Exam 4

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

"I will reduce my exercise schedule to 3 days a week"

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new order for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

"It promotes fetal lung maturity"

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

"It sounds like you are feeling sad that things didn't go as planned."

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer?

"You must be feeling scared and Powerless"

A nurse is preparing to administer atenolol 50 mg PO daily to a client. The amount available is atenolol 100 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 tablets

A nurse is administering a unit of RBC 350 mL over 3 hr to a client who has anemia. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

117 mL / hr

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?

A client who is experiencing preterm labor at 26 weeks of gestation

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) A) Administer magnesium sulfate B) Provide a dark, quiet environment C) Ensure calcium gluconate is readily available D) Ensure oxytocin is readily available E) Prepare for emergency c-section

A) Administer magnesium sulfate B) Provide a dark, quiet environment C) Ensure calcium gluconate is readily available

What information regarding a fractured clavicle is most important for the nurse to take into consideration when planning the infant's care? a. Prone positioning facilitates bone alignment. b. No special treatment is necessary. c. Parents should be taught range-of-motion exercises. d. The shoulder should be immobilized with a splint.

ANS - B. No special treatment is necessary. Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. Movement should be limited, and the infant should be gently handled. Performing range-of-motion exercises on the infant is not necessary. A fractured clavicle does not require immobilization with a splint.

A woman with preeclampsia has a seizure. What is the nurse's highest priority during a seizure? a. To insert an oral airway b. To suction the mouth to prevent aspiration c. To administer oxygen by mask d. To stay with the client and call for help

ANS - D. To stay with the client and call for help If a client becomes eclamptic, then the nurse should stay with the client and call for help. Nursing actions during a convulsion are directed toward ensuring a patent airway and client safety. Insertion of an oral airway during seizure activity is no longer the standard of care. The nurse should attempt to keep the airway patent by turning the client's head to the side to prevent aspiration. Once the seizure has ended, it may be necessary to suction the client's mouth. Oxygen is administered after the convulsion has ended.

A pregnant woman has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia for 24 hours. On assessment, the nurse finds the following vital signs: temperature 37.3° C, pulse rate 88 beats per minute, respiratory rate 10 breaths per minute, BP 148/90 mm Hg, absent deep tendon reflexes (DTRs), and no ankle clonus. The client complains, "I'm so thirsty and warm." What is the nurse's immediate action? a. To call for an immediate magnesium sulfate level b. To administer oxygen c. To discontinue the magnesium sulfate infusion d. To prepare to administer hydralazine

ANS: C - To discontinue the magnesium sulfate infusion Regardless of the magnesium level, the client is displaying the clinical signs and symptoms of magnesium toxicity. The first action by the nurse should be to discontinue the infusion of magnesium sulfate. In addition, calcium gluconate, the antidote for magnesium, may be administered. Hydralazine is an antihypertensive drug commonly used to treat hypertension in severe preeclampsia. Typically, hydralazine is administered for a systolic BP higher than 160 mm Hg or a diastolic BP higher than 110 mm Hg.

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

Abruptio placentae

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

Ambulate twice daily

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

An excessive amount of amniotic fluid is present

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? A) "I'll basically follow the same diet that I was following before I became pregnant." B) "Because I need extra protein, I'll have to increase my intake of milk and meat." C) "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D) "I'll adjust my diet and insulin based on the results of my urine tests for glucose.

Ans: C - "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." In pregnancy, placental hormones cause insulin resistance at a level that tends to parallel the growth of the fetoplacental unit. Nutritional management focuses on maintaining balanced glucose levels. Thus, the woman will probably need to make adjustments in her diet. Protein needs increase during pregnancy, but this is unrelated to diabetes. Blood glucose monitoring results typically guide therapy.

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Ask the client if she has considered harming the newborn

A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?

Asymmetric thigh folds

A nurse is caring for a client and reviewing the findings of the client's biophysical profile (BPP). Which of the following variables are included in this test? (Select all that apply.) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Reactive FHR E. Amniotic fluid volume

B. Fetal breathing movement C. Fetal tone D. Reactive FHR E. Amniotic fluid volume

Which compound would the nurse have readily available for a client who is receiving magnesium sulfate to treat severe preeclampsia? A. calcium carbonate B. calcium gluconate C. potassium chloride D. ferrous sulfate

B. calcium gluconate

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?

Call for help Apply internal upward pressure to the presenting part using two gloved fingers

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

Cluster the newborn's care activities

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? A) Temperature B) Fetal heart rate C) Bowel sounds D) Respiratory rate

D) Respiratory rate

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?

Disseminated intravascular coagulation (DIC)

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

Dry, cracked skin

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

Dyspnea

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

Elevate her leg

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

Excessive uterine enlargement

A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

Glyburide

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

Heart rate 110/min

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

Hyperinsulinemia

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care?

Hypoglycemia

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

Increase IV fluids to wide open rate

A client comes to the emergency room reporting severe abdominal cramping and heavy bleeding at 10 weeks gestation. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experiencing?

Inevitable

A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care?

Initiate a controlled low-protein diet

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following?

Location of the placenta

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant?

Maintain O2 sat between 93-95%

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

Maternal hypertension

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate?

Meconium aspiration, hypoglycemia, and dry, cracked skin

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

Obtain blood glucose by heel stick

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

Offer option to view products of conception

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?

Pelvic pain

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads with blood in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action?

Preparation for cesarean birth

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

Report of headache

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

The mother applies lotion to the newborn's skin

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation

Unilateral, cramp like pain

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 11 lb 6 oz. (5160 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

Uterine atony

A nurse is caring for a client Who is at 36 weeks of gestation. And who has a suspected placenta Previa. Which of the following finding support this? a) Painless red vaginal bleeding b) Painful bleeding c) Painful uterine contractions d) painless arm tingling

a) Painless red vaginal bleeding

A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse? a. Blood pressure (BP) increase to 138/86 mm Hg b. Weight gain of 0.5 kg during the past 2 weeks c. Dipstick value of 3+ for protein in her urine d. Pitting pedal edema at the end of the day

c. Dipstick value of 3+ for protein in her urine

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful? a. Using the words lost or gone rather than dead or died b. Making sure the family understands that naming the baby is important c. Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby d. Setting a firm time for ending the visit with the baby so that the parents know when to let go

c. Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby

The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the oxytocin (Pitocin) infusion, the nurse reviews the woman's latest laboratory test findings, which reveal a platelet count of 90,000 mm3, an elevated aspartate aminotransaminase (AST) level, and a falling hematocrit. The laboratory results are indicative of which condition? a. Eclampsia b. Disseminated intravascular coagulation (DIC) syndrome c. Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome d. Idiopathic thrombocytopenia

c. Hemolysis, elevated liver enzyme levels, and low platelet levels (HELLP) syndrome