MCS AQ

In which location would the nurse expect the fundus to be palpated if involution is progressing as expected in a postpartum client 12 hours after birth?

1 cm above the umbilicus

Where would the nurse expect the fundus to be located on the second postpartum day?

1-2 fingerbreadths below the umbilicus

Which conclusion is indicated by a positive contraction stress test (CST)?

Late deceleration of the FHR are occurring with each contraction

Which additional nursing care is needed for the postpartum client after a cesarean birth due to her postsurgical status?

Administering the prescribed pain meds

A multiparous client with a hx of gestational HTN and previous hx of abruption is in the transition phase of labor. The electronic fetal monitor shows bradycardia, and a change is seen in the contour of the client's abd. Which is the nurse's immediate action?

Alerting staff to the need for immediate cesarean delivery

Which information in a postpartum client's health hx would alert the nurse to monitor the client for signs of infection?

Blood loss of 850mL after a vaginal birth

A client is admitted at 40 wks gestation with her cervix dilated 5cm and 100% effaced, the presenting part at station 0, and fetal heart tones heard just above the umbilicus. Which fetal presentation is indicated by these assessment findings?

Breech

The nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. Which changes would the nurse explain result from melanocyte stimulating hormone?

Chloasma Linea nigra

The nurse plans to delegate some of the tasks for the DC of a postpartum client to an unlicensed health care worker. Which activity must be performed by the nurse?

Comparing the ID bands of mother and infant

A client at 35 wks gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The nurse would direct the client to call back after which action?

Drink a glass of orange juice and time 10 fetal movements

Which fetal position would the nurses suspect when the fetal heartbeat is heard most distinctly in the upper left quadrant of the abd of the client in early labor

Left sacral anterior

When listening for the fetal heart, the nurses hears a beat at the rate of 136 in the RUQ of the client's abd and at the midline below the umbilicus. Which are the sources of these two sounds?

Funic souffle and FHR

Which factor puts a client at increased risk for postpartum hemorrhage?

Giving birth to a baby weighing 9lb 8oz

which is not a potential nutrition risk in pregnancy

HTN

The nurse is assessing a pregnant 16 y/o client. Which factors associated with adolescent pregnancy would the nurse consider when developing a plan of care for this client?

Higher rate of postpartum depression inappropriate dietary choices higher rate of anemia incomplete bone mass

Which assessment findings are suggestive of postpartum depression

Lethargy Ambivalence Emotional lability

Which assessment and interventions are needed once and epidural catheter has been inserted

Maintain IV fluid admin Have oxygen available in case of hypotension Check the bladder for distention Q2H Monitor FHR and labor progress per hospital protocol

Which action would the nurse take when a lab report indicates that a postpartum client being prepared for DC has aWBC count of 16,000/mm3

place the report in the client's record because this is an expected postpartum finding

Which problem predisposes a client to postpartum hemorrhage

Multifetal pregnancy

Which position of the fetus most often causes low back pain during labor

Occiput posterior

Which FHR pattern during labor would concern the nurse?

One that drops to 100 bpm after the peak of a contraction

Which cardiac disease has the lowest risk for maternal mortality

Patent dutus arteriosus

When planning care for a client with Type 1 DM, which change in insulin requirements would the nurse anticipate on the first post partum day?

Sudden decrease

Which sign would indicate possible heart failure in a client with heart disease in the immediate postpartum period?

Tachypnea

A primipara about to be DC's with her newborn asks the nurse many questions regarding infant care. Which phase of maternal adjustment does this behavior illustrate?

Taking-hold

Which info would be given to a client about her position while an internal fetal monitor is in place

The most comfortable position may be assumed

A client has a blood pressure of 90/50 during her first visit to the prenatal clinic. On a subsequent visit, at 34wks her bp is 120/76. Which would the nurse conclude might have caused the change

The possible development of preeclampsia

Which info would the nurse include in the discharge teaching of a postpartum client

The prenatal Kegel tightening exercises should be continued

A pregnant client asks how smoking will affect her baby. Which info about cigarette smoking will influence the nurse's response.

The resulting vasoconstriction affects both fetal and maternal blood vessels

For which reason is a client with worsening preeclampsia placed in a nonstimulating environment

To reduce the probability of tonic-clonic seizures

A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable and says she is going to vomit. Which phase of the first stage of labor does the nurse suspect the client has entered.

Transition

Which conditions increase the risk for postpartum hemorrhage?

Twin birth Overdistended bladder Retained placental fragments

The nurse is assessing a client with a tentative dx of hydatidiform mole. Which clinical finding would the nurse anticipate

Unusual uterine enlargement

a 16 y/o adolescent visits the prenatal clinic b/c she has missed three menstrual periods. Before her physical exam she says, "I don't know what the problem is, but I just can't be pregnant." Which is the nurse's most appropriate response

Why did you decide to come to the prenatal clinic

A client at 37 wks gestation is in the ED after a MVA. VS upon admission are 110/72 98. The client begins c/o sudden, sharp abd pain, and repeated VS are 90/60 108. Which nursing intervention is the priority at this time?

apply an electronic fetal monitor

A client states her husband is a fraternal twin and asks about her probability of having twins. Which is an appropriate response by the nurse

You have no greater probability of having twins than anyone else in the general population

Which nursing intervention would be indicated in the care of a client in the first stage of labor with the FHR baseline that was in the 150s and is now in the 130s with variability present?

Continuing to monitor the client

A client at her first visit to the prenatal clinic states that she has missed 3 periods and thinks that she is carrying twins because her abd is so large. She now has a brownish vaginal discharge. Her BP is increased, indicating that she may have gestational HTN. Which condition is suggested by this client profile

Hydatidiform mole

A client with gestation HTN is receiving education from the nurse in self care. Which instruction would the nurse give for this client

ensure adequate sodium intake

Which is the initial nursing action when a multipara requests something for pain

examining the client's cervix for dilation and effacement

Which clinical condition concerns the nurse the most for an OB client with heart disease

obesity, anemia, HTN, emotional distress

A client with preeclampsia has delivered and is receiving magnesium sulfate postpartum. Which nursing action is the priority during the immediate 4 hours after delivery?

observing amount of lochia

Which fetal heart tracing during labor can most likely result in fetal hypoxia and metabolic acidosis.

Recurrent late decelerations

Which are presumptive signs of pregnancy that the nurse would expect when assessing a client at 10 wks gestation?

Amenorrhea, breast changes, urinary frequency

A client who reports that she has been following the recommended pregnancy diet is dx with gestation HTN. Which instruction would the nurse give about her diet at this time.

Change nothing

The nurse applies fetal and uterine monitors to the abd of a client in active labor. When the client has contractions, the nurse notes a 15 bpm deceleration of the FHR below the baseline lasting 15 seconds. Which is the next nursing action

Changing maternal position

A client's membranes ruptured when her cervix is dilated to 7cm and the fetal head is at station +1. Which action would the nurse take in response to this situation

Check the FHR while observing the color of the amniotic fluid

During a nonstress test, the baseline FHR of 130-140 bpm rises to 160 twice and 157 once during a 20 minute period. Each of these episodes lasts 20 seconds. Which action would the nurse take

DC the test because the pattern is within the normal range

The nurse admits a client to the birthing unit at 40wks gestation and determines that her contractions are 10mins apart and her cervix is dilated 2cm Which stage of labor is the client in

Latent first stage

Which position increases cardiac output in the OB client with cardiac disease

Lateral positioning

a 37 y/o G3P2001 client with HTN and type 1 DM with good glycemic control is seen in the antepartum testing unit for a NST at 36 wks. Her OB hx includes an intrauterine fetal death at 38 wks. What risk factors in the client's hx indicate the need for an NST

age older than 35 the risk for placental insufficiency a hx of stillbirth from her last pregnancy HTN Type 1DM

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. Which nursing action will help relieve this discomfort

applying pressure against her sacrum

12 hours after a spontaneous birth a client's temperature is 100.4. which condition would the nurse suspect as the cause of the increase in temp?

dehydration

Which response would the nurse provide to a husband who is stating that his wife has been irritable and crying frequently after bringing her fourth child home from the hospital 3 weeks ago?

having 4 children is tiring, and assistance and assessment are needed

Which nursing action best promotes parent-infant attachment behaviors

keeping the new family together immediately after the birth

A client in active labor is 100% effaced, dilated cm and at +1 station. Which stage of labor has the client reached

first

Which action would the nurse take before birth when meconium staining is present

gathering equipment for neonatal resuscitation

Which are risk factors of DM in pregnancy

preterm birth, HTN, C-section

Which factor in a client's hx suggests a risk for preterm labor

multiple UTIs

Which complication is the result of type one DM in a pregnant client

increased risk of hypertensive states

The nurse is caring for a client whose fetus is in a breech presentation. The membranes rupture and meconium appears in the vaginal introitus. Which would the nurse recognize this indicates?

A common occurrence in breech presentation

a primigravida at 42 wks gestation has fluid leaking from her vagina and is complaining of back pain. Which conclusion is supported by the assessment data recorded

Cesarean birth is anticipated

Which response would the nurse give to a newly delivered client who asks to take the placenta home with her upon DC?

I need to check the hospital protocol for our policy on that practice

Which finding indicates a complication of the labor process in a client with a hx of T5 spinal cord injury

Increased BP

Which assessment findings support the conclusion that a client is entering the transition phase of the first stage of labor?

Increased bloody show, irritability, and shaking

Which is a potential cause of fetal tachycardia when a client is in active labor?

Increased maternal metabolism

The nurse who is admitting a newborn to the nursery observes a fetal scalp monitor site on the scalp. Which complication would the nurse monitor this newborn for?

Infection

Which intervention would the nurse question when caring for a client who has tested positive for HIV?

Internal fetal scalp electrode

The nurse concludes that the parents of a newborn with Erb's palsy have an accurate understanding of the infant's prognosis. Which statement made by the parents confirms this conclusion

Recovery usually occurs in about 3 months

After 6 hrs in labor a client is dilated 5 cm and at -1 station. In the next hour her contractions gradually become irregular and more uncomfortable. Which possibility would the nurse immediately consider

The client has a full bladder

A client in active labor is admitted to the birthing room. A vaginal exam reveals that her cervix is dilated 6-7 cm. In light of this finding, which would the nurse expect

The client's contractions will become longer and more frequent

Late FHR declerations begin to appear when a client's cervis is dilated 6cm and her contractions are occurring q4m and lasting 45 seconds. Which is the likely cause of these late declerations?

Uteroplacental insufficiency

Which type of lochia would the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?

moderate rubra

Which intervention becomes critical when a client's membranes spontaneously ruptures at 37 weeks and she has no contractions

monitor for fever

Which information would the nurse include when teaching a client experiencing a postterm pregnancy

monitor for signs of labor, perform daily fetal movement counts, go to the birthing facility soon after labor begins, call the PCP if the membranes rupture, keep appointments for fetal assessment tests and cervical checks

Which is correct regarding the safety of caffeinated beverages during pregnancy

one 12oz cup of coffee per day is probably fine; high consumption is often r/t a decrease in birth wt

The nurse in the postpartum unit is teaching self-care to a group of new mothers. Which color would the nurse teach them that the locial discharge will be on the fourth postpartum day?

pinkish brown

Late declerations are present on the monitor strip of a cline with an IV who received epidural anesthesia 20 mins ago. Which action would the nurse take immediately?

reposition the client from supine to left lateral

How would the nurse explain the cause of caput succedaneum in a newborn to the new mother

swelling of the soft tissue of the scalp as a result of pressure during labor

The nurse is teaching a childbirth preparation class regarding the discomforts of labor. Which condition has the greatest influence on the perception of pain for a woman in labor

tension of client