ATI Maternal Newborn Practice A & B
A nurse is teaching a postpartum client about the steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? "The nurse will carry your newborn to the nursery for procedures." "We will document the relationship of visitors in your medical record." "Your baby will stay in the nursery while you are asleep." "Staff members who take care of your baby will be wearing a photo identification badge."
"Staff members who take care of your baby will be wearing a photo identification badge."
A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 ml of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many ml/hr?
50 ml/hr
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? Decreased uterine contractions An increase in the client's hemoglobin levels A reduction in respiratory distress in the newborn Increased production of antibodies in the newborn
A reduction in respiratory distress in the newborn
A nurse on an antepartum unit is caring for 4 clients. Which of the following clients should the nurse identify as the priority? A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A client who is at 34 weeks of gestation and reports epigastric pain A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
A client who is at 34 weeks of gestation and reports epigastric pain
A nurse is assessing 4 newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on his face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? Monitor the FHR. Assess uterine activity. Administer oxygen via a nonrebreather mask. Start a bolus of IV fluids.
Administer oxygen via a nonrebreather mask.
A nurse is teaching a client who is at 24 weeks of gestation regarding a 1 hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? "You will need to drink the glucose solution 2 hours prior to the test." "Limit your carbohydrate intake for 3 days prior to the test." "A blood glucose of 130 to 140 is considered a positive screening result." "You will need to fast for 12 hours prior to the test."
"A blood glucose of 130 to 140 is considered a positive screening result."
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? "Obtain an informed consent prior to obtaining the specimen." "Collect at least 1 milliliter of urine for the test." "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." "Premature newborns may have false negative tests due to immature development of liver enzymes."
"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen."
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? "I can administer oxytocin 4 hours after the insertion of the medication." "You will need a full bladder prior to the insertion of the medication." "Remain in a side-lying position for 15 minutes after the medication is inserted." "An antacid will be given 20 minutes prior to the insertion of the medication."
"I can administer oxytocin 4 hours after the insertion of the medication."
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicated an understanding of the teaching? "I should increase my protein intake to 60 grams each day." "I should drink 2 liters of water each day." "I should increase my overall daily caloric intake by 300 calories." "I should take 600 micrograms of folic acid each day."
"I should take 600 micrograms of folic acid each day."
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should have a goal of maintaining my fasting blood glucose between 100 and 120." "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." "I will continue taking my insulin if I experience nausea and vomiting." "I will ensure that my bedtime snack is high in refined sugar."
"I will continue taking my insulin if I experience nausea and vomiting."
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? "I will eat foods that taste good instead of balancing my meals." "I will avoid having a snack before I go to bed each night." "I will have a cup of hot tea with each meal." "I will eliminate products that contain dairy from my diet."
"I will eat foods that taste good instead of balancing my meals."
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? "I will get injections of the medication once daily until my labor stops." "My blood sugar may be low while I'm on this medication." "I will have blood tests because my potassium might decrease." "My blood pressure may increase while I'm on this medication."
"I will have blood tests because my potassium might decrease."
A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at least 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? "I will not gain more than 15 to 20 pounds during my pregnancy." "I will likely need to use alternative positions for sexual intercourse." "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." "I'm glad I have a light complexion and will not get any stretch marks."
"I will likely need to use alternative positions for sexual intercourse."
A nurse is teaching a client who is Rh negative about Rh(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? "I will receive this medication if my baby is Rh-negative." "I will receive this medication when I am in labor." "I will need a second dose of this medication when my baby is 6 weeks old." "I will need this medication if I have an amniocentesis."
"I will need this medication if I have an amniocentesis."
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? "My sister will be able to carry my baby from the nursery to my room when she arrives." "The nurse will match my wrist band to my baby's crib card when they bring him to me." "The person who comes to take my baby's pictures will be wearing a photo identification badge." "My baby doesn't need to wear the electronic security bracelet when he's in my room."
"The person who comes to take my baby's pictures will be wearing a photo identification badge."
A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration? "This medication will stop your labor." "This medication stimulates fetal lung maturity." "This medication will decrease your risk for uterine infections." "This medication will increase your baby's weight."
"This medication stimulates fetal lung maturity."
A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? "I think that is something you should discuss with your doctor." "This procedure should have no effect on your sexual performance or adequacy." "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." "If this concerns you, perhaps you should reconsider and use another form of contraception."
"This procedure should have no effect on your sexual performance or adequacy"
A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? "You can miss your period for several other reasons. Describe your typical menstrual cycle." "If you have been sexually active and haven't used protection, it is likely that you are pregnant." "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."
"You can miss your period for several other reasons. Describe your typical menstrual cycle."
A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? "You can share your room with your baby for the next few weeks." "Cover your baby with a light blanket while sleeping." "Check the temperature of your baby's bath water with your hand." "Your baby can nap in the car seat during the daytime."
"You can share your room with your baby for the next few weeks."
A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? "You can resume sexual activity in 1 week." "You won't need to do Kegel exercises since you had a cesarean." "You can still become pregnant if you are breastfeeding." "You are safe to start adding sit-ups to your exercise routine in 2 weeks."
"You can still become pregnant if you are breastfeeding."
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? "You should replace the diaphragm every 5 years." "You should leave the diaphragm in place for at least 6 hours after intercourse." "You should use an oil-based product as a lubricant when inserting the diaphragm." "You should insert the diaphragm when your bladder is full."
"You should leave the diaphragm in place for at least 6 hours after intercourse."
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include? "The test should take 10 to 15 minutes to complete." "You will lay in a supine position throughout the test." "You should not eat or drink for 2 hours before the test." "You should press the handheld button when you feel your baby move."
"You should press the handheld button when you feel your baby move."
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? "You should take the medication within 72 hr following unprotected sex" "You should avoid taking this medication is you are on an oral contraceptive" "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test" One dose of this medication will prevent you from becoming pregnant for 14 days after taking it"
"You should take the medication within 72 hr following unprotected sex"
A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? "You will receive IV fluids prior to this test" "The procedure will take approximately 10-15 minutes" "You will be offered orange juice to drink during the test" "You will need to sign an informed consent form each time you have this test"
"You will be offered orange juice to drink during the test"
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make? "Let me help you into a comfortable pushing position so you can begin bearing down." "I am going to call the doctor to get a prescription for medication to ripen your cervix." "I will give you some IV pain medicine to strengthen your contractions." "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."
"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice Caput succedaneum
Jaundice
A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states, "administer azithromycin 1 g orally now." Available is 250 mg tablets. How many tablets should the nurse administer?
4 tablets
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
A client who is at 11 weeks of gestation and reports abdominal cramping
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? Protect the client's head and feet from cold air. Bathe the client within 12 hr following birth. Ambulate the client within 24 hr following birth. Offer the client a glass of cold milk with her first meal.
Protect the client's head and feet from cold air.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? Feed the newborn 1 oz of water every 4 hr. Apply lotion to the newborn's skin three times per day. Remove all clothing from the newborn except the diaper. Discontinue therapy if the newborn develops a rash.
Remove all clothing from the newborn except the diaper.
A nurse in an antepartum clinic is assessing a client who is at 32 weeks gestation. Which of the following findings should the nurse report to the provider? Fundal height 34 cm Report of decreased fetal movement Report of occasional ankle swelling BP 110/80 mm Hg
Report of decreased fetal movement
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? Administer penicillin G 2.4 million units IM to the client. Instruct the client to schedule an annual pelvic examination. Tell the client she will start medication for HIV immediately after delivery. Report the client's condition to the local health department.
Report the client's condition to the local health department.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress
Respiratory distress
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? Give the client orange juice Elevate the client's legs Have the client change position Establish IV access
Have the client change position
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply) Heart rate 154/min Axillary temperature 36° C (96.8° F) Respiratory rate 58/min Length 43 cm (16.9 in) Weight 2,600 g (5 lb 12 oz)
Heart Rate 154/min Respiratory Rate 58/min Weight 2.6 kg (5 lb 12 oz)
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. Identify the attitude of the head Palpate the fundus to identify the fetal part Determine the location of the fetal back Palpate for the fetal part presenting at the inlet
Identify the attitude of the head Determine the location of the fetal back Palpate the fetal part presenting at the inlet Palpate the fundus to identify the fetal part
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 ml/hr Respiratory rate 10/min Client reports feelings flushed
Respiratory rate 10/min
A nurse is calculating a client's expected date of birth using Nagele's rule. The client teslls the nurse that her last menstrual cycle started on November 27. Which of the following dates is the client's expected date of birth?
September 3
A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider? Shortness of breath Breakthrough bleeding Vomiting Breast tenderness
Shortness of breath
A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? Insert the syringe tip before compressing the bulb. Suction each of the nares before suctioning the mouth. Insert the tip of the syringe into the center of the newborn's mouth. Stop suctioning when the newborn's cry sounds clear.
Stop suctioning when the newborn's cry sounds clear.
A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? Acrocyanosis of the extremities Murmur at the left sternal border Substernal chest retractions while sleeping Positive Babinski reflex
Substernal chest retractions while sleeping
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? Substernal retractions Acrocyanosis Overlapping suture lines Head circumference 33 cm (13 in)
Substernal retractions
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? Swelling of the face Varicose veins in the calves Nonpitting 1+ ankle edema Hyperpigmentation of the cheeks
Swelling of the face
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? O2 saturation Temperature Blood pressure Urinary output
Temperature
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. Wrap the visible cord tightly with sterile, dry gauze. Apply oxygen to the client at 2 L/min via nasal cannula. Place the client in the lithotomy position and apply fundal pressure.
Insert two gloved fingers into the vagina and apply upward pressure to the presenting part.
A nurse is planning care for a client who is to undergo an nonstress test. Which of the following actions should the nurse include in the plan of care? Maintain the client NPO throughout the procedure. Place the client in a supine position. Instruct the client to massage the abdomen to stimulate fetal movement. Instruct the client to press the provided button each time fetal movement is detected.
Instruct the client to press the provided button each time fetal movement is detected.
A nurse in a women's health clinic is providing teaching about nutritional intake to a client whop is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients? Calcium Vitamin E Iron Vitamin D
Iron
A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? Lays the newborn across her lap and gently sways Places the newborn in the crib in a prone position Offers the newborn a pacifier dipped in formula Prepares a bottle of formula mixed with rice cereal
Lays the newborn across her lap and gently sways
A nurse is developing an plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the client's blood pressure every hour. Restrict the total hourly intake to 200 mL. Monitor the FHR continuously. Administer protamine sulfate for manifestations of toxicity.
Monitor the FHR continuously.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? Oligohydramnios Hyperemesis gravidarum Leukorrhea Periodic tingling of the fingers
Oligohydramnios
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test.
Perform Leopold maneuvers.
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? Bruising over the buttocks Hard nodules on the roof of the mouth Petechiae over the head Bilateral periauricular papillomas
Petechiae over the head
A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational diabetes mellitus
Pregestational diabetes mellitus
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? Report of visual disturbances Report of tingling of the fingers Report of urinary frequency Report of leg cramps
Report of visual disturbances
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? Reports increased urinary output Diaphoresis Reports blurred vision Shallow respirations
Reports increased urinary output
A nurse is caring for a prenatal client who has parvovirus B18 (fifth disease). Which of the following actions should the nurse take? Administer antiviral medication. Schedule an ultrasound examination. Administer Haemophilus influenzae type b vaccine. Schedule an indirect Coombs' test.
Schedule an ultrasound examination.
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? To estimate the fetal weight To locate a pocket of fluid To determine multiparity To prescreen for fetal anomalies
To locate a pocket of fluid
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2-3 min apart, each lasting 80-90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse identify that the client is in which of the following phases of labor? Active Transition Latent Descent
Transition
A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? Persistent abdominal striae Temperature 37.8° C (100° F) Unilateral breast pain Brownish-red discharge on day 5
Unilateral breast pain
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? Lochia serosa vaginal drainage Vaginal pressure Intermittent vaginal pain Yellow exudate vaginal drainage
Vaginal pressure
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? Large for gestational age Hyperglycemia Bradypnea Vomiting
Vomiting
A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? (Put the steps in the correct order) Clean the newborn's diaper area. Wash the newborn's neck by lifting the newborn's chin. Wipe the newborn's eyes from the inner canthus outward. Cleanse the skin around the newborns umbilical cord stump. Wash the newborn's legs and feet.
Wipe the newborn's eyes from the inner canthus outward. Wash the newborn's neck by lifting the newborn's chin. Cleanse the skin around the newborns umbilical cord stump. Wash the newborn's legs and feet. Clean the newborn's diaper area.
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record.
Verify that the parent's identification band matches the newborn's identification band.
A nurse is caring for a newborn who has transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? Confirm the newborn's Apgar score. Verify the newborn's identification. Administer vitamin K to the newborn. Determine obstetrical risk factors.
Verify the newborn's identification.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions
Weight gain of 2.2 kg (4.8 lb)
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? Abruptio placenta Placenta previa Preeclampsia Maternal bradycardia
Abruptio placenta
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible
Acrocyanosis Positive Babinski reflex Two umbilical arteries visible
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? Place warm, moist packs on the breasts. Apply cabbage leaves to the breasts. Wear a loose-fitting bra. Put green tea bags on the breasts.
Apply cabbage leaves to the breasts.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? Reassess the client in 2 hr. Administer simethicone. Assist the client to empty her bladder. Instruct the client to lie on her right side.
Assist the client to empty her bladder.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test
Biophysical profile
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? Percutaneous umbilical blood sampling Amnioinfusion Biophysical profile (BPP) Chorionic villus sampling (CVS)
Biophysical profile (BPP)
A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider? Hgb 20 g/dL Total bilirubin 5 mg/dL Blood glucose 30 mg/dL WBC count 20,000/mm3
Blood glucose 30 mg/dL
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? 2+ deep tendon reflexes Proteinuria of 200 mg in a 24-hr specimen Polyuria Blurred vision
Blurred vision
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (select all that apply) Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder
Cholecystitis Hypertension Migraine headaches
A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? Cold cabbage leaves Purified lanolin cream A snug-fitting support bra Breast shells
Cold cabbage leaves
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Cover the newborn's eyes while under the phototherapy light Keep the newborn in a shirt while under the phototherapy light Apply a light moisturizing lotion to the newborn's skin Turn and reposition the newborn every 4 hr while undergoing phototherapy
Cover the newborn's eyes while under the phototherapy light
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following? Emotional lability Focusing phase Cognitive restructuring Couvade syndrome
Emotional lability
A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? Tell the client to follow up with a dermatologist. Explain to the client this is an expected occurrence. Instruct the client to increase her intake of vitamin D. Inform the client she might have an allergy to her skin care products.
Explain to the client this is an expected occurrence.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Urine protein 2+ FHR 152/min
FHR 152/min
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? 1-hr glucose tolerance test Hematocrit Fundal height measurement Fetal heart rate (FHR)
Fundal height measurement
A nurse is caring for a client who is preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? Restrict hourly fluid intake to 150 mL/hr. Have calcium gluconate readily available. Assess deep tendon reflexes every 6 hr. Monitor intake and output every 4 hr.
Have calcium gluconate readily available.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? Shortness of breath when climbing stairs Swelling of feet and ankles at the end of the day Headache that is unrelieved by analgesia Braxton Hicks contractions
Headache that is unrelieved by analgesia
A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 15,000/mm3 RBC count 5.8 million/mm3 Hematocrit 34%
Hemoglobin 10 g/dL
A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 10,000/mm3 Platelets 250,000/mm3 Fasting blood glucose 90 mg/dL
Hemoglobin 10 g/dL
A nurse is assessing a client who received carboprost for post partum hemorrhage. Which of the following findings is an adverse effect of this medication? Hypertension Hypothermia Constipation Muscle weakness
Hypertension
A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take? Perform a vaginal exam to determine cervical dilation every 2 hr Instruct the client to ambulate in the hallway once every 4 hr Administer betamethasone to the client via IM injection Initiate continuous external fetal monitoring
Initiate continuous external fetal monitoring
A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? Jitteriness Hypertonia Abdominal distention Mottling
Jitteriness
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones? Just above the umbilicus Just above the symphysis pubis The right lower quadrant The left lower quadrant
Just above the symphysis pubis
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? Kleihauer-Betke test Progesterone serum level Lecithin/sphingomyelin (L/S) ratio Maternal Alpha-fetoprotein (AFP)
Kleihauer-Betke test
A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply to the ultrasound transducer to assess the point of maximum intensity of the fetal heart? LUQ RUQ LLQ RLQ
LLQ
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor
Late Decelerations
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? Increased fetal movement Leakage of fluid from the vagina Upper abdominal discomfort Urinary frequency
Leakage of fluid from the vagina
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? Administer aspirin for pain. Maintain the client on bed rest. Massage the affected leg every 12 hr. Apply cold compresses to the affected calf.
Maintain the client on bed rest.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? Check the client's capillary refill. Massage the client's fundus. Insert an indwelling urinary catheter for the client. Prepare the client for a blood transfusion.
Massage the client's fundus
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemia shock. After notifying the provider, which of the following actions should the nurse take next? Massage the client's fundus. Insert an indwelling urinary catheter. Administer oxygen at 10 L/min. Elevate the client's right hip.
Massage the client's fundus.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil Popliteal angle of 90° Creases over the entire foot sole Raised areolas with 3 to 4 mm buds
Minimal arm recoil
A nurse is caring for a client who is at 15 weeks gestation, is Rh negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature. Observe for uterine contractions. Administer Rho(D) immune globulin. Monitor the FHR.
Monitor the FHR.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? Place the client in a supine position for 30 min following the first dose of anesthetic solution. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? Fentanyl Butorphanol Naloxone Meperidine
Naloxone
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7 year old child in accepting the new family member? Allow the sibling to hold the newborn during a bath. Make sure the sibling kisses the newborn each night. Obtain a gift from the newborn to present to the sibling. Switch the sibling's room with the nursery.
Obtain a gift from the newborn to present to the sibling.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? Apply a cool pack for 10 min to the heel prior to the puncture. Request a prescription for IM analgesic. Use a manual lance blade to pierce the skin. Place the newborn skin to skin on the mother's chest.
Place the newborn skin to skin on the mother's chest.
A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? Administer terbutaline. Discuss possible genetic anomalies with the client. Administer nalbuphine. Discontinue external fetal monitoring.
Administer terbutaline
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? Place a rolled towel beneath one of the client's hips Apply internal upward pressure to the presenting part using two gloved fingers Administer oxygen to the client via a nonrebreather mask at 10 L/min Increase the IV infusion rate
Apply internal upward pressure to the presenting part using two gloved fingers
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? Apply sacral counterpressure. Perform transcutaneous electrical nerve stimulation (TENS). Initiate slow-paced breathing. Assist with biofeedback.
Apply sacral counterpressure.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL within 8 hr Urine negative for ketones
BUN 25 mg/dL
A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring.
Begin FHR monitoring.
A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? Bilirubin 9 mg/dL Hemoglobin 18 g/dL Platelets 175,0000/mm3 Hematocrit 45%
Bilirubin 9 mg/dL
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? Calcium gluconate Hydralazine Medroxyprogesterone acetate Methylergonovine
Calcium gluconate
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Decreased heart rate Chin quivering Pinpoint pupils Slowed respirations
Chin quivering
A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include? Place the shoulder harness in the slots above the newborn's shoulders. Place the retainer clip at the level of the newborn's armpits. Place the newborn at a 60° angle in the car seat. Place the newborn in a blanket before securing them in the car seat.
Place the retainer clip at the level of the newborn's armpits.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? Decreased platelet count Increased erythrocyte sedimentation rate (ESR) Decreased megakaryocytes Increased WBC
Decreased platelet count
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and her partner Repeat information to ensure client understanding Listen to the client and her partner as they reflect upon the birth experience Demonstrate to the client how to perform a newborn bath
Demonstrate to the client how to perform a newborn bath
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? Depression Polyuria Hypotension Urticaria
Depression
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? Determine respiratory function. Increase the IV fluid rate. Access emergency medications from cart. Collect a maternal blood sample for coagulopathy studies.
Determine respiratory function.
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? Hct 39% Serum albumin 4.5 g/dL WBC 9,000/mm3 Platelets 50,000/mm3
Platelets 50,000/mm3
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (select all that apply) Flaccid uterus Cervical laceration Excess vaginal bleeding Increased afterbirth cramping Increased maternal temperature
Flaccid uterus Excess vaginal bleeding
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? Excessive bleeding Oligohydramnios Premature rupture of membranes Proteinuria
Premature rupture of membranes