs? A. The client passes the bloody show B. The contractions vary in length and intensity C. The client begins back labor D. The client experiences a rupture of membranes
D
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out "0 station" refers to which sign? A. "This is just a way of determining your progress in labor." B. "This indicates that you start labor within the next 24 hours." C. "This means +1 and the baby is entering the true pelvis." D. "The presenting part is at the true pelvis and is engaged."
D
The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? A. Temperature of 97.6°F B. Heart rate 158 C. Respiratory rate 42 D. Blood sugar 42 mg/dL
D
The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A. have a smaller body surface compared to body mass. B. lose more body heat when they sweat than adults. C. have an abundant amount of subcutaneous fat all over. D. are unable to shiver effectively to increase heat production.
D
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? A. Report tachypnea. B. Recheck blood pressure in 15 minutes. C. Put warming blanket over infant. D. Document normal findings.
D
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.
D
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? A. Send a family member to accompany the infant when leaving the room. B. Check the name on the baby's identification bracelet. C. Provide a list of approved visitors who came spend time with the infant. D. Check the identification badge of any health care worker before releasing baby from room.
D
The nurse notes the following while assessing a client 3 hours after delivery: Fundus boggy, 2 above U, deviated to right. Which should be the nurse's next action? A. Notify the provider B. Apply ice to the perineum C. Assess vital signs D. Assist the client to the bathroom
D
The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? A. Lower rate of urinary tract infections B. Reduced risk of penile cancer C. Fewer complications than if done later in life D. Anesthetic may not be effective during the procedure
D
Which newborn is of highest concern? A. R = 42, P = 142 B. R = 34, P = 114 C. R = 30, P = 160 D. R = 66, P = 154
D
Which of the following findings is most worrisome in Melissa, a woman in her 26th week of pregnancy? A. Generalized hair loss B. A hyperpigmented rash over the maxillary region bilaterally C. Nosebleeds D. Facial edema
D
Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy? A. Split S1S2 B. Premature ventricular contractions C. S4 (atrial gallop) D. Soft systolic murmur
D
Which statement is true regarding fetal and newborn senses? A. A newborn cannot experience pain. B. A newborn cannot see until several hours after birth. C. A newborn does not have the ability to discriminate between tastes. D. The rooting reflex is an example that the newborn has a sense of touch. E. A fetus is unable to hear in utero.
D