MN ATI CMS Quiz
A nurse in a health clinic is reviewing contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? A. "A water-soluble lubricant should be used with condoms." B. "A diaphragm should be removed 2 hours after intercourse." C. "Oral contraceptives can worsen a case of acne." D. "A contraceptive patch is replaced once a month."
A. "A water-soluble lubricant should be used with condoms."
A nurse is conducting a home visit for a client whois 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? A. "Apply cold compresses between feedings." B. "Take a warm shower right after feedings." C. "Apply breast milk to the nipples and allow them to air dry." D. "Use the various infant positions for feedings."
A. "Apply cold compresses between feedings."
A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? A. "It assists with blood clotting." B. "It promotes maturation of the bowel." C. "It is a preventative vaccine." D. "It provides immunity."
A. "It assists with blood clotting."
A nurse in a clinic is caring for a client who is postoperative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? A. "It is good to know that I won't have a tubal pregnancy in the future." B. "The doctor said that this surgery can affect my ability to get pregnant again." C. "I understand that one of my fallopian tubes had to be removed." D. "Ovulation can still occur because my ovaries were not affected."
A. "It is good to know that I won't have a tubal pregnancy in the future."
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? A. "They are tablets administered vaginally." B. "They act by absorbing fluid from tissues." C. "They promote dilation of the os." D. "They include an amniotomy."
A. "They are tablets administered vaginally."
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery."
A. "This is more commonly seen in newborns who have dark skin."
A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching? A. "Wear a supportive bra continuously for the first 72 hours." B. "Pump your breast every 4 hours to relieve discomfort." C. "Use breast shells throughout the day to decrease milk supply." D. "Apply warm compresses until milk suppression occurs."
A. "Wear a supportive bra continuously for the first 72 hours."
A nurse in a clinic is teaching a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Weight fluctuations can occur." B. "You are protected against STIs." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "Irregular vaginal spotting can occur."
A. "Weight fluctuations can occur." C. "You should increase your intake of calcium." E. "Irregular vaginal spotting can occur."
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position. B. Apply a fetal scalp electrode. C. Insert an IV catheter. D. Perform a vaginal exam.
A. Assist the client into the left-lateral position.
A nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? A. Betamethasone B. Indomethacin C. Nifedipine D. Methylergonovine
A. Betamethasone
A nurse is teaching a client who is at 6 weeksof gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (Select all that apply.) A. Breast tenderness B. Urinary frequency C. Epistaxis D. Dysuria E. Epigastric pain
A. Breast tenderness B. Urinary frequency C. Epistaxis
A nurse on the postpartum unit is assessing a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? (Select all that apply.) A. Calf tenderness to palpation B. Mottling of the affected extremity C. Elevated temperature D. Area of warmth E. Report of nausea
A. Calf tenderness to palpation C. Elevated temperature D. Area of warmth
A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse expect the provider will prescribe? A. Ceftriaxone B. Fluconazole C. Metronidazole D. Zidovudine
A. Ceftriaxone
A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3T1 P0 A1 L1. How should the nurse interpret this information? (Select all that apply.) A. Client has delivered one newborn at term. B. Client has experienced no preterm labor. C. Client has been through active labor. D. Client has had two prior pregnancies. E. Client has one living child.
A. Client has delivered one newborn at term. D. Client has had two prior pregnancies. E. Client has one living child.
A nurse in a prenatal clinic is providing education to a client who is at 8 weeks of gestation. The client states, "I don't like milk." Which of the following foods should the nurse recommend as a good source of calcium? A. Dark green leafy vegetables B. Deep red or orange vegetables C. White breads and rice D. Meat, poultry, and fish
A. Dark green leafy vegetables
A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply.) A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Postmaturity D. Placenta previa E. Amniotic fluid emboli
A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Postmaturity
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptationand parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those of family members E. Interprets the newborn's behavior as meaningful and a way of expressing needs
A. Demonstrates apathy when the newborn cries C. Views the newborn's behavior as uncooperative during diaper changing
A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? (Select all that apply.) A. Diabetes B. Multifetal pregnancy C. Maternal age greater than 40 D. Gestational trophoblastic disease E. Oligohydramnios
A. Diabetes B. Multifetal pregnancy D. Gestational trophoblastic disease
A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include? A. Eat crackers or plain toast before getting out of bed. B. Awaken during the night to eat a snack. C. Skip breakfast and eat lunch after nausea has subsided. D. Eat a large evening meal.
A. Eat crackers or plain toast before getting out of bed.
A nurse is caring for a client who is at 40 weeksof gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated,80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (Select all that apply.) A. Encourage use of patterned breathing techniques. B. Insert an indwelling urinary catheter. C. Administer opioid analgesic medication. D. Suggest application of cold. E. Provide ice chips.
A. Encourage use of patterned breathing techniques. C. Administer opioid analgesic medication. D. Suggest application of cold.
A nurse is discussing risks factors for urinary tract infections with a newly licensed nurse. Whichof the following conditions should the nurse include in the teaching? (Select all that apply). A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic examinations D. History of UTIs E. Vaginal birth
A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic examinations D. History of UTIs
A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? (Select all that apply.) A. Fatigue B. Insomnia C. Euphoria D. Flat affect E. Delusions
A. Fatigue B. Insomnia D. Flat affect
A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (Select all that apply.) A. Fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension
A. Fetal distress C. Vaginal bleeding D. Cervical dilation greater than 6 cm
A nurse is caring for a client who has been in labor for 12 hr with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? A. Fetal engagement B. Fetal lie C. Fetal attitude D. Fetal position
A. Fetal engagement
A nurse is caring for a client having contractions every 8 min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with a FHR around 140/min. Which of the following stages and phases of labor is this client experiencing? A. First stage, latent phase B. First stage, active phase C. First stage, transition phase D. Second stage of labor
A. First stage, latent phase
A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? (Select all that apply.) A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus beta-hemolytic E. TORCH infection
A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus beta-hemolytic
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. Hands and knees B. Lithotomy C. Trendelenburg D. Supine with a rolled towel under one hip
A. Hands and knees
A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (Select all that apply.) A. Hypospadias B. Hydrocele C. Family history of hemophilia D. Hyperbilirubinemia E. Epispadias
A. Hypospadias C. Family history of hemophilia E. Epispadias
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. Increasing pulse and decreasing blood pressure B. Dizziness and increasing respiratory rate C. Cool, clammy skin, and pale mucous membranes D. Altered mental status and level of consciousness
A. Increasing pulse and decreasing blood pressure
A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15
A. January 8
A nurse in an antepartum clinic is assessing a clientwho has a TORCH infection. Which of the following findings should the nurse expect? (Select all that apply.) A. Joint pain B. Malaise C. Rash D. Urinary frequency E. Tender lymph nodes
A. Joint pain B. Malaise C. Rash E. Tender lymph nodes
A nurse is called to the birthing room to assist with the assessment of a newborn who was born at32 weeks of gestation. The newborn's birth weight is 1,100 g. Which of the following are expected findings in this newborn? (Select all that apply.) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face
A. Lanugo C. Weak grasp reflex D. Translucent skin
A nurse is caring for a client in the third stage of labor. Which of the following findings indicate placental separation? (Select all that apply.) A. Lengthening of the umbilical cord B. Swift gush of clear amniotic fluid C. Softening of the lower uterine segment D. Appearance of dark blood from the vagina E. Fundus firm upon palpation
A. Lengthening of the umbilical cord D. Appearance of dark blood from the vagina E. Fundus firm upon palpation
Anurseisperformingafundalassessmentforaclient who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. Moderate lochia rubra B. Excessive lochia serosa C. Light lochia rubra D. Scant lochia serosa
A. Moderate lochia rubra
A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/ min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following? (Select all that apply.) A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia
A. Moderate variability B. FHR accelerations D. Normal baseline FHR
A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? (Select all that apply.) A. Occupation B. Menstrual history C. Childhood infectious diseases D. History of falls E. Recent blood transfusions
A. Occupation B. Menstrual history C. Childhood infectious diseases
A nurse is caring for a client who is 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnioinfusion? (Select all that apply.) A. Oligohydramnios B. Hydramnios C. Fetal cord compression D. Hydration E. Fetal immaturity
A. Oligohydramnios C. Fetal cord compression
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate
A. Oxygen saturation
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Precipitous delivery B. Obesity C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments
A. Precipitous delivery C. Inversion of the uterus E. Retained placental fragments
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. Preeclampsia B. Thrombophlebitis C. Placenta previa D. Hyperemesis gravidarum
A. Preeclampsia
A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing,and a vaginal delivery is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? A. Pudendal B. Epidural C. Spinal D. Paracervical
A. Pudendal
A nurse is administering magnesium sulfate IVfor seizure prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.) A. Respirations less than 12/min B. Urinary output less than 25 mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased level of consciousness E. Flushing and sweating
A. Respirations less than 12/min B. Urinary output less than 25 mL/hr D. Decreased level of consciousness
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? A. Staphylococcus aureus B. Chlamydia trachomatis C. Klebsiella pneumonia D. Clostridium perfringens
A. Staphylococcus aureus
A nurse is caring for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of this condition? (Select all that apply). A. Urinary tract infection B. Multifetal pregnancy C. Oligohydramnios D. Diabetes mellitus E. Uterine abnormalities
A. Urinary tract infection B. Multifetal pregnancy D. Diabetes mellitus E. Uterine abnormalities
A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information shouldthe nurse include? (Select all that apply.) A. Use a perineal squeeze bottle to cleanse the perineum. B. Sit on the perineum while resting in bed. C. Apply a topical anesthetic cream or spray to the perineum. D. Wipe the perineum thoroughly with a back-and-forth motion. E. Apply cold or ice packs to the perineum.
A. Use a perineal squeeze bottle to cleanse the perineum. C. Apply a topical anesthetic cream or spray to the perineum. E. Apply cold or ice packs to the perineum.
A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? (Select all that apply.) A. Vacuum extractor B. Oxytocin infusion C. Forceps D. Cesarean birth E. Internal fetal monitoring
A. Vacuum extractor C. Forceps E. Internal fetal monitoring
A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following complications should the nurse include? A. Vaginal bleeding B. Swelling of the ankles C. Heartburn after eating D. Lightheadedness when lying on back
A. Vaginal bleeding
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I will need to use contraception for 3 months before considering pregnancy." B. "I need a second vaccination at my postpartum visit." C. "I was given the vaccine because my baby is O-positive." D. "I will be tested in 3 months to see if I have developed immunity."
B. "I need a second vaccination at my postpartum visit."
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Whichof the following statements should thenurse include? (Select all that apply.) A. "It is considered a noninvasive procedure." B. "It can detect abnormal fetal heart tones early." C. "It can determine the amount of amniotic fluid you have." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity."
B. "It can detect abnormal fetal heart tones early." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity."
A client who is at 8 weeks of gestation tells the nurse "I am not sure I am happy about being pregnant." Which of the following responses should the nurse make? A. "I will inform the provider that you are having these feelings." B. "It is normal to have these feelings during the first few months of pregnancy." C. "You should be happy that you are going to bring new life into the world." D. "I am going to make an appointment with the counselor for you to discuss these thoughts."
B. "It is normal to have these feelings during the first few months of pregnancy."
A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? A. "The newborn will have decreased muscle tone." B. "The newborn will have a continuous high-pitched cry." C. "The newborn will sleep for 2 to 3 hours after a feeding." D. "The newborn will have mild tremors when disturbed."
B. "The newborn will have a continuous high-pitched cry."
A nurse is caring for a client who is 2 days postpartum. The client states, "My 4-year oldson was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training pants." B. "Your son is showing an adverse sibling response." C. "Your son may need counseling." D. "You should try sending your son to preschool to resolve the behavior."
B. "Your son is showing an adverse sibling response."
A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? A. 1.8 kg (4 lb) weight gain and is in the first trimester B. 3.6 kg (8 lb) weight gain and is in the first trimester C. 6.8 kg (15 lb) weight gain and is in the second trimester D. 11.3 kg (25 lb) weight gain and is in the third trimester
B. 3.6 kg (8 lb) weight gain and is in the first trimester
A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration B. A client who does not wash their hands between perineal care and breastfeeding C. A client who is not breastfeeding and is using measures to suppress lactation D. A client who has a cesarean incision that is well-approximated with no drainage
B. A client who does not wash their hands between perineal care and breastfeeding
A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? A. A client who experienced a precipitous labor less than 3 hr in duration B. A client who had premature rupture of membranes and prolonged labor C. A client who delivered a large for gestational age infant D. A client who had a boggy uterus that was not well-contracted
B. A client who had premature rupture of membranes and prolonged labor
A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? A. A client whose sister has alopecia B. A client whose partner has von Willebrand disease C. A client who has an allergy to sulfa D. A client who had rubella 3 months ago
B. A client whose partner has von Willebrand disease
A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states, "My water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A. Place the client in the Trendelenburg position. B. Apply pressure to the presenting part with the fingers. C. Administer oxygen at 10 L/min via a face mask. D. Initiate IV fluids.
B. Apply pressure to the presenting part with the fingers.
A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age
B. Appropriate for gestational age
A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed. B. Ask the client if they have thoughts of harming themselves or their infant. C. Monitor the infant for indications of failure to thrive. D. Review the client's medical record for a history of bipolar disorder.
B. Ask the client if they have thoughts of harming themselves or their infant.
A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? A. Spits up clear mucus B. Attempts to place their hand in their mouth C. Turns the head toward sounds D. Lies quietly with their eyes open
B. Attempts to place their hand in their mouth
A nurse is providing care for a client who hasa marginal abruptio placentae. Which of the following findings are risk factors for developing the condition? (Select all that apply.) A. Fetal position B. Blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking
B. Blunt abdominal trauma C. Cocaine use E. Cigarette smoking
A nurse is caring for a client who is 40 weeks of gestation and reports having large gush of fluid from the vagina while walking from the bathroom. Which of the following actions should the nurse take first? A. Examine the amniotic fluid for meconium. B. Check the FHR. C. Dry the client and make them comfortable. D. Apply a tocotransducer.
B. Check the FHR.
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? (Select all that apply.) A. Paranoia that their infant will be harmed B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a parent D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a parent
B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a parent D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a parent
A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? A. Blood-tinged sputum B. Dizziness C. Pallor D. Somnolence
B. Dizziness
A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? A. Frequency of every 2 min B. Duration of 90 to 120 seconds C. Intensity of 60 to 90 mm Hg D. Resting tone of 15 mm Hg
B. Duration of 90 to 120 seconds
A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device." The nurse should suspect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole
B. Ectopic pregnancy
A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (Select all that apply.) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Fetal position E. Amniotic fluid volume
B. Fetal breathing movement C. Fetal tone E. Amniotic fluid volume
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the clientwill not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? A. Come back later when the client is more cooperative. B. Give the client time to express feelings. C. Tell the client they need to be quiet so the assessment can be completed. D. Redirect the client's focus so that they will become quiet.
B. Give the client time to express feelings.
A nurse is reviewing the health record of a client whois pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (Select all that apply.) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening
B. Goodell's sign C. Ballottement D. Chadwick's sign
A nurse is reviewing the medical record of a client who is to undergo hysterosalpingography. Which of the following data alert the nurse that the client is at risk for a complication related to this procedure? A. Vital signs B. History and physical C. Laboratory findings D. Medications
B. History and physical
A nurse is completing an admission assessment fora client who is 39 weeks of gestation and reportsfluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing? A. Cord prolapse B. Infection C. Postpartum hemorrhage D. Hydramnios
B. Infection
A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (Select all that apply.) A. Tinnitus B. Irregular vaginal bleeding C. Weight gain D. Nausea E. Gingival hyperplasia
B. Irregular vaginal bleeding C. Weight gain D. Nausea
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of thefollowing tests to assess fetal lung maturity? A. Alpha-fetoprotein (AFP) B. Lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. Indirect Coombs' test
B. Lecithin/sphingomyelin (L/S) ratio
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus. C. Grasp lower uterine segment between thumb and fingers. D. Stand facing client's feet with fingertips outlining cephalic prominence.
B. Palpate the fundus of the uterus.
A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A. Assist the client to the bathroom. B. Prepare for an impending delivery. C. Prepare to remove a fecal impaction. D. Encourage the client to take deep, cleansing breaths.
B. Prepare for an impending delivery.
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? A. Prolonged labor B. Reduced fetal oxygen supply C. Delayed cervical dilation D. Increased maternal stress
B. Reduced fetal oxygen supply
A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? A. Abdominal effleurage B. Sacral counterpressure C. Showering if not contraindicated D. Back rub and massage
B. Sacral counterpressure
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony? A. Poor involution B. Urinary retention C. Hemorrhage D. Infection
B. Urinary retention
A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase 20 IU/L D. Blood glucose 114 mg/dL
B. Urine ketones present
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. "Limit the amount of time the infant nurses on each breast." B. "Nurse the infant only on the unaffected breast until resolved." C. "Completely empty each breast at each feeding or use a pump." D. "Wear a tight-fitting bra until lactation has ceased."
C. "Completely empty each breast at each feeding or use a pump."
A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I will take this pill with my breakfast." B. "I will take this medication with a glass of milk." C. "I plan to drink more orange juice while taking this pill." D. "I plan to add more calcium-rich foods to my diet while taking this medication."
C. "I plan to drink more orange juice while taking this pill."
A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. "The circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form." C. "I will clean the penis with each diaper change." D. "I will give him a tub bath within a couple of days."
C. "I will clean the penis with each diaper change."
A nurse is reviewing discharge teaching with aclient who has a urinary tract infection. Which ofthe following statements by the client indicates understanding of the teaching? (Select all that apply.) A. "I will perform perineal care and apply a perineal pad in a back-to-front direction." B. "I will drink grape juice to make my urine more acidic." C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." D. "I will go back to breastfeeding after I have finished taking the antibiotic." E. "I will take Tylenol for any discomfort."
C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." E. "I will take Tylenol for any discomfort."
A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make? A. "It is needed to promote increased urine output." B. "It is needed to counteract respiratory depression." C. "It is needed to counteract hypotension." D. "It is needed to prevent oligohydramnios."
C. "It is needed to counteract hypotension."
A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? A. "You will need to see a genetic counselor as part of the assessment." B. "It is usually the female who is having trouble, so the male doesn't have to be involved." C. "The male is the easiest to assess, and the provider will usually begin there." D. "Think about adopting first because there are many babies that need good homes."
C. "The male is the easiest to assess, and the provider will usually begin there."
A nurse is caring for a client and partner during the second stage of labor. The client's partner asks the nurse to explain how to know when crowning occurs. Which of the following responses should the nurse make? A. "The placenta will protrude from the vagina." B. "Your partner will report a decrease in the intensity of contractions." C. "The vaginal area will bulge as the baby's head appears." D. "Your partner will report less rectal pressure."
C. "The vaginal area will bulge as the baby's head appears."
A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodesof maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A. "This is due to an increase in blood volume." B. "This is due to pressure from the uterus on the diaphragm." C. "This is due to the weight of the uterus on the vena cava." D. "This is due to increased cardiac output."
C. "This is due to the weight of the uterus on the vena cava."
A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? A. "You will lay on your right side during the procedure." B. "You should not eat anything for 24 hours prior to the procedure." C. "You should empty your bladder prior to the procedure." D. "The test is done to determine gestational age."
C. "You should empty your bladder prior to the procedure."
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow
C. A normal postural discharge of lochia
A nurse is completing an assessment. Which of the following data indicate the newborn is adaptingto extrauterine life? (Select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing
C. Apnea for 10-second periods D. Obligatory nose breathing
A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement? A. Apply Gelfoam powder to the site. B. Place the newborn in the prone position. C. Apply petroleum gauze to the site. D. Avoid changing the diaper until the first voiding.
C. Apply petroleum gauze to the site.
A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? A. Front seat, rear-facing B. Front seat, forward-facing C. Back seat, rear-facing D. Back seat, forward-facing
C. Back seat, rear-facing
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone
C. Erythromycin
A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation
C. Evaporation
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea; vomiting; and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor
C. Hydatidiform mole
A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. Burp the newborn at the end of the feeding. B. Hold the newborn close in a supine position. C. Keep the nipple full of formula throughout the feeding. D. Refrigerate any unused formula.
C. Keep the nipple full of formula throughout the feeding.
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A. Sit-ups B. Pelvic tilt exercises C. Kegel exercises D. Abdominal crunches
C. Kegel exercises
A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? A. Ask the parent to state their full name. B. Look at the name on the newborn's bassinet. C. Match the parent's identification band with the newborn's band. D. Compare name on the bassinet and room number.
C. Match the parent's identification band with the newborn's band.
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A. Intrauterine growth restriction B. Hyperglycemia C. Meconium aspiration D. Polyhydramnios
C. Meconium aspiration
A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (Select all that apply.) A. Avoid any lifting. B. Perform Kegel exercises twice a day. C. Perform the pelvic rock exercise every day. D. Use proper body mechanics. E. Avoid constrictive clothing.
C. Perform the pelvic rock exercise every day. D. Use proper body mechanics.
A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use a disinfectant wipe to clean the lid of the formula can. B. Store prepared formula in the refrigerator for up to 72 hr. C. Place used bottles in the dishwasher. D. Check the nipple for appropriate flow of formula. E. Use tap water to dilute concentrated formula.
C. Place used bottles in the dishwasher. D. Check the nipple for appropriate flow of formula. E. Use tap water to dilute concentrated formula.
A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version? A. Prostaglandin gel B. Magnesium sulfate C. Rho(D) immune globulin D. Oxytocin
C. Rho(D) immune globulin
A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Increased appetite
C. Shortness of breath
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings? A. Scant, nonodorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipple with cracks and fissures D. Decreased response with sexual activity
C. Sore nipple with cracks and fissures
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash
C. Sunken fontanels
A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? A. Second stage B. Fourth stage C. Transition phase D. Latent phase
C. Transition phase
A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? A. "Obtain an immunization against rubella early in pregnancy." B. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy." C. "A client should avoid crowded places during pregnancy." D. "A client should avoid consuming undercooked meat while pregnant."
D. "A client should avoid consuming undercooked meat while pregnant."
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hr. Which of the following statements should the nurse make? A. "A full bladder increases the risk for fetal trauma." B. "A full bladder increases the risk for bladder infections." C. "A distended bladder will be traumatized by frequent pelvic exams." D. "A distended bladder reduces pelvic space needed for birth."
D. "A distended bladder reduces pelvic space needed for birth."
A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam." B. "I cannot get an IUD until after I've had a child." C. "I should plan on regaining fertility 5 months after the IUD is removed." D. "I will check to be sure the strings of the IUD are still present after my periods."
D. "I will check to be sure the strings of the IUD are still present after my periods."
A nurse is reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? A. "I am glad I can have my morning coffee." B. "I should take folic acid to increase my milk supply." C. "I will continue adding 330 calories per day to my diet." D. "I will continue my calcium supplements because I don't like milk."
D. "I will continue my calcium supplements because I don't like milk."
A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? A. "It is used to stimulate uterine contractions." B. "It will decrease the incidence of uterine contractions." C. "It lulls the fetus to sleep." D. "It awakens a sleeping fetus."
D. "It awakens a sleeping fetus."
A nurse in a clinic receives a phone call from a client who would like to be tested in the clinicto confirm a pregnancy. Which of the following information should the nurse provide to the client? A. "You should wait until 4 weeks after conception to be tested." B. "You should be off any medications for 24 hours prior to the test." C. "You should be NPO for at least 8 hours prior to the test." D. "You should collect urine from the first morning void."
D. "You should collect urine from the first morning void."
A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? A. "Your baby will have excess body fat." B. "Your baby will have flat areola without breast buds." C. "Your baby's heels will easily move to his ears." D. "Your baby's skin will have a leathery appearance."
D. "Your baby's skin will have a leathery appearance."
A nurse is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin C. Nifedipine D. Betamethasone
D. Betamethasone
A nursing is caring for a client who is receivingIV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine B. Pyridoxine C. Ferrous sulfate D. Calcium gluconate
D. Calcium gluconate
A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving a vitamin K injection D. Covering the newborn's head with a cap
D. Covering the newborn's head with a cap
A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss? A. Over-the-shoulder B. Supine C. Chin-supported D. Cradle
D. Cradle
A nurse is planning care for a newly admitted client who reports, "I am in labor and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? A. Inspect the introitus for a prolapsed cord. B. Perform a test to identify the ferning pattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.
D. Defer vaginal examinations.
A nurse is completing a newborn assessmentand observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls
D. Epstein's pearls
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.
A nurse is reviewing discharge teaching with aclient who has premature rupture of membranesat 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? A. Use a condom with sexual intercourse. B. Avoid bubble bath solution when taking a tub bath. C. Wipe from the back to front when performing perineal hygiene. D. Keep a daily record of fetal kick counts.
D. Keep a daily record of fetal kick counts.
A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? A. Cover the cord with a small gauze square. B. Trickle clean water over the cord with each diaper change. C. Apply hydrogen peroxide to the cord twice a day. D. Keep the diaper folded below the cord.
D. Keep the diaper folded below the cord.
A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. Apply cold compresses to the affected extremity. B. Massage the affected extremity. C. Allow the client to ambulate. D. Measure leg circumferences.
D. Measure leg circumferences.
A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? A. Iron deficiency anemia B. Poor bone formation C. Macrosomic fetus D. Neural tube defects
D. Neural tube defects
A nurse is reviewing a new prescription for iron supplements with a client who is at 8 weeks of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with? A. Ice water B. Low-fat or whole milk C. Tea or coffee D. Orange juice
D. Orange juice
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which ofthe following actions should the nurse take? A. Administer oxygen via nasal cannula at 2 L/min. B. Apply a warm blanket. C. Assist the client to a side-lying position. D. Place an oxygen mask over the client's nose and mouth.
D. Place an oxygen mask over the client's nose and mouth.
A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. Encourage the parents to touch and explore the neonate's features. B. Limit noise and interruption in the delivery room. C. Place the neonate at the client's breast. D. Position the neonate skin-to-skin on the client's chest.
D. Position the neonate skin-to-skin on the client's chest.
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? A. Postpartum fatigue B. Postpartum psychosis C. Letting-go phase D. Postpartum blues
D. Postpartum blues
A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. Precipitous labor B. Premature rupture of membranes C. Postmaturity syndrome D. Prolapsed umbilical cord
D. Prolapsed umbilical cord
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? A. Hand the parent the newborn, and suggest that they change the diaper. B. Ask the parent why they are so anxious and nervous. C. Tell the parent that they will grow accustomed to the newborn. D. Provide education about infant care when the parent is present.
D. Provide education about infant care when the parent is present.
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions
D. Relaxation between uterine contractions
A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition? A. No alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus C. Blood progesterone greater than the expected reference range D. Report of severe shoulder pain
D. Report of severe shoulder pain
A client calls a provider's office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing? A. Braxton Hicks contractions B. Rupture of membranes C. Fetal descent D. True contractions
D. True contractions
A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicates understanding of the teaching? A. The parent places a few drops of water on their nipple before feeding. B. The parent gently removes their nipple from the infant's mouth to break the suction. C. When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger. D. When latched on, the infant's nose, cheek, and chin are touching the breast.
D. When latched on, the infant's nose, cheek, and chin are touching the breast.
