final review

The nurse is caring for a patient diagnosed with idiopathic thrombocytopenic purpura. Which intervention should the nurse perform first?

ANS: administration of platelet transfusions as prescribed

Congenital myelomeningocele is commonly associated with which condition?

ANS: hydrocephalus

why are newborns born to diabetic mothers prone to hypoglycemia?

Elevated insulin production metabolized glucose faster

A nurse is explaining the Apgar scoring to a new mother and her partner. What should the nurse point out about this scoring method? Select all the apply.

- The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation. - The baby is considered vigorous if the 5-minute score is above 7. - It is done at 1 and 5 minutes after birth.

The nurse reviews the antenatal history and notes of a term newborn. The mother admits to continual daily use of alcohol throughout her pregnancy. For which should the nurse assess the infant? Select all that apply.

- Abnormal smallness of the head - A flatter groove between the nose and upper lip - Weight below the 10th percentile for gestational age - Inadequate sucking

The nurse is preparing discharge instructions for a pregnant patient experiencing preterm rupture of membranes. What should the nurse include in this teaching? Select all that apply.

- Avoid douching. - Measure oral temperature twice a day.

A mother is experiencing postpartum hemorrhage shortly after delivery of her infant. Which nursing interventions would be appropriate for this client? Select all that apply.

- Encourage the mother to breast-feed her infant if she is breast-feeding. - Turn the mother on her side and inspect the area under her buttocks for blood. - Encourage increased fluid intake. - Monitor vital signs every 15 minutes.

A female client who has very recently given birth arrives at a health care center complaining of painful urination. Assessment also reveals that the client has a temperature of 102 F 38.9 C. The physician suspects the client has pyelonephritis. Which of the following would the nurse expect to assess? Select all that apply

- Flank pain - Chills - Anorexia

Which actions by a graduate nurse on the postpartum unit would require the nurse manager to intervene? Select all that apply

- Graduate nurse questions how a lesbian couple could have a baby together. - Graduate nurse speaks to the surrogate mother about the care of the newborn.

A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply.

- Heart rate is 180 beats per minutes. - Oxygen saturation level is 88%. - The infant has facial grimacing and quivering chin.

An infant is experiencing transient tachypnea of the newborn (TTN). Symptoms that may be seen in this infant include which of the following? Select all that apply

- Nasal flaring - Respirations of 60 per minute - Retractions - Expiratory grunting

A woman has just given birth to a healthy term newborn. Upon assessing the umbilical cord, the nurse would identify what findings as normal? Select all that apply.

- One vein - Two arteries

Which of the following is a cause of retinopathy of prematurity (ROP)? Select all that apply.

- Oxygen saturation maintained above 95% - Presence of immature retinal blood vessels

The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply

- Swaddling the newborn closely - Offering a pacifier prior to a procedure - Encouraging kangaroo care during procedures

On postpartum day 4, a client has a temperature of 101.4°F (38.6°C). Which findings would be consistent with a diagnosis of endometritis? Select all that apply.

- Tender uterus - Foul-smelling lochia

The nurse is assisting a young mother who has decided not to breastfeed her infant. The nurse should make which suggestions to the client to ease discomfort and prevent breast engorgement? Select all that apply.

- Wear tight supportive bra 24 hours each day. - Apply ice to the breast for approximately 15 to 20 minutes every other hour. -Avoid sexual stimulation.

A new mother is diagnosed with a venous thromboembolism in her left calf. Which risk factor is associated with this problem? Select all that apply. - cesarean birth -obesity

- cesarean birth -obesity

The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. Which interventions should the nurse prioritze? Select all that apply.

- maintaining NPO status for the first day or two - administering antiemetic agents. - obtaining baseline blood electrolyte levels - monitoring intake and output

The nurse is teaching a pregnant woman with a prepregnancy body mass index of 26 about recommended weight gain. The nurse determines that the teaching was successful when the woman states that she should gain approximately how much during pregnancy?

15 to 25 pounds

A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment finding? Select all that apply

ANS: -cervical dilation of 6 cm - contractions every 2 to 3 minutes

The nurse is working with a group of parents of children who have congenital heart disorders. Which statement made by the parents should the nurse prioritize for further assessment?

ANS: "She gets so tired when she is eating."

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?

ANS: 0 zero

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 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse would document her obstetric history as:

ANS: 4 1 1 1 3

A 6-week gestation client asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods? A) Spinach, oranges, and beans B) Milk, yogurt, and cheese C) Bananas, avocados, and coconut D) Pork, beans, and poultry

ANS: A

A nurse is caring for an antenatal mother diagnosed with umbilical cord prolapse. For which should the nurse monitor the fetus? fetal hypoxia preeclampsia placental pathology coagulation defects

ANS: A

A woman with severe preeclampsia is receiving magnesium sulfate. The woman's serum magnesium level is 9.0 mEq/L. Which finding would the nurse most likely note? A- diminished reflexes B- elevated liver enzymes C- seizures D- serum magnesium level of 6.5 mEq/L

ANS: A

An experienced nurse is working with a new graduate on the postpartum unit. Which comment by the new graduate about a client would require the nurse to intervene? A) I have ordered a kosher diet for the Jewish client, since that is usually what they prefer. B) The Pakistani client has requested no male caretakers so I reassigned the male student to another client. C) The Hispanic client has many family members, which I have allowed to visit during the day. D) The Vietnamese client has requested only hot foods, so I contacted dietary to make note of this request.

ANS: A

During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After delivery during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. In what way does the woman get rid of this fluid? A. Urinary elimination B. Elimination of solid wastes C. Being too tired to eat D. Breathing off fluid vapor

ANS: A

A client at 34 weeks gestation has reported to the hospital in labor. The following is documented on history and physical assessment: • No rupture of membranes, mild cramping, no bleeding • Reassuring pattern on fetal heart monitor • Cervix is dilated 3 cm, effacement 30%. The nurse anticipates which treatment plan? A) Admission to the hospital, bed rest, and tocolytic agent B) Discharge instructions including rest and increased fluids C) Admission to the hospital for continued labor and vaginal birth D) Admission to the hospital and immediate cesarean birth

ANS: A) Admission to the hospital, bed rest, and tocolytic agent

A community health nurse is teaching a group of clients about Zika virus which statements by the clients indicate to the nurse that the teaching was effective? Select all that apply a. There is no treatment for newborns with zika, but they will have supportive care based on the defects. b. Zika can be transmitted by mosquitoes, sexual activity, and blood exposure. c. Women who have been exposed to zika should wait six months before attempting conception. d. It is best for men who have been exposed to zika to wait six months before attempting conception. e. A pregnant woman with zika may have a baby with microcephaly and other congenital anomalies.

ANS: A, B, D, E

What is a risk factor for developing a postpartum infection? Select all that apply. ANS: A, C, D A) diabetes type 1 B. thin build C) prolonged labor D) cesarean birth E) rupture of membranes at time of birth

ANS: A, C, D

During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. What findings would correlate with this suspicion? Select all that apply. ANS: A, C, D, F A). The newborn has green staining of the fingernails. B) The umbilical cord is stained bright red. C) The newborn has labored abdominal respirations. D) The newborn makes bearing down movements. E) The anterior fontanels are sunken at birth. F). Green amniotic fluid is present at birth.

ANS: A, C, D, F

Mrs. Carter is admitted to the labor and birth unit. The lab results of her cervical culture for group B streptococcal were positive. What priority intervention will be initiated?

ANS: Ampicillin or cefazolin intravenous is given before delivery.

A client is admitted to the labor and birthing suite in early labor. On review of her prenatal history, the nurse determines that the clients pelvic shape as identified in the antepartal progress notes is the most favorable one for a vaginal delivery. Which pelvic shape would the nurse have noted? A) Platypelloid B) Gynecoid C) Android D) Anthropoid

ANS: B

A nurse is describing the hormones involved in the menstrual cycle to a group of young adult women who are planning to get pregnant. The nurse determines the teaching was successful when the group identifies the follicle-stimulating hormone as being secreted by the: A) hypothalamus. B) anterior pituitary gland. C) ovaries. D) corpus lute

ANS: B

A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which of the following? a. Excess folic acid, which could increase the risk for neural tube defects b. Mercury, which could harm the developing fetus if eaten in large amounts c. Lactose, which leads to abdominal discomfort, gas, and diarrhea d. Low-quality protein that does not meet the woman's requirements

ANS: B

A woman at 32 weeks' gestation is admitted in preterm labor. On your admission assessment, which of following findings should cause the nurse to question the administration of a tocolytic agent? a) A spontaneous abortion in an earlier pregnancy. b) Cervical dilation of 5 cm. c) Fetus in a breech presentation. d) Strong, regular contractions.

ANS: B

A woman who had a cesarean delivery of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect? a) fluid volume overload b) pulmonary emboli c) infection d) hemorrhage

ANS: B

After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A) Holding a pillow against my incision will help me when I cough. B) I'm going to have to wait a few days before I can start breast-feeding. C) I guess the nurses will be getting me up and out of bed rather quickly. D) Ill probably have a tube in my bladder for about 24 hours or so.

ANS: B

The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time? A. Administer oxygen. B. Have the woman change her position. C. Notify the health care provider. D. Continue to monitor the pattern every 15 minutes.

ANS: B

The nurse is requested to assist the physician with an external version. What intervention should the nurse perform prior to and immediately after the external version? a) An electrocardiogram. b) A non-stress test c) Administer tocolytics. d) Administer a narcotic analgesic

ANS: B

When giving a postpartum client a self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" a) Saturating 1 pad in 6 hours b) Saturating 1 pad in 1 hour c) Saturating 1 pad in 8 hours d) Saturating 1 pad in 3 hours

ANS: B

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply. a- Apply talc powder to the diaper area with each diaper change. b- Wash the penis with warm water at each diaper change. c- Fasten the diaper loosely to prevent unnecessary friction as irritation. d- Report if there is a bleeding spot the size of a dime on the diaper. e- Notify the doctor if the newborn does not void after 4 hours.

ANS: B, C

. What intervention would the nurse recommend for a new breastfeeding mother with mastitis? Select all that apply. A) Encourage the client to breastfeed the infant every 3 to 4 hours. B) Begin feedings on the unaffected breast C)Take prescribed antibiotics for 10 dayS D) Apply warm compresses as a comfort measure for her pain. E) Stop breastfeeding until the infection clears up.

ANS: B, C, D

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.) a) Administer methotrexate b) Apply an ice pack to the site c) Administer a mild analgesic as prescribed d) Administer an antibiotic e) Estimate the size of the hematoma and report it f) Perform fundal massage

ANS: B, C, E,

A client has not received any medication during her labor. She is having frequent contractions every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 50 % effaced. The nurse interprets these findings as indicating: A) Latent phase of the first stage of labor B) Active phase of the first stage of labor C) Transition phase of the first stage of labor D) Pelvic phase of the second stage of labor

ANS: C

The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize? A- Infection B- Dehydration C- Hemorrhage D- Bladder distention

ANS: C

When palpating the fundus during a contraction, the nurse notes that it feels like a chin. The nurse interprets this finding as indicating which type of contraction? A) Intense B) Strong C) Moderate D) Mild

ANS: C

While talking with a pregnant woman who has undergone genetic testing, the woman informs the nurse that her baby will be born with Down syndrome. The nurse understands that Down syndrome is an example of: A) Multifactorial inheritance B) X-linked recessive inheritance C) Trisomy numeric abnormality D) Chromosomal deletion

ANS: C) Trisomy numeric abnormality

After teaching a group of adolescents about female reproductive anatomy, the nurse determines that the teaching was successful when the adolescents identify which structure as the site of fertilization? A. uterus B. vestibule C. fallopian tubes D. vagina

ANS: C. fallopian tubes

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism?

ANS: Calf swelling

A woman arrives in the L & D unit in the beginning early phase with her contractions 5 to 8 minutes apart and dilated 1 cm. Thirty minutes later the nurse finds the woman in hard, active labor and 8 cm dilated. The nurse calls for assistance, prepares for a precipitate birth, and monitors the woman for which priority assessment caused by a rapid birth?

ANS: Check perineal area frequently for bleeding.

For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin?

ANS: Chlamydia trachomatis.

When assessing a infant born at 32 weeks' gestation, which finding would lead the nurse to suspect to suspect that the newborn has a patent ductus arteriosus (PDA)?

ANS: Continuous murmur on auscultation

The nurse is helping her client to recognize signs of hunger in her newborn. the nurse knows that her client needs additional teaching when she states that which sign is one of the early signs of hunger?

ANS: Crying

A newborn has been diagnosed with a Group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause? A) Improper handwashing B) Contaminated formula C) Nonsterile catheter insertion D) Mother's birth canal

ANS: D

A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? a. leg pain on ambulation with mild ankle edema b. calf pain with dorsiflexion of the foot c. perineal pain with swelling along the episiotomy d. sharp stabbing chest pain with shortness of breath

ANS: D

A nurse is assessing a pregnant woman in her last trimester, which question would be most appropriate to use to gather information about weight gain and fluid retention? A) "What's your usual dietary intake for a typical day?" B) "What size maternity clothes are you wearing now?" C) "How puffy does your face look by the end of a day?" D) "How swollen do your ankles appear before you go to bed?

ANS: D

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which condition would the nurse identify as necessitating the cautious administration of this drug? a) low blood pressure b) mild fever c) respiratory problems d) cardiovascular disease

ANS: D

A pregnant client at 20 weeks' gestation arrives at the health care facility reporting excessive vaginal bleeding and no fetal movements. Which assessment finding would the nurse anticipate in this situation? A- congenital malformations B- placenta previa C- ectopic pregnancy D- cervical insufficiency

ANS: D

Some women experience a rupture of their membranes before going into true labor. A nurse recognizes that a woman who presents with premature prelabor rupture of membranes (PPROM) has completed how many weeks of gestation? less than 38 weeks less than 40 weeks less than 39 weeks less than 37 weeks

ANS: D

The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse determines that the women understood the description when they identify the condition as postpartum: ANS: D A. bipolar disorder. B. depression. C. psychosis. D. blues.

ANS: D

A patient who is 16 weeks pregnant is passing pieces of body tissue along with blood clots and dark red blood from the vagina. What should the nurse direct the patient to do at this time? A) Begin immediate bed rest. B) Count the number of perineal pads that are saturated with blood. C) Continue with normal daily activity and monitor pulse rate every hour. D) Seek immediate medical attention and bring the expressed vaginal material.

ANS: D) Seek immediate medical attention and bring the expressed vaginal material.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions? a) Postpartum depression b) Postpartum blues c) Postpartum panic disorder d) Postpartum psychosis

ANS: D. Postpartum psychosis

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

ANS: Epstein's pearls.

The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor?

ANS: Every 15 to 30 minutes

Two weeks after a vaginal delivery, a client presents with low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection?

ANS: Foul-smelling vaginal discharge

The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority?

ANS: Initiate early oral feedings.

A nurse finds that a client is bleeding excessively after a vaginal delivery. Which assessment finding would indicate retained placental fragments as a cause of bleeding?

ANS: Large uterus with painless dark-red blood mixed with clots

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 of the following?

ANS: Moderately strong contractions every 4 minutes, lasting about 1 minute

The nurse examines a woman at 34 weeks gestation who present to labor and delivery with vaginal bleeding and back pain which finding would led to a diagnosis of placental abruption?

ANS: Onset of vaginal bleeding was sudden and painful

When caring for a client requiring a forceps-assisted birth, the nurse would be alert for:

ANS: Potential lacerations and bleeding.

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

ANS: Prepare the client for a cesarean birth.

The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?

ANS: Prepare to assist with external version.

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of her perineum. What is the nurse's best action?

ANS: Report the finding promptly to the primary care provider.

which type of nutrition would the nurse expect to administer to a preterm infant who was born at 34 weeks gestation and has developed NEC?

ANS: TPN

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention?

ANS: a forceps and vacuum-assisted birth

Assessment reveals that a young mother has several risk factors for giving birth to an infant with a neural tube defect. Which laboratory test would the nurse expect to be used to monitor the fetus for this birth defect?

ANS: alpha-fetoprotein levels

While reviewing standard obstetric care with newly pregnant client the nurse informs her that pregnant women screened for which complication during the second trimester?

ANS: gestational diabetes

A client has arrived to the birthing center in labor, requesting a VBAC. The nurse knows that she would be a good candidate after reading the client's previous history based on which finding?

ANS: has previous lower abdominal incision

An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication?

ANS: hydrocephalus.

A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms?

ANS: necrotizing enterocolitis

A nurse is providing care to a multiparous client. The client has a history of cesarean births. The nurse anticipates the need to closely monitor the client for which condition?

ANS: placenta Accreta

A woman pregnant with twins comes to the clinic for an evaluation. The nurse closely assesses the client for which potential problem?

ANS: preeclampsia

A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for?

ANS: twin-to-twin transfusion syndrome (TTTS)

A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?

ANS: uterine rupture

A nurse is caring for a client who is experiencing acute onset of dyspnea and hypotension. The physician suspects the client has amniotic fluid embolism. What other sign or symptoms would alert the nurse to the presence of this condition? select all that apply

Ans: - Cyanosis - Pulmonary edema

A nurse is providing care to a couple who have experienced intrauterine fetal demise. Which action would be least effective in assisting a couple at this time?

Avoid any discussion of the situation with the couple.

The nurse notes persistent early decelerations on the fetal monitoring strip. which action should the nurse prioritize in this situation?

Continue to monitor the FHR because this pattern is benign

At 31 weeks' gestation, a 37-year-old woman who has a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Her cervix is 2.1 cm long; she has fetal fibronectin in her cervical secretions, and her cervix is dilated 3 to 4 cm. For what do you prepare her? a) Careful monitoring of fetal kick counts b) Bed rest and hydration at home c) Hospitalization, tocolytic therapy, and IM corticosteroids d) An emergency cesarean section

NAS: C

A pregnant client in her 34th week of gestation is diagnosed with amnionitis due to group B streptococcus. The nurse monitors the client closely based on the understanding that the client is at risk for which of the following?

Preterm birth

A nurse assessing the laboratory results of a pregnant client in her second trimester notes that she has a hemoglobin level of 11 gm/dL. What will the nurse interpret this finding to most likely indicate?

hemodilution of pregnancy