Exam 2 P2
A client at 39 weeks gestation calls the OB triage and questions the nurse concerning a bloody mucous discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse?
"A one time discharge of bloody mucus in the toilet might have been your mucous plug." ✓
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?
1 cm below the umbilicus ✓
The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?
110 to 160 bpm ✓
A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?
Decrease activity and rest more often. ✓
The nurse is meeting with a client at 28 weeks' gestation. To prepare her for the final trimester, which factor should the nurse prioritize in the teaching session?
Decreasing shortness of breath ✓
The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?
Dilation of cervix ✓
The new parents are spending time with their newborn. However, they are concerned with the edema and ecchymosis on the baby's scalp. How should the nurse explain this to the parents after noting the baby was ROA in labor?
Ecchymosis with edema on the scalp is where the infant was pushed out of the canal. ✓
A client at 27 weeks' gestation still walks daily but reports 'terrible' heartburn at night. Which action should the nurse point out will best address this situation?
Elevate the head of the bed. ✓
The nurse is preparing discharge teaching for a client who is 2 days postpartum. Which action should the nurse prioritize to encourage prevention of constipation?
Encourage fiber-rich foods. ✓
The nurse has obtained the vital signs of a postpartum client 24 hours after delivery and records: 99.0 F, RR 18, HR 78, and BP 140/90 mm Hg. Which action should the nurse prioritize?
Notify the RN of the slight elevation in BP. ✓
The multigravida client is moving into the transition phase and asks for a narcotic, stating she doesn't remember the pain being this bad before. Which response from the nurse will be best?
Pain medication can affect the baby's breathing; let's try to focus and breathe." ✓
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack. ✓
A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?
Practicing effleurage on the abdomen ✓
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta ✓
A client with limited prenatal care presents in labor and is requesting a VBAC. What is the nurse's response after verifying the client had a classical incision with the last cesarean delivery?
"Based on your history, a vaginal delivery is not recommended, it might cause your uterus to rupture." ✓
A 32-year-old woman with epilepsy mentions to the nurse during a routine well-visit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?
"I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet." ✓
A multigravida client at 39 weeks' gestation has been in labor for 8 hours without much change. The last vaginal exam revealed cervix 8 cm dilated and zero station. Which is the best response if the client asks the nurse how far the fetus has advanced in the past half hour?
"Once your labor signs change, we can find out." ✓
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge teaching to address this issue?
"Ovulation may return as soon as 3 weeks after birth." ✓
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?
"She is in active labor; she is progressing at this point and we will keep you posted." ✓
A primigravidia client at 38 weeks' gestation calls the clinic and reports, 'My baby is lower and it is more difficult to walk.' Which response should the nurse prioritize?
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." ✓
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?
"The baby is coming. I'll explain what's happening and guide you." ✓
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?
"The presenting part is at the true pelvis and is engaged." ✓
During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?
24 hour recall ✓
The nursing instructor is preparing to illustrate the various changes between the nonpregnant and pregnant female body. The instructor should point out the blood volume in the pregnant woman can increase by what percentage?
40% to 45% ✓
The nurse is spending time with a client who has just learned, unexpectedly, that she is pregnant. Which initial task should the nurse assist the client to focus on?
Accepting the pregnancy ✓
A client is reporting considerable postpartum abdominal and perineal pain at a 7 on a scale of 1 to 10. The nurse will prioritize which action after noting the client is currently receiving ibuprofen 600 mg every 8 hours?
Administer acetaminophen with codeine. ✓
A client at 19 weeks' gestation reports continued alcohol use 1 to 2 times each week to the nurse at her prenatal visit. Which suggestion should the nurse prioritize for this client?
Alcohol should not be consumed during pregnancy. ✓
The nurse discovers a new prescription for RhoGAM for a client who is about to undergo a diagnostic procedure. The nurse will administer the RhoGAM after which procedure?
Amniocentesis ✓
A young couple are very excited to discover they are pregnant and ask the nurse when to expect the baby. Based on a July 20 LMP, which day will the nurse predict for delivery?
April 27 ✓
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?
Ask the woman to describe why she believes that she is in labor. ✓
A client has been admitted for induction of labor and is asking the nurse what happens next. The nurse should point out that the health care provider will conduct which evalution to determine what happens next?
Bishop score system ✓
The nurse is assessing a client who has just given birth and notes her prelabor vital signs reveal a temperature 98.8 F (37.1 C), blood pressure 120/70 mm Hg, HR 80, and RR 20. Which current vital sign assessment should the nurse prioritize?
Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. ✓
A pregnant woman with sickle cell anemia is very concerned her infant will also develop the disease and questions the nurse about that possibility. Which is the best response from the nurse?
Both parents have to carry the trait. ✓
The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning?
Calling the baby "it" or "they" ✓
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?
Change the position of the client. ✓
The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?
Client priorities and preferences are incorporated into the plan. ✓
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?
Continuous labor support ✓
A client has moved into the active phase of labor and is now at 6 cm dilated and +1 station. The nurse is prepared to monitor the contraction pattern how often?
Every 30 minutes ✓
A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet?
Fortified cereals ✓
As part of the first prenatal visit, the nurse is assessing a pregnant woman's obstetrical history, which includes an 18-month-old daughter, born 2 days after her estimated date of birth; a 3-year-old son born at 35 weeks' gestation; and two lost pregnancies, one at 12 weeks and one at 21 weeks. How should the nurse document this history?
G5 T1 P2 A1 L2 ✓
During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency?
Hair loss and hair that is easily removed from the scalp ✓
A woman at 9 weeks' gestation is admitted to the obstetrical unit for hyperemesis gravidarum. Which action should the nurse prioritize immediately?
Instruct on NPO status ✓
A client who is uncertain when her LMP occurred is given an EDD of April 23 after the first ultrasound. Based on this information, the nurse determines the client's LMP was probably which day?
July 16 ✓
A client calls to cancel an appointment for the first prenatal visit after reporting a home pregnancy test is negative. Which instruction should the nurse prioritize?
Keep the appointment. ✓
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8 F, contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?
Meconium in the fluid ✓
The nurse is assessing a pregnant client at her 12-weeks gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are?
Montgomery tubercles; secrete lubricant for the nipples ✓
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?
Neglects to engage or provide care or show interest in infant. ✓
A client at 27 weeks' gestation is admitted to the OB unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals BP consistently above 136/90 mm Hg. The nurse anticipates the health care provider will order magnesium sulfate to accomplish which primary goal?
Prevent maternal seizures ✓
The nursing instructor is teaching a session on how labor starts. The instructor determines the session is successful when the class correctly chooses which causative factor that initiates labor?
Prostaglandins may be the causative factor of labor. ✓
The nursing instructor is teaching a group of student nurses about the current use of episiotomies during the labor process. The instructor determines the session is successful when the students correctly choose which situation that may require the health care provider to perform an episiotomy?
Shoulder dystocia ✓
A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?
Stop and walk every two hours. ✓
The health care provider has prescribed an over-the-counter antacid for a pregnant client in her first trimester who is having ongoing nausea, vomiting, and heartburn. Which instruction concerning the antacid should the nurse prioritize after noting the client is also prescribed a multivitamin supplement?
Take antacid 1 hour after the multivitamin. ✓
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?
The client reports back pain, and the cervix is effacing and dilating. ✓
The nurse is assessing a pregnant client in her third trimester who is reporting a first- time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?
The intestines are displaced by the growing fetus. ✓
The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?
engorgement ✓
During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?
essential fatty acid ✓
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?
The urge to push occurs. ✓
A primigravida 21-year-old client at 24 weeks' gestation has a 2-year history of HIV. As the nurse explains the various options for delivery, which factor should the nurse point out will influence the decision for a vaginal birth?
The viral load ✓
During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations?
This measurement indicates that the patient is overweight and should follow a plan of diet and exercise to lose weight. ✓
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?
Thoroughly wash the hands before and after client contact. ✓
The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event?
Uteroplacental insufficiency ✓
The nursing instructor is teaching a class on the nutritional needs of the pregnant client. The instructor determines the session is successful when the students correctly choose which supplement as being known to prevent up to 70% of CNS birth defects?
folic acid ✓
The nurse is preparing a postpartum nursing care plan for a single HIV-positive primigravida client. The nurse should prioritize in the plan how to acquire which resource?
formula ✓
The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage?
cervix ✓
A pregnant patient with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to:
check her blood sugars frequently and adjust insulin accordingly. ✓
The nurse is assessing a new client who is being admitted for induction of labor. The client is very upset and keeps mentioning that she has an infection. The nurse interprets this to indicate the client most likely has which condition?
chorioamniotitis ✓
The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize?
hemorrhage ✓
The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?
increase even if relaxing and taking a shower ✓
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?
latent phase ✓
The client is asking the nurse about the various options for pain relief and requests more information about the intradermal water injection her sister had. When explaining the procedure, the nurse should point out these injections are given at which location?
lower back ✓
The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme iron-rich foods should the nurse encourage her to add to her diet?
meats ✓
A client in latent labor for the past 12 hours is requesting medication to help her rest. The nurse predicts the health care provider will prescribe which medication?
meperidine secobarbital fentanyl morphine NO ANSWER
The nurse is preparing a client for treatment to ripen her cervix in anticipation of labor. When comparing the various options for the client, which one will the nurse point out provides an oral option?
misoprostol ✓
The nurse is conducting a prenatal class for a group of pregnant women and their partners. When illustrating the various potential complications that can necessitate a cesarean delivery, which primary reason should the nurse point out?
nonreassuring fetal status ✓
The nurse is assessing a client with type I diabetes who has just been informed she is 8 weeks pregnant. The nurse should explain that her health care provider will probably refer her to which specialist to assist with this high-risk pregnancy?
perinatologist ✓
A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?
respiratory rate ✓
The nurse is caring for a pregnant client who has a class II heart disease. The nurse is prepared to intensify monitoring during which period of the pregnancy?
second trimester ✓
The nurse is preparing to teach a group of new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens?
shoulder ✓
The nurse is assessing a primigravida woman who reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. The nurse suspects the woman has contracted which disorder?
trichomoniasis ✓