MATERNAL FINAL

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching? "I will breastfeed every 2 hours." "I will apply ice packs to my breasts after feeding." "I should apply hot packs to my breasts during feeding." "I should crush cabbage leaves and place them on my breasts."

"I should apply hot packs to my breasts during feeding."

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations? "It is used to stop preterm labor contractions." "It halts cervical dilation." "It promotes fetal lung maturity." "It increases the fetal heart rate."

"It promotes fetal lung maturity."

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? "These exercises help prevent constipation." "These exercises help pelvic muscles to stretch during birth." "They can help reduce back aches." "They can prevent further stretch marks."

"These exercises help pelvic muscles to stretch during birth."

for chlamydia. Which of the following statements should the nurse provide? "This infection is treated with one dose of azithromycin." "If your sexual partner has no symptoms, no medication is needed." "You have to avoid sexual relations for 3 days." "You need to return in 6 months for retesting."

"This infection is treated with one dose of azithromycin."

A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? "This will occur during the last trimester of pregnancy." "This will happen by the end of the first trimester of pregnancy." "This will occur between the fourth and fifth months of pregnancy." "This will happen once the uterus begins to rise out of the pelvis."

"This will occur between the fourth and fifth months of pregnancy."

A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? 4-0-1-2-2 3-0-2-0-2 2-0-0-2-0 4-2-0-2-2

4-0-1-2-2

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? 22/min 48/min 100/min 110/min

48/min

A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score.

6

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 fetal death at 32 weeks of gestation A client who is experiencing preterm labor at 26 weeks of gestation A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation A client who has a post-term pregnancy at 42 weeks of gestation

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

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? Decreased vaginal discharge A surge of energy Urinary retention Weight gain of 0.5 to 1.5 kg

A surge of energy

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? Placenta previa Prolapsed cord Incompetent cervix Abruptio placentae

Abruptio placentae

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients? A client who has mitral valve prolapse A client who has been exposed to AIDS All of the clients A client who has a history of preterm labor

All of the clients

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? Assess deep tendon reflexes every hour. Obtain a daily weight. Continuous fetal monitoring Ambulate twice daily.

Ambulate twice daily.

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? Assist the family to identify prior use of positive coping skills in family crises. Ask the client if she has considered harming her newborn. Anticipate a prescription by the provider for an antidepressant. Reinforce postpartum and newborn care discharge teaching.

Ask the client if she has considered harming her newborn.

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? Vertex Shoulder Breech Mentum

Breech

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? Limit alcohol consumption. Increase intake of iron-rich foods. Consume foods fortified with folic acid. Avoid foods containing aspartame.

Consume foods fortified with folic acid.

A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? Contractions lasting longer than 90 seconds Contractions occurring every 3 to 5 min Contractions are strong in intensity Client reports feeling contractions in lower back

Contractions lasting longer than 90 seconds

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? Chvostek's sign Cullen's sign Chadwick's sign Goodell's sign

Cullen's sign

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? Decrease the rate of infusion of the maintenance IV solution. Discontinue the infusion of the IV oxytocin. Increase the rate of infusion of the IV oxytocin. Slow the client's rate of breathing.

Discontinue the infusion of the IV oxytocin.

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? Document the findings and continue to monitor the client. Notify the client's provider. Increase the frequency of fundal massage. Encourage the client to empty her bladder.

Document the findings and continue to monitor the client.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? Maintain the client in the lithotomy position. Perform vaginal examinations frequently. Remind the client to bear down with each contraction. Encourage the client to empty her bladder every 2 hr.

Encourage the client to empty her bladder every 2 hr.

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? Evaluate the firmness of the uterus. Initiate oxygen therapy by nonrebreather mask. Administer oxytocin infusion Obtain a type and crossmatch.

Evaluate the firmness of the uterus.

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? Cephalic Transverse Posterior Frank breech

Frank breech

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? Fundus firm to palpation Increase in blood pressure Increase in lochia Report of absent breast pain

Fundus firm to palpation

A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect? Fundus soft, 1 cm to the right of the umbilicus Fundus firm, at the level of the umbilicus Fundus present, to the left of the umbilicus Fundus soft, 2 cm above the umbilicus

Fundus firm, at the level of the umbilicus

A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? This test assesses fetal lung maturity. It assesses various markers of fetal well-being. This test identifies an Rh incompatibility between the mother and fetus. It is a screening test for spinal defects in the fetus.

It is a screening test for spinal defects in the fetus.

A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (Select all that apply.) Eczema Psoriasis Linea nigra Chloasma Striae gravidarum

Linea nigra Chloasma Striae gravidarum

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference? Sternal notch Nipple line Xiphoid process Fifth intercostal space

Nipple line

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take? Have the client stand at the bedside with her arms at her side. Administer a 500 mL bolus of 5% dextrose in water prior to induction. Inform the client the anesthetic effect will last for approximately 6 hr. Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction.

Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction.

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? Administer oxygen via nasal cannula. Offer option to view products of conception. Instruct the client to increase potassium-rich foods in the diet. Maintain the client on bed rest.

Offer option to view products of conception.

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 findings support this diagnosis? Painless red vaginal bleeding Increasing abdominal pain with a nonrelaxed uterus Abdominal pain with scant red vaginal bleeding Intermittent abdominal pain following passage of bloody mucus

Painless red vaginal bleeding

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time? Palpate the client's uterine fundus. Assist the client on a bedpan to urinate. Prepare to administer oxytocic medication. Increase the client's fluid intake.

Palpate the client's uterine fundus.

A nurse is providing teaching to a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet? Peanut butter Potatoes Apple juice Broccoli

Peanut butter

A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn? Acrocyanosis of hands and feet Anterior fontanel soft and level Plantar creases cover 2⁄3 of sole Vernix caseosa in inguinal creases

Plantar creases cover 2⁄3 of sole

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider? Poor sucking Blue coloring of the hands and feet Soft, edematous area on the scalp Facial edema

Poor sucking

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider? Respiratory depression Facial flushing Nausea Drowsiness

Respiratory depression

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? Respiratory distress Hypothermia Accidental lacerations Acrocyanosis.

Respiratory distress

A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? Babinski Rooting Moro Stepping

Rooting

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? Shortly after giving birth In the third trimester Immediately During her next attempt to get pregnant

Shortly after giving birth

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? Suction the nose with a bulb syringe. Suction the mouth with a bulb syringe. Use a suction catheter with low negative pressure. Turn the newborn on his side.

Suction the mouth with a bulb syringe.

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? The fetal head is in the left occiput posterior position. The largest fetal diameter has passed through the pelvic outlet. The posterior fontanel is palpable. The lowermost portion of the fetus is at the level of the ischial spines.

The lowermost portion of the fetus is at the level of the ischial spines.

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse? A pink rash appears on the newborn's trunk. The newborn's eyes are covered with a mask. The mother applies lotion to the newborn's skin. The newborn's stools increase in number.

The mother applies lotion to the newborn's skin.

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? Respirations 16/min Headache for 30 min Urinary output 40 mL in 2 hr Fetal heart rate 158/min

Urinary output 40 mL in 2 hr

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? Early decelerations Accelerations Late decelerations Variable decelerations

Variable decelerations

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching? "I will place my baby on his stomach when he is sleeping." "I should remove extra blankets from my baby's crib." "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps." "I should place my baby's crib next to the heater to keep him warm during the winter."

"I should remove extra blankets from my baby's crib."

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching? "I will have to lie on my back during the test." "My baby's heart rate will be monitored during the test." "I should schedule the test when the baby is usually active." "It will take 20 to 30 minutes to complete the test."

"I will have to lie on my back during the test."

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 should limit my carbohydrates to 50% of caloric intake." "I will reduce my exercise schedule to 3 days a week." "I will take my glyburide daily with breakfast." "I know I am at increased risk to develop type 2 diabetes."

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

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.) "I am likely to have a fever during the first week I am home." "I will resume taking my prenatal vitamins." "I will call my provider if I have discharge from my incision." "I should not have unrelieved pain in my abdomen." "I will rest in a recliner until my incision is healed."

"I will resume taking my prenatal vitamins." "I will call my provider if I have discharge from my incision." "I should not have unrelieved pain in my abdomen."

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction? "I will keep my baby's head elevated while he is feeding." "I will allow my baby to burp several times during each feeding." "I will tip the nipple so air is present as my baby sucks." "My baby will have soft, formed yellow stools."

"I will tip the nipple so air is present as my baby sucks."

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.) "I'll expect the plastic ring to fall off by itself within a week." "I'll apply petroleum jelly to his penis with diaper changes." "I'll wash his penis with warm water and mild soap each day." "I'll call the doctor if I see any bleeding." "I'll make sure his diaper is loose in the front."

"I'll expect the plastic ring to fall off by itself within a week." "I'll call the doctor if I see any bleeding." "I'll make sure his diaper is loose in the front."

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching? "I'll let my baby drain one breast at each feeding." "I'll try drinking an herbal tea to reduce the engorgement." "I'll apply cold compresses 20 minutes before each feeding." "I'll feed my baby every 2 hours."

"I'll feed my baby every 2 hours."

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition? Moist skin Protruded abdomen Gray umbilical cord Wide skull sutures

Wide skull sutures

A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse? "Fertilization takes place in the outer third of the fallopian tube." "Implantation occurs between 2 and 3 weeks after conception." "Sperm remain viable in the woman's reproductive tract for 2 to 3 days." "Bleeding or spotting can accompany implantation."

"Implantation occurs between 2 and 3 weeks after conception."

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? "This will determine if there is more than one fetus." "It is useful for estimating fetal age." "It assists in identifying the location of the placenta and fetus." "This is a screening tool for spina bifida."

"It assists in identifying the location of the placenta and fetus."

A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? "It determines if kernicterus will occur in the newborn." "It detects Rh-negative antibodies in the newborn's blood." "It detects Rh-positive antibodies in the mother's blood." "It determines the presence of maternal antibodies in the newborn's blood."

"It detects Rh-positive antibodies in the mother's blood."

A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? "It's a minor inconvenience, which you should ignore." "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." "There is no way to predict how long it will last in each individual client." "It occurs during the first trimester and near the end of the pregnancy."

"It occurs during the first trimester and near the end of the pregnancy."

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." "At least you know you have a healthy baby." "Maybe next time you can have a vaginal delivery." "You can resume sexual relations sooner than if you had delivered vaginally."

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

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? "Preterm newborns have a smaller body surface area than normal newborns." "The added brown fat layer in a preterm newborn reduces his ability to generate heat." "Preterm newborns lack adequate temperature control mechanisms." "The heat in the incubator rapidly dries the sweat of preterm newborns."

"Preterm newborns lack adequate temperature control mechanisms."

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make? "It would be best if you gained about 11 to 20 pounds." "The recommendation for you is about 15 to 25 pounds." "A gain of about 25 to 35 pounds is recommended for you." "A gain of about 1 pound per week is the best pattern for you."

"The recommendation for you is about 15 to 25 pounds."

A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? "You should not receive the rubella vaccine while breastfeeding." "You should receive a varicella vaccine before you deliver." "You can receive an influenza vaccination during pregnancy." "You cannot receive the Tdap vaccine until after you deliver."

"You can receive an influenza vaccination during pregnancy."

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take? Apply an ice pack to the affected area. Offer a warm sitz bath. Provide a squeeze bottle of antiseptic solution. Place a hot pack to the perineum.

Apply an ice pack to the affected area.

A nurse is providing teaching to a client who is planning on becoming pregnant about the changes she should expect. Identify the sequence of maternal changes. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Amenorrhea Goodell's sign Quickening Lightening

A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC? Antihypertensives Anticonvulsants Antioxidants Antiemetics

Anticonvulsants

A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? Observe color and consistency of fluid Assess the fetal heart rate pattern Assess the client's temperature Evaluate client for the presence of chills and increased uterine tenderness using palpation.

Assess the fetal heart rate pattern

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? Recheck the client's temperature in 4 hr. Administer glucocorticoids intramuscularly. Assess the odor of the amniotic fluid. Prepare the client for emergency cesarean section.

Assess the odor of the amniotic fluid.

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? Encourage the client to perform Kegel exercises. Encourage the client to move to the left lateral position. Ask the client to rate her pain. Assist the client to the bathroom to void.

Assist the client to the bathroom to void.

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? Prepare for a cesarean birth. Assist the client to an upright position. Prepare for an immediate vaginal delivery. Assist the client to turn onto her side.

Assist the client to turn onto her side.

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? At the level of the umbilicus 2 cm above the umbilicus One fingerbreadth above the symphysis pubis To the right of the umbilicus

At the level of the umbilicus

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.) Blot the perineal area dry after cleansing. Clean the perineal area from front to back. Perform hand hygiene before and after voiding. Apply ice packs to the perineal area several times daily. Wash the perineal area using a squeeze bottle of warm water after each voiding.

Blot the perineal area dry after cleansing. Clean the perineal area from front to back. Perform hand hygiene before and after voiding. Wash the perineal area using a squeeze bottle of warm water after each voiding.

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? Contractions that last for 60 seconds each with a 4-min rest between contractions A contraction that lasts 4 min followed by a period of relaxation Contractions that last for 60 seconds each with a 3-min rest between contractions Contractions that last 45 seconds each with a 3-min rest between contractions

Contractions that last for 60 seconds each with a 3-min rest between contractions

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? Saturated perineal pad in 30 min Deep tendon reflexes 4+ Fundus at level of umbilicus Approximated edges of episiotomy

Deep tendon reflexes 4+

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? 1+ pitting sacral edema 3+ protein in the urine Blood pressure 148/98 mm Hg Deep tendon reflexes of +1

Deep tendon reflexes of +1

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? Ask another nurse to verify the heart rate. Document this as an expected finding. Call the provider to further assess the newborn. Prepare the newborn for transport to the NICU.

Document this as an expected finding.

A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times? Every morning before arising On days 13 to 17 of her menstrual cycle 1 hour following intercourse Before going to bed every night

Every morning before arising

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? Fetal attitude is in general flexion. Fetal lie is longitudinal. Maternal pelvis is gynecoid. Fetal position is persistent occiput posterior.

Fetal position is persistent occiput posterior.

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended? Client report of frequent uterine contractions Less than 2.5 cm of rubra lochia on perineal pad Fundus palpable to right of midline Client report of increased thirst

Fundus palpable to right of midline

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy? Gradual lordosis Increased abdominal muscle tone Posterior neck flexion Decreased mobility of pelvic joints

Gradual lordosis

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? Assist the client into a comfortable position. Observe the perineum for signs of crowning. Have the client pant during the next contractions. Help the client to the bathroom to void.

Have the client pant during the next contractions.

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 Hypomagnesemia Hyperbilirubinemia Hypocalcemia

Hypoglycemia

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? Vomiting Tachycardia Respiratory depression Hypotension

Hypotension

A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta? Increased blood pressure in the arms with decreased blood pressure in the legs Decreased blood pressure in the arms with increased blood pressure in the legs Increased blood pressure in both the arms and the legs Decreased blood pressure in both the arms and the legs

Increased blood pressure in the arms with decreased blood pressure in the legs

A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? Assess client's blood pressure. Assess the bladder for distention. Massage the client's fundus. Prepare to administer a prescribed oxytocic preparation.

Massage the client's fundus.

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? Begin phototherapy. Initiate early feeding. Suction excess mucus with a bulb syringe. Prepare for an exchange blood transfusion.

Initiate early feeding.

A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature? Phosphatidylglycerol (PG) absent Biophysical profile score of 8 Lecithin/sphingomyelin (L/S) ratio of 2:1 Nonstress test is reactive

Lecithin/sphingomyelin (L/S) ratio of 2:1

A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? Administer prescribed analgesic medication. Encourage the client to rest between contractions. Massage the client's back. Turn the client onto her left side.

Massage the client's back.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next? Insert an indwelling urinary catheter. Administer oxytocin by continuous IV infusion. Tilt the client onto her right side with her legs elevated to at least 30°. Massage the client's fundus to promote contractions.

Massage the client's fundus to promote contractions.

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? Maternal/newborn blood group incompatibility Absence of vitamin K Physiologic jaundice Maternal cocaine abuse

Maternal/newborn blood group incompatibility

A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings? Incomplete miscarriage Missed miscarriage Inevitable miscarriage Complete miscarriage

Missed miscarriage

A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? Perform a sharp hand clap near the infant. Hold the newborn vertically allowing one foot to touch the table surface. Place a finger at the base of the newborn's toes. Turn the newborn's head quickly to one side.

Perform a sharp hand clap near the infant.

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take? Notify the provider of the findings. Position the client with one hip elevated. Ask the client if she needs pain medication. Have the client void.

Position the client with one hip elevated.

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 in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? Examination to determine cervical status A magnesium sulfate infusion Initiation of pushing Preparation for cesarean birth

Preparation for cesarean birth

A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform? Bladder distention Pulse rate Respiratory rate Color of lochia

Pulse rate

Which of the following findings should the nurse expect? Cyanosis with crying Systolic murmur Weak pulses Chronic hypoxemia

Systolic murmur

A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.) Take the newborn for a ride in the car. Keep the newborn in the center of a large crib. Carry the newborn in a front or back pack. Swaddle the newborn in a receiving blanket. Allow the newborn to continue crying.

Take the newborn for a ride in the car. Carry the newborn in a front or back pack. Swaddle the newborn in a receiving blanket.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? There is evidence of cervical incompetence. There is no evidence of two or more accelerations in fetal heart rate in 20 min. There is no evidence of uteroplacental insufficiency. There are less than 3 uterine contractions in a 10-min period.

There is no evidence of uteroplacental insufficiency.

A nurse is assessing a newborn who has Trisomy 21 (Down's Syndrome). Which of the following are common characteristics? (Select all that apply.) Transverse palmar creases Large ears Muscular hypertonicity Protruding tongue Low birth weight

Transverse palmar creases Low birth weight

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? Variable decelerations are due to umbilical cord compression. Variable decelerations are caused by uteroplacental insufficiency. Variable decelerations are a result of the administration of IV narcotic analgesics. Variable decelerations are related to fetal head compression.

Variable decelerations are due to umbilical cord compression.

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? Vastus lateralis Ventrogluteal Dorsogluteal Deltoid

Vastus lateralis

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.) Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes Lidocaine gel to the umbilical stump Haemophilus influenza type b immunization (Hib)

Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect? Fetal heart rate 100/min Weakened uterine contractions Enhanced production of fetal lung surfactant Maternal blood glucose 63 mg/dL

Weakened uterine contractions