HESI QUIZ 1
Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? Pregnancy induced hypertension. Placenta previa. Gestational diabetes. Postpartum hemorrhage.
A Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension (A) is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. (B, C, and D) are not contraindications for the use of Methergine.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? Encourage the mother to provide total care for her infant. Provide privacy so the mother can develop a relationship with the infant. Encourage the father to provide most of the infant's care during hospitalization. Meet the mother's physical needs and demonstrate warmth toward the infant.
C
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? Come to the clinic today for an ultrasound. Go immediately to the emergency room. Lie on your left side for about one hour and see if the bleeding stops. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.
A
A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? Complete a sterile vaginal exam. Take maternal temperature every 2 hours. Prepare for an immediate cesarean birth. Obtain sterile suction equipment.
A
What nursing action should be implemented when intermittently gavage-feeding a preterm infant? Allow formula to flow by gravity. Avoid letting infant suck on tube. Insert feeding tube through nares. Apply steady pressure to syringe.
A
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous . Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. Maternal and fetal heart rates. Hourly urinary output. Deep tendon reflexes.
B Monitoring maternal and fetal heart rates is most important when terbutaline is being administered becauseTerbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2 receptors (causing uterine relaxation, a desired effect of the drug).
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? Wear support stockings. Reduce salt in her diet. Move about every hour. Avoid constrictive clothing.
C
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? Gravidity and parity. Time and amount of last oral intake. Date of last normal menstrual period. Frequency and intensity of contractions.
C
A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? Notify the pediatrician immediately. Suction the infant's nares, then the oral cavity. Check the infant's oxygen saturation rate. Position the infant on the right side.
C
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? Biophysical profile (BPP). Ultrasound for fetal anomalies. Maternal serum alpha-fetoprotein (AF) screening. Percutaneous umbilical blood sampling (PUBS).
A A BPP (biophysical profile) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to an aging placenta, not screening for fetal anomalies.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? Bathe the infant with an antimicrobial soap. Measure the head and chest circumference. Obtain the infant's footprints. Administer vitamin K (AquaMEPHYTON).
A To reduce direct contact with the human immuno-virus in blood and body fluids on the newborn's skin, a bath with an antimicrobial soap should be administered first.
What action should the nurse implement with the family when an infant is born with anencephaly? Ensure that measures to facilitate the attachment process are offered. Prepare the family to explore ways to cope with the imminent death of the infant. Inform the family about multiple corrective surgical procedures that will be needed. Provide emotional support to facilitate the consideration of fetal organ donation.
B Anencephaly, a neural tube congenital malformation, is the incomplete embryological formation of both cerebral hemispheres, which often results in death due to respiratory failure. While comfort measures are provided, there is no resuscitation effort or successful treatment available, so the family should be prepared for the infant's imminent death (B) and encouraged to explore ways to cope with the loss and express grief. Providing opportunities with the infant promote a realistic experience of connectedness and facilitates parental closure, not attachment (A). (C) is not warranted. Although (D) may be considered, it may not be the most therapeutic family-centered intervention when initially confronting the parents with the infant's prognosis.
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? Elicit a positive scarf sign on the affected side. Observe for an asymmetrical Moro (startle) reflex. Watch for swelling of fingers on the affected side. Note paralysis of affected extremity and muscles.
B Rationale The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? Walking. Squatting. Kneeling. Lithotomy.
B Squatting (B) helps to align the fetus with the pelvic outlet and allows gravity to assist in fetal descent and gives the client an adventitious position for birth. Although walking (A) and kneeling (C) also help to align the fetus with the pelvic outlet and allow for gravity to assist in fetal descent, these do not accomodate birth easily. The predominant position in the United States for physician-attended births is the lithotomy position which requires a woman to be in a reclined position with her legs in stirrups in which gravity has little effect in this position (D).
A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? Cervical dilation of 5 cm with 90% effacement. White blood cell count of 12,000/mm3. Hemoglobin of 12 mg/dl and hematocrit of 38%. A platelet count of 67,000/mm3.
C
The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? Begin as soon as your baby is born to establish a four-hour feeding schedule. Resting helps with milk production. Ask that your baby be fed at night in the nursery. Feed your baby every 2 to 3 hours or on demand, whichever comes first. Do not allow your baby to nurse any longer than the prescribed number of minutes.
C
A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? Ask to meet with the client and infant without family members present. Do a brief assessment for only the infant while family members are present. Observe interactions of family members with the newborn and each other. Reschedule the visit so that the mother and infant can be assessed privately.
C An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented, so the nurse should first observe the interaction of the family members (C). Although family members can remain during the assessment of the newborn (B), the mother should be assessed also. Privacy to assess the mother should be assured (A and D), but evaluation of the family dynamics provides essential data about mother-child bonding and should be determined at this time.
A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? Contraction stress test. Internal fetal monitoring. Abdominal ultrasound. Lecithin-sphingomyelin ratio.
C Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B and D) are invasive procedures that increase the risk for premature onset of labor, and are not indicated at this client's gestation.
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? Vaginal bleeding. Complaints of abdominal pain. Changes in fetal heart rate patterns. Alteration in maternal blood pressure.
C Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in the mother. (A, B, and D) are not the first findings of internal hemorrhage in the pregnant client.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? 4+ reflexes. Urinary output of 50 ml per hour. A decrease in respiratory rate from 24 to 16. A decreased body temperature.
C Magnesium sulfate is a CNS depressant that helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? Provide phototherapy for 30 minutes q8h. Feed the newborn sterile water hourly. Encourage the mother to breastfeed frequently. Assess the newborn's blood glucose level.
C The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin.
Which action is most important for the nurse to implement for a client at 36-weeks gestation who is admitted with vaginal bleeding? Monitor uterine contractions. Apply disposable pads under the client. Determine fetal heart rate and maternal vital signs. Obtain blood samples for hemoglobin hematocrit levels.
C The priority nursing action is assessment of the fetal heart rate and maternal vital signs (C) to evaluate the impact of blood loss in the mother and fetus. Although monitoring uterine activity (A), applying pads to assess bleeding amount (B), and obtaining samples for hemoglobin and hematocrit levels (D) should be implemented, these are not as important as assessing maternal and fetal well-being.
The nurse is counseling a client who wants to become pregnant. The client tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. Which date accurately reflects the calculation of the client's next fertile period? January 14-15. January 22-23. January 30-31. February 6-7.
C This client can expect her next period to begin 36 days from the first day of her last menstrual period. A menstrual cycle begins at the first day of the cycle and continues to the first day of the next cycle, therefore if January 8 was the first day on her last menstrual cycle, her next period would begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period so this client would be ovulating on January 30- 31.
A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? Heart rate of 100 beats/minute. Variable fetal heart rate. Onset of uterine contractions. Burning on urination.
C Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging. The risk of hemorrhage is the priority.
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? Slowly increasing urinary output over the last week. Respiratory rate changes from the 40s to the 60s. Changes in apical heart rate from the 180s to the 140s. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
C Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an increase in RBCs. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? 3+ deep tendon reflexes and hyperclonus. Periorbital edema, flashing lights, and aura. Epigastric pain in the third trimester. Recent decreased urinary output.
A
A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? Patellar reflex 4+. Blood pressure 158/80. Four-hour urine output 240 ml. Respiration 12/minute.
A A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of an impending seizure.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous . Which assessment is the highest priority for the nurse to monitor during the administration of this drug?
B
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? 4+ reflexes. Urinary output of 50 ml per hour. A decrease in respiratory rate from 24 to 16. A decreased body temperature.
C
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent? Back pain. Abdominal pain. Shoulder pain. Leg cramps.
C
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? Notify the healthcare provider. Move the newborn to an isolation nursery. Document the finding in the infant's record. Obtain a culture of the vesicles.
C Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a normal finding that is documented in the infant's record, and requires no further action.
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply Some correct answers were not selected Litmus paper. Fetal scalp electrode. A sterile glove. An amnihook. Sterile vaginal speculum. Lubricant.
CD
A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? Cervical dilation of 5 cm with 90% effacement. White blood cell count of 12,000/mm3. Hemoglobin of 12 mg/dl and hematocrit of 38%. A platelet count of 67,000/mm3.
D
The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? August 1. August 10. September 3. September 8.
D Rationale Calculation of a client's EDC provides baseline data to monitor fetal gestation. N gele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? Insert an internal fetal monitor. Assess for cervical changes q1h. Monitor bleeding from IV sites. Perform Leopold's maneuvers.
C
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? Administer oxygen by face mask. Notify the healthcare provider of the client's symptoms. Have the client breathe into her cupped hands. Check the client's blood pressure and fetal heart rate.
C
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which response is best for the nurse provide? "Weigh the baby daily, and if she is gaining weight, she is eating enough." "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." "Offer the baby extra bottle milk after her feeding, and see if she is still hungry." "If you're concerned, you might consider bottle feeding so that you can monitor her intake."
B
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? Dehydration. Hyperstimulation. Galactorrhea. Fetal tachycardia.
B
The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? Two vessels: one artery and one vein. Two vessels: two arteries and no veins. Three vessels: two arteries and one vein. Three vessels: two veins and one artery.
C
During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? Discontinue all forms of contraception. Make sure to include adequate folic acid in the diet. Lose weight so more weight is gained during pregnancy. Continue to take any medications that are taken regularly.
B
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? Elicit a positive scarf sign on the affected side. Observe for an asymmetrical Moro (startle) reflex. Watch for swelling of fingers on the affected side. Note paralysis of affected extremity and muscles
B
The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement? Obtain a serum glucose level. Give the infant medication for pain. Feed the newborn 1 ounce of formula. Request a genetic consultation.
B
While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? Molding. Cephalohematoma. Caput succedaneum. Bulging fontanel.
B
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? Raise the foot of the bed. Assess for vaginal bleeding. Evaluate the fetal heart rate. Take the client's blood pressure.
A
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? Choking, coughing, and cyanosis. Projectile vomiting and cyanosis. Apneic spells and grunting. Scaphoid abdomen and anorexia.
A
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) Select all that apply Some correct answers were not selected Admission weight of 4 pounds, 15 ounces ( 2244 grams). Head to heel length of 17 inches (42.5 cm). Frontal occipital circumference of 12.5 inches (31.25 cm). Skin smooth with visible veins and abundant vernix. Anterior plantar crease and smooth heel surfaces. Full flexion of all extremities in resting supine position.
AC
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. Maternal and fetal heart rates. Hourly urinary output. Deep tendon reflexes.
B
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? Supplementary iron is more efficiently utilized during pregnancy. It is difficult to consume 18 mg of additional iron by diet alone. Iron absorption is decreased in the GI tract during pregnancy. Iron is needed to prevent megaloblastic anemia in the last trimester.
B
A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? The length of labor and method of delivery. The infant's condition at birth and treatment received. The feeding method chosen by the parents. The history of drugs given to the mother during labor.
B
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pad are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? Cleanse the perineum. Obtain a blood pressure. Palpate the firmness of the fundus. Inspect the perineum for lacerations.
C
The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? Herpes. Staphylococcus. Gonorrhea. Syphilis.
C
The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? Cuddles the baby close to her. Rocks and soothes the infant in her arms. Places the infant prone in the bassinet. Wraps the baby in a warm blanket after bathing.
C
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply Litmus paper. Fetal scalp electrode. A sterile glove. An amniotic hook. Sterile vaginal speculum. A Doppler.
CDF
A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? It is not necessary to keep such a close watch on weight gain. Try to exercise more because too much weight has been gained. Increase the calories in your diet to gain more weight per week. The weight gain is acceptable for the number of weeks pregnant.
D The normal pattern of weight gain is 2 to 4 pounds in the first trimester (by 13-weeks) and 1 pound per week after that. At 28-weeks gestation, a weight gain between 17 and 20 pounds is acceptable (D). (A, B and C) do not provide accurate information.
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.)
4 A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. Four of the these assessment findings should receive a score of 1, and the 5th finding (synchronized chest and abdominal movement) receives a score of 0. Therefore, the total score is 4. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be November 22. November 8. December 22. October 22.
A
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. When preparing to document the client's delivery history, it is important for the nurse to document in the client's record which GTPAL history? 3-1-2-0-3. 4-1-2-0-3. 2-1-2-1-2. 3-1-1-0-3.
D
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately? Give the medication as prescribed and monitor for efficacy. Encourage the client to breastfeed rather than bottle feed. Have the client empty her bladder and massage the fundus. Call the healthcare provider to question the prescription.
D
Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? Decrease in pulse rate. Decrease in blood pressure. Increase in heart sounds (S1, S2). Increase in red blood cell production.
A Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease (A) should be assessed further. During the second trimester, both systolic and diastolic pressures decrease by about 5 to 10 mm Hg (B), a more audible splitting of S1 and S2 occurs (C), and there is an accelerated production of red blood cells (D).
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? Between the time the temperature falls and rises. Between 36 and 48 hours after the temperature rises. When the temperature falls and remains low for 36 hours. Within 72 hours before the temperature falls.
A
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? Between the time the temperature falls and rises. Between 36 and 48 hours after the temperature rises. When the temperature falls and remains low for 36 hours. Within 72 hours before the temperature falls.
A In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone making between the time of the temperature fall and rise is the best time to try to conceive.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.) Select all that apply Dark, red vaginal bleeding. Lower back pain. Premature rupture of membranes. Increased uterine irritability. Bilateral pitting edema. A rigid abdomen.
ADF
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? Encourage the mother to provide total care for her infant. Provide privacy so the mother can develop a relationship with the infant. Encourage the father to provide most of the infant's care during hospitalization. Meet the mother's physical needs and demonstrate warmth toward the infant.
D
A client who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? Elevate lower legs while resting. Increase caloric intake by 200 to 300 calories per day. Increase water intake to 8 full glasses per day. Take prescribed multivitamin and mineral supplements.
D
The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? Discuss various contraceptive methods to use until pregnancy is desired. Provide written or verbal information about prenatal care. Ask the client about risk factors associated with complications of pregnancy. Encourage healthy lifestyles for families desiring pregnancy.
D
When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth? Only the woman and her midwife should be present during the delivery. The woman should live no more than 15 minutes from the hospital. The woman's extended family should be allowed to attend the home birth. Medical backup should be available quickly in case of complications.
D
Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? Tactile stimulation. Commercial warm packs. Skin-to-skin contact with parent. Oral sucrose and nonnutritive sucking.
D
A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which designation is the most accurate summary of this client's obstetrical history? 3-1-1-1-3. 4-1-2-0-3. 3-0-3-0-3. 4-3-1-0-2.
B
A client in active labor complains of cramps in her leg. What intervention should the nurse implement? Ask if she takes a daily calcium tablet. Extend the leg and dorsiflex the foot. Lower the leg off the side of the bed. Elevate the leg above the heart.
B
The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? Discuss various contraceptive methods to use until pregnancy is desired. Provide written or verbal information about prenatal care. Ask the client about risk factors associated with complications of pregnancy. Encourage healthy lifestyles for families desiring pregnancy.
D Preconception care has an overall goal to prepare the client for a healthy pregnancy. It begins with encouraging healthy lifestyle choises in the family and should focus on measures to assist the client in reducing lifestyle variables that may increase the risk for problems in pregnancy.
Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? Silver nitrate. Erythromycin (Ilotycin ointment). Ceftriaxone (Rocephin). Vitamin K (AquaMEPHYTON).
D The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of neonatal bleeding, newborns receive a single injection of vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic ophthalmic agents used to prevent neonatal ophthalmia. (C) is an antibiotic used to treat neonatal infections.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. Which answer accurately reflects the nurse's understanding of the the variation of an accumulation of blood between the periosteum and skull that does not cross the suture line? a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. a subarachnoid hematoma, which requires immediate drainage to prevent further complications. molding, caused by pressure during labor and will disappear within 2 to 3 days. a subdural hematoma which can result in lifelong damage.
A
A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? Determine the firmness of the fundus. Give oxytocin (Pitocin) intravenously. Inform the healthcare provider of the bleeding. Assess the vital signs for indicators of shock.
A The first step in recognizing the potential cause of postpartum bleeding is to evaluate the contractility of the uterus (A). (B) should not be implemented until the cause of the bleeding is determined. The nurse should implement (C) after completing the assessment of the potential cause for bleeding. (D) is important, but (A) is a higher priority.
What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? Maternal bradycardia. Hard, board-like abdomen. Decrease in fundal height. Decrease in abdominal pain.
B Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its edges do not. The formation of a hematoma behind the placenta and subsequent infiltration of the blood manifests as a firm, board-like abdomen (B), which should be reported immediately to the healthcare provider. As bleeding occurs, fetal oxygenation and maternal stability are compromised leading to fetal and maternal tachycardia, not (A). With abruptio placenta, fundal height and abdominal pain increase, not (C and D).
Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? Request help with ambulation and perineal care. Exhibit interest in learning more about infant care. Sleep most of the time when the baby is not present. Be very excited and talkative about the birth experience.
B By the third postpartum day, the new mother should start to "take hold" of caring for her infant, by asking questions about infant care and initiating care of her infant (B). This client should be independent with self-care (A). Excessive sleeping (C) is more indicative of immediate post-delivery behavior when the new mother is tired from the process of labor. Being excited and talkative about the birth is more characteristic of "taking in" behavior, seen in the first 24 to 48 hours after delivery (D).
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous . Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. Maternal and fetal heart rates. Hourly urinary output. Deep tendon reflexes.
B Monitoring maternal and fetal heart rates is most important when terbutaline is being administered becauseTerbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2 receptors (causing uterine relaxation, a desired effect of the drug).
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment? Assess fetal response to the procedure. Note any complaint of sudden chest pain. Monitor for premature ventricular contractions. Observe for maternal blood pressure changes.
C During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be monitored for the occurrence of any ventricular ectopy (C). Although fetal well-being (A) is important, the primary nursing assessment at this time is monitoring for immediate cardiac changes in the mother. Adverse cardiac responses to PAC insertion should first identify changes in the client's heart rhythm before the client complains of chest pain (B). Manual blood pressures (D) evaluate systemic perfusion, but the primary purpose in monitoring pulmonary artery pressures is to detect early cardiac changes due to left ventricular failure
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? Discontinue the oxytocin (Pitocin) infusion. Place the client in a semi-Fowler's position. Inform the healthcare provider. Apply firm pressure to sacral area.
D
A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? The client may have a bladder or kidney infection. Bladder capacity increases during pregnancy. During pregnancy a woman is especially sensitive to body functions. The growing uterus is putting pressure on the bladder.
D
A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement? Notify the client's healthcare provider. Bring the delivery table to the room. Prepare to administer an oxytocic. Document the findings in the client record.
D This labor pattern indicates that the client is in the active phase of the first stage of labor and has a normal labor pattern, so the findings should be documented in the client's medical record (D). There is no indication to notify the healthcare provider (A) or bring the delivery table into the room (B) at this time. Oxytocin augmentation (C) is not needed for this labor pattern.
