Mod 6-11 Practice

A nurse is caring for a pregnant client with preeclampsia. She is at the bedside and notes that the client has now progressed to eclampsia. What would be the nurse​'s first​ priority? 1. Administer oxygen by mask. 2. Assess BP and fetal heart rate. 3. Maintain an open airway. 4. Administer magnesium sulfate IV.

1. Administer oxygen by mask. A patent airway is the immediate action when someone is having a seizure. When the client progresses from preeclampsia to eclampsia a seizure is involved. The other options are all actions that would be​ done, but maintaining a patent airway is the priority concern.

A nurse is caring for a pregnant client who is being monitored for gestational hypertension. Which assessment finding indicates a worsening of gestational hypertension and the need to notify the health care​ provider? 1. Complaints of blurred vision and a headache 2. Edema​ 2+ 3. Urine output has increased. 4. Blood pressure is​ 140/90.

1. Complaints of blurred vision and a headache

A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.

1. Confusion, drowsiness, and vomiting.

A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has just been weighed in the newborn nursery. The nurse determines that the baby has lost 3.5% of the birth weight. Which of the following nursing actions is appropriate? 1. Do nothing because this is a normal weight loss. 2. Notify the neonatologist of the significant weight loss. 3. Advise the mother to bottle feed the baby at the next feed. 4. Assess the baby for hypoglycemia with a glucose monitor.

1. Do nothing because this is a normal weight loss. The baby has lost less than 4% of its birth weight. Babies often lose between 5% and 10% of their birth weight. A loss greater than 10% is considered pathological. neonates lose weight after birth and that the weight loss is not considered pathological unless it exceeds 10%.

The nurse is discussing the neonatal blood screening test with a new mother. The nurse knows that the teaching was successful when the mother states that the test screens for the presence in the newborn of which of the following? select all that apply 1. Hypothyroidism 2. Sickle cell disease 3. Galactosemia 4. Cerebral palsy 5. Cystic fibrosis

1. Hypothyroidism 2. Sickle cell disease 3. Galactosemia 5. Cystic fibrosis Cerebral palsy is a disorder characterized by motor dysfunction resulting from a non progressive injury to brain tissue that may occur during preg, labor, delivery or shortly after delivery and blood screening is not diagnostic.

The nurse auscultates a fetal heart rate of 152 on a client in early labor. Which of the following actions by the nurse is appropriate? 1.Inform the mother that the rate is normal. 2.Reassess in 5 minutes to verify the results. 3.Immediately report the rate to the health care practitioner. 4.Place the client on her left side and apply oxygen by face mask.

1. Inform the mother that the rate is normal.

The labor and delivery nurse performs Leopold's maneuvers. A soft round mass is felt in the fundal region. A flat object is noted on the left and small objects are noted on the right of the uterus. A hard round mass is noted above the symphysis. Which of the following positions is consistent with these findings? 1. Left occipital anterior (LOA) 2. Left sacral posterior (LSP) 3. Right mentum anterior (RMA) 4. Right sacral posterior (RSP)

1. Left occipital anterior (LOA)

To reduce the risk of hypoglycemia in a full-term newborn weighing 2,900 grams, what should the nurse do? 1. Maintain the infant's temperature above 97.7°F. 2. Feed the infant glucose water every 3 hours until breastfeeding well. 3. Assess blood glucose levels every 3 hours for the first twelve hours. 4. Encourage the mother to breastfeed every 4 hours.

1. Maintain the infant's temperature above 97.7°F. Hypothermia in the neonate is defined as a temperature below 97.7°F. Cold stress syndrome may develop if the baby's temperature is below that level. It is important for the student to know that a baby weighing 2900 grams is an average sized baby (range 2500-4000 g). Hypoglycemia can result when a baby develops cold stress syndrome because babies must metabolize food to create heat. When they use up their food stores, they become hypoglycemic.

A woman admitted to the hospital with a diagnosis of possible ectopic pregnancy is presenting with abdominal pain and vaginal spotting for the past 24 hours. In reviewing her medical history the nurse knows that which of the following factors may be associated with ectopic​ pregnancy? 1. Previously diagnosed with pelvic inflammatory disease​ 2. Age younger than 20 years 3. Recurrent spontaneous abortions 4. Multiparity

1. Previously diagnosed with pelvic inflammatory disease​

Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings

1. Put the client in the knee chest position.

A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first? 1. Remove wet blankets. 2. Assess Apgar score. 3. Insert eye prophylaxis. 4. Elicit the Moro reflex.

1. Remove wet blankets.

While evaluating the fetal heart monitor tracing on a client in labor, the nurse notes that there are fetal heart decelerations present. Which of the following assessments must the nurse make at this time? 1. The relationship between the decelerations and the labor contractions. 2. The maternal blood pressure. 3. The gestational age of the fetus. 4. The placement of the fetal heart electrode in relation to the fetal position

1. The relationship between the decelerations and the labor contractions.

When caring for a laboring patient with oligohydramnios, the nurse should be aware that: (Select all that apply) 1. There is an increased risk of cord compression. 2. Respiratory support personnel should be standing by at the birth. 3. Labor progress is often more rapid than average. 4. Early decelerations are more likely. 5. During gestation, fetal skin and skeletal abnormalities can occur.

1. There is an increased risk of cord compression. 2. Respiratory support personnel should be standing by at the birth. 4. Early decelerations are more likely. 5. During gestation, fetal skin and skeletal abnormalities can occur.

A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? 1. Tightly swaddle the baby. 2. Place the baby prone in the crib. 3. Provide needed stimulation to the baby. 4. Feed the baby half-strength formula.

1. Tightly swaddle the baby Tightly swaddling drug-addicted babies often helps to control the hyperreflexia that they may exhibit.

A client, 38 weeks' gestation, is being induced with IV oxytocin (Pitocin) for hyper-tension and oligohydramnios. She is contracting every 3 min for 60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. Turn off the oxytocin infusion. 2. Administer oxygen via face mask. 3. Reposition the patient. 4. Call the obstetrician

1. Turn off the oxytocin infusion.

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1. Type O negative ABO incompatibility can = hemolytic jaundice which can arise when the MOM IS type O and the baby is either type A or type B.

A nurse is caring for a laboring woman who is in transition. Which of the following signs/symptoms would indicate that the woman is progressing into the second stage of labor? Select all that apply. 1.Bulging perineum. 2.Increased bloody show. 3.Spontaneous rupture of the membranes. 4.Uncontrollable urge to push. 5.Inability to breathe through contractions

1.Bulging perineum. 2.Increased bloody show. 4.Uncontrollable urge to push.

The patient has undergone an ultrasound, which estimated fetal weight at 4500 g (9 pounds 14 ounces). Which statement indicates that additional teaching is needed? 1. "I am at risk for excessive bleeding after delivery." 2. "His blood sugars could be high after he is born." 3. "My perineum could experience trauma during the birth." 4. "His shoulders could get stuck and a collarbone broken."

2. "His blood sugars could be high after he is born."

A woman is in the transition phase of labor. Which of the following comments should the nurse expect to hear? 1. "I am so excited to be in labor." 2. "I can't stand this pain any longer!" 3. "I need ice chips because I'm so hot." 4. "I have to push the baby out right now!"

2. "I can't stand this pain any longer!"

A baby has just been admitted into the neonatal nursery. Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following? 1. Evaporation. 2. Conduction. 3. Radiation. 4. Convection.

2. Conduction.

Immediately following administration of an epidural anesthesia, the nurse must monitor the mother for which of the following? 1. Paresthesias in her feet and legs. 2. Drop in blood pressure. 3. Increase in central venous pressure. 4. Fetal heart accelerations

2. Drop in blood pressure.

Which of the following physical findings would lead the nurse to suspect that a client with severe preeclampsia has developed HELLP syndrome? 1. +3 pitting edema and pulmonary edema. 2. Epigastric pain and systemic jaundice. 3. +4 deep tendon reflexes and clonus. 4. Oliguria and elevated specific gravity

2. Epigastric pain and systemic jaundice. Epigastric pain and jaundice are reflective of hemolysis of red blood cells and of severe liver damage. These symptoms should make the nurse suspect HELLP syndrome.

A gravid client, G3 P2002, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to move her bowels. Which of the following actions should the nurse perform first? 1. Offer the client the bedpan 2. Evaluate the progress of labor. 3. Notify the physician. 4. Encourage the patient to push

2. Evaluate the progress of labor.

A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? 1. Contraction pattern is every 3 min x 60 sec. 2. Fetal monitor tracing shows late decelerations. 3. Client sleeps between contractions. 4. The blood pressure is 150/90

2. Fetal monitor tracing shows late decelerations.

A fetal weight is estimated at 4490 grams in a gravida 1 at 38 weeks' gestation. Counseling should occur before labor regarding the: 1. Mother's undiagnosed diabetes. 2. Likelihood of a cesarean delivery. 3. Effectiveness of epidural anesthesia with a large fetus. 4. Need for early delivery.

2. Likelihood of a cesarean delivery.

The nurse is making a plan of care for a client with severe preeclampsia. One of the complications is HELLP syndrome. Which of the following laboratory values would indicate the patient has gone into HELLP ​syndrome? Select all that apply. 1. Low liver enzymes 2. Low platelets 3. Low hematocrit 4. Elevated liver enzymes 5. Low hemoglobin

2. Low platelets 3. Low hematocrit 4. Elevated liver enzymes

A nurse is writing a plan of care for a client at 34 weeks gestation with a placenta partially covering the cervical os. The plan of care includes which of the ​following? (Select all that apply) 1. Assessing for severe unilateral abdominal pain 2. Ensuring there are no vaginal exams 3. Bed rest with bathroom privileges 4. Checking urine for protein levels 5. Assess uterine tone

2. No vaginal exams 3. Bed rest with bathroom privaledges 5. Assess uterine tone Putting the client on bed rest will give the fetus more time to mature and decrease the pressure of the fetus on the cervical os to decrease any bleeding the client may be having. Doing a vaginal exam would increase bleeding and possibly put the client into preterm labor. If the uterus becomes​ hard, it is a good indication that the placenta is separating away from the wall of the uterus.

A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is "purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following? 1. Petechiae are indicative of severe bacterial infections. 2. Rapid deliveries can injure the neonatal presenting part. 3. Petechiae are characteristic of the normal newborn rash. 4. The injuries are a sign that the child has been abused.

2. Rapid deliveries can injure the neonatal presenting part

A patient was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. The assessment data that would be most beneficial is: 1. Blood pressure 2. Temperature 3. Pulse 4. Respiration

2. Temperature

The nurse notes that a newborn, who is 5 minutes old, exhibits the following characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is? 1. 6 2. 7 3. 8 4. 9

3. 8 2 for heart rate, 2 for respiratory rate, 1 for color, 2 for reflex irritability, 1 for flexion. The total is 8.

This hormone acts similar to oxytocin and is released in response to the mother being dehydrated: 1. FSH 2. LH 3. ADH 4. Estrogen

3. ADH Both are secreted from posterior pituitary. You do not want a mother in PTL to be dehydrated because ADH has similar properties to oxytocin

When monitoring a fetal heart rate with moderate variability, the nurse notes V-shaped decelerations to 80 from a baseline of 120. One occurred during a contraction while another occurred 10 seconds after the contraction and a third occurred 40 seconds after yet another contraction. The nurse interprets these findings as resulting from which of the following? 1. Metabolic acidosis. 2. Head compression. 3. Cord compression. 4. Insufficient uteroplacental blood flow

3. Cord compression. The contractions described in the scenario are variable decelerations and result from cord compression

An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the procedure? 1. Maternal blood pressure. 2 .Maternal pulse. 3. Fetal heart rate. 4. Fetal fibronectin level.

3. Fetal heart rate

The labor nurse has just received shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 gm/dL. 2. G2P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. 4. G2P1001, 39 weeks, Rh negative, today's hematocrit 31%

3. G1P0000, 32 weeks, placental abruption, fetal heart (15 minutes ago) 120 bpm. A placental abruption is a life threatening situation for the fetus. It has been 15 minutes since the fetal heart was assessed. This is the nurse's priority

A multigravida client at 12 weeks gestation comes to the clinic reporting that she is experiencing severe morning sickness and that she​ "has not been able to keep anything down for 6​ days." The nurse should assess for the signs and symptoms of which of the​ following? 1. Hypercalcemia 2. Hyperglycemia 3. Hypokalemia 4. Hypobilirubinemia

3. Hypokalemia

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48%. 2. Potassium 5.5 mEq/L. 3. Platelets 75,000. 4. Sodium 130 mEq/L

3. Platelets 75,000

A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold's maneuver results. 2 .Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure

3. Presence of abdominal pain.

A nurse has just performed a vaginal examination on a client in labor. The nurse palpates the baby's buttocks as facing the mother's right side. Where should the nurse place the external fetal monitor electrode? 1.Left upper quadrant (LUQ). 2.Left lower quadrant (LLQ). 3.Right upper quadrant (RUQ). 4.Right lower quadrant (RLQ)

3. Right upper quadrant (RUQ).

While performing Leopold's maneuvers on a woman in labor, the nurse palpates a hard round mass in the fundal area, a flat surface on the left side, small objects on the right side, and a soft round mass just above the symphysis. Which of the following is a reasonable conclusion by the nurse? 1. The fetal position is transverse. 2. The fetal presentation is vertex. 3. The fetal lie is vertical. 4. The fetal attitude is flexed.

3. The fetal lie is vertical.

A delirious patient is admitted to the hospital in labor. She has had no prenatal care and cocaine is found in her pockets. The nurse monitors this client carefully for which of the following intrapartal complications? 1. Prolonged labor. 2. Prolapsed cord. 3. Abruptio placentae. 4. Retained placenta

3.Abruptio placentae.

A laboring client is complaining of severe back pain. Which of the following nursing interventions would be most effective? 1.Assist mother with childbirth breathing. 2.Encourage mother to have an epidural. 3.Provide direct sacral pressure. 4.Use a hydrotherapy tub

3.Provide direct sacral pressure. This is indicated for severe back pain usually caused by the babe being OP and its head pushing on the sacrum

The nurse is assessing a prenatal client diagnosed with possible placenta previa. What signs and symptoms should the nurse expect this patient to demonstrate? 1. Dark red vaginal bleeding 2. Severe abdominal pain 3. Absence of fetal heart sounds 4. Bright red vaginal bleeding

4. Bright red vaginal bleeding

A nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex response. 2. Urinary output 30 cc/hr. 3. Respiratory rate 16 rpm. 4. Client has no grand mal seizures

4. Client has no grand mal seizures... The absence of seizures is an expected outcome related to magnesium sulfate administration

Which of the following statements describe a variable deceleration? 1. Variable decelerations are uniform. 2. On the fetal tracing, the heart rate will mirror the mother's contraction and represent uteroplacental insufficiency. 3. On the fetal tracing, the heart rate will increase after the mother's contraction and return to baseline after the contraction ends. 4. On the fetal tracing, the heart rate will go up and down and present when the cord is being compressed.

4. On the fetal tracing, the heart rate will go up and down and present when the cord is being compressed.

A client at 8 weeks gestation is diagnosed with hyperemesis gravidarum. The nurse knows that this excessive vomiting during pregnancy will often result in which of the following​ conditions? 1. Bowel perforation 2. hypertension 3. Abortion 4. Electrolyte imbalance

4. Electrolyte imbalance Excessive vomiting in clients with hyperemesis gravidarum often causes fluid and electrolyte​ imbalances, weight​ loss, and acid base imbalance. Bowel​ perforation, abortion, and gestational hypertension are not related to hyperemesis gravidarum

A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the pediatrician? 1. If the baby feeds 8 to 12 times each day. 2. If the baby urinates 6 to 10 times each day. 3. If the baby has stools that are watery and bright yellow. 4. If the baby has eyes and skin that are tinged yellow.

4. If the baby has eyes and skin that are tinged yellow.

A woman, who is in active labor, is told by her obstetrician, "Your baby is in the flexed attitude." When she asks the nurse what that means, what should the nurse say? 1.The baby is in the breech position. 2.The baby is in the horizontal lie. 3.The baby's presenting part is engaged. 4.The baby's chin is resting on its chest

4. The baby's chin is resting on its chest

A woman, 40 weeks' gestation, calls the labor unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labor and should proceed to the hospital? 1."The contractions are 5 to 20 minutes apart." 2."I saw a pink discharge on the toilet tissue when I went to the bathroom." 3."I have had cramping for the past 3 or 4 hours." 4."The contractions are about a minute long and I am unable to talk through them."

4."The contractions are about a minute long and I am unable to talk through them."

Contractions felt in the lower back, radiating to lower portion of abdomen are a sign of: a. True Labor b. False Labor

a. True Labor

A newborn nursery nurse notes that a baby's body is jaundiced at 36 hours of life. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2. Have the mother feed the baby frequently. Bilirubin is excreted through the bowel. The more the baby consumes, the more stools, and therefore the more bilirubin the baby will expel.