NCLEX Maternity/Newborn

A nurse has provided postpartum discharge instructions to a client who had a cesarean section. What statement by the client would indicate to the nurse that further teaching is necessary? 1. "I will relax and contract my pelvic floor muscles 10 times, eight times a day." 2. "Driving is permitted in one week if I am pain free." 3. "Lifting anything heavier than my baby is not advised." 4. "I will not cross my legs while sitting."

2. "Driving is permitted in one week if I am pain free." (2. Correct: This is an incorrect statement. C-sections require a much longer recovery. The client will not have the abdominal muscles to press down on the brake pedal in an emergency. Therefore, new moms who had C-sections should wait until after the three week postpartum appointment to drive. 1. Incorrect: This would be a correct statement. The client should do Kegel exercises to prevent incontinence and strengthen the pelvic muscles. 3. Incorrect: This is a correct statement. Lifting heavy objects can cause bleeding. New moms are not able to lift anything more than the baby's weight. 4 Incorrect: This is a correct statement. Avoid sitting for prolonged periods of time with legs crossed to prevent thrombophlebitis.)

The nurse is assessing a pregnant client returning for her first, one month check-up. The client has normal vital signs, blood count, and urinalysis, but has gained 6 pounds (2.7 kg). What is the most important assessment at this time? 1. Blood glucose level 2. Ankles for edema 3. Twenty-four hour diet recall 4. Confirmation of last menstrual period

3. Twenty-four hour diet recall (3. Correct: What is she eating? how much? Are the calories healthy? This is too much weight. 1. Incorrect: Weight gain: think eating or fluid, not blood sugar 2. Incorrect: First month: this weight gain is from excessive eating, snacking, etc. 4. Incorrect: Not an indication that the date is wrong)

Which client should the nurse see first? 1. Primigravida on IV magnesium sulfate with deep tendon reflexes of 2+ 2. Multigravida on po terbutaline with a pulse rate of 110/per minute 3. Primigravida on IV oxytocin with contractions every 3-4 minutes 4. Multigravida on po methyldopa with a blood pressure of 142/90.

4. Multigravida on po methyldopa with a blood pressure of 142/90. (4. Correct: A systolic blood pressure of ≥ 140 mmHg or a diastolic BP of ≥ 90 mmHg indicates hypertension. This client is already on methyldopa, which is an antihypertensive medication. Her hypertension is worsening and may compromise fetal well being. 1. Incorrect: + DTRs are normal. Clinical signs of safe dosage of magnesium sulfate include normal deep tendon reflexes. Adverse effects include depressed reflexes. 2. Incorrect: Maternal tachycardia (up to 120 bpm) is expected when on this medication. Terbutaline is a beta adrenergic agonist could have significant cardiovascular effects. 3. Incorrect: The desired contraction pattern with oxytocin is 3 in 10 minutes. A contraction every 3-4 minutes would equal 3 contractions in 10 minutes. The dosage of the oxytocin is individualized until the desired contraction rate is achieved.)

The nurse is caring for a client that is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery the mother asks to see the infant. What is the nurse's best response? 1. Bring the swaddled baby to the mother. 2. Explain that the cause of death must be determined before she can see the baby. 3. Ask her if she is sure she wants to see the baby. 4. Tell her it would be better to wait until she is in her room before she sees the baby.

1. Bring the swaddled baby to the mother. (1. Correct: Let the grieving mother see the infant to continue the grieving process. The mother has the right to make her own decision. 2. Incorrect: This is an untrue statement. In some cases, the cause may never be found. 3. Incorrect: This is non-therapeutic and implies that the nurse disagrees with the mother's decision to see the infant. 4. Incorrect: This is non-therapeutic and delays the mother's request. This response may also cause additional fear and anxiety.)

The lactation consultant is preparing to make rounds on the breastfeeding clients on the Labor, Delivery, Recovery, Postpartum (LDRP). Which client should the consultant see first? 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good that she has to wake him for each feeding.

4. The mother who stated that her baby was so good that she has to wake him for each feeding. (4. Correct: A baby who is so sleepy that he doesn't wake on his own for feeding is at high risk for dehydration and malnourishment. This newborn needs further evaluation and close monitoring to prevent serious complications. 1. Incorrect: This is a normal finding for a breastfeeding mother and is not the priority concern for the consultant. 2. Incorrect: This is a normal finding for a breastfeeding mother and is not the priority concern for the consultant. 3. Incorrect: Blisters and pain are concerns that need to be assessed, but the sleepy baby situation has first priority. This would be the next client for the consultant to see, but not the first.)

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. "Go to the hospital immediately if your membranes rupture." 2. "You should leave for the hospital as soon as you lose your mucus plug." 3. "Go to the hospital when you have a burst of energy followed by a backache." 4. "You need to go to the hospital when contractions are 2 minutes apart."

1. "Go to the hospital immediately if your membranes rupture." (1. Correct: This is the appropriate teaching. A gush or trickle of fluid from the vagina should be evaluated regardless of whether contractions are occurring. Infection and compression of the umbilical cord are possible complications. 2. Incorrect: No. The mucus plug is lost prior to the beginning of active labor, so too early to go to the hospital. Some women lose their mucus plug weeks before labor begins, others lose it right as labor starts. 3. Incorrect: Nesting? That's too early and not specific enough. This is not labor. 4. Incorrect: The client should go when contractions are 5 minutes apart, for 1 hour if it is her first pregnancy. Labor may be faster for the woman who has given birth before than for the nullipara. Multiparas are instructed to go to the hospital when contractions are regular, 10 minutes apart, for 1 hour.)

The nurse is providing prenatal education for a couple expecting a first child. The expectant mother asks about fetal movements. What is the best explanation by the nurse? 1. "You should feel activity between weeks 16 to 20." 2. "The fetus is too small to feel any movements." 3. "Maybe around the end of the 1st trimester." 4. "It is different for each individual woman."

1. "You should feel activity between weeks 16 to 20." (1. Correct: Quickening is the term used to refer to fetal movement when first sensed by the expectant mother. It is challenging for first time mothers to differentiate between actual fetal movement and other sensations, but usually between weeks 16 and 20, actual kicks or changes in fetal body position are noted by the mother. 2. Incorrect: As a first time mother, the client is requesting information about fetal movement. This response by the nurse does not provide the healthcare facts needed by the mother. While this is statement is accurate, the nurse has not addressed the client's question. 3. Incorrect: Not only is this response vague, it is also incorrect. The end of the first trimester is too soon, even though there is in fact movement, because the fetus is too small. 4. Incorrect: Though this is an accurate statement, the nurse has not specifically addressed the client's question. Expectant parents have many questions, and the mother in particular is anxious about changes or sensations within her body. The nurse needs to provide specific and detailed information when teaching clients.)

The nurse is preparing to make initial shift rounds. Which primipara client should the nurse see first? 1. 39 weeks with a board like abdomen and scant dark red bleeding. 2. 38 weeks gestation with blood streaked vaginal discharge 3. 40 weeks gestation reporting urinary frequency 4. 36 weeks gestation with pitting pedal edema

1. 39 weeks with a board like abdomen and scant dark red bleeding. (1. Correct: This client has symptoms of a placental abruption (abruptio placentae). There is an extremely high risk for fetal loss and maternal disseminated intravascular coaculation (DIC) which is a potentially life threatening clotting disorder in which blood clots form throughout the body's small blood vessels. 2. Incorrect: This describes loss of the mucous plug, which is a normal occurrence at term. 3. Incorrect: Urinary frequency without dysuria at term indicates descent of the fetus. This is a normal occurrence at 40 weeks gestation. 4. Incorrect: Edema confined to the feet and ankles is a normal discomfort of pregnancy at term.)

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? 1. A private room on the gynocological unit. 2. A private room on the postpartum unit. 3. Discharge her home as soon as her condition is stable. 4. Room her with another client with a pregnancy loss.

1. A private room on the gynocological unit. (1. Correct: This client needs a private room so she can feel free to grieve and have family members stay with her for support. She should be transferred to a gynocological unit so the sights and sounds of the maternity unit do not contribute to her pain. 2. Incorrect: Difficult for mother with stillborn to be on postpartum unit with mothers and their babies. The mother should not be surrounded by these reminders. 3. Incorrect: She does not need to be rushed out of the hospital. She needs to have time with her stillborn and also still needs to be assessed for postpartum complications. Remember that she is going through all of these postpartum stages of normal delivery and requires observations. 4. Incorrect: I know we say like illnesses go together but not here. This client needs privacy and time with her family.)

The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? Select all that apply 1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed.

1. Apply ice to perineum for first 12 hours. 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed. (1., 3., 4., 5., & 6. Correct: Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Chemical ice packs or clean gloves filled with ice may be used during the first 12 hours after a vaginal birth. Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling and help repair broken skin. Analgesics such as acetaminophen and nonsteroidal anti inflammatory drugs (NSAIDs) such as ibuprofen frequently are prescribed to provide relief for mild to moderate discomfort. Topical anesthetic may be used as needed to decrease surface discomfort and allow more comfortable ambulation. Sexual intercourse prior to healing of the episiotomy may contribute to further perineal damage. 2. Incorrect: This temperature is too hot and can damage the injured tissue. The sitz bath should be at a temperature of 100-104°F (38-40°C).​)

A nurse is planning to provide education to a client wishing to breastfeed. What instructions should the nurse include when teaching this client? Select all that apply 1. Apply warm compresses to breast just prior to breastfeeding. 2. Establish a routine for breastfeeding. 3. Massage breasts during feeding. 4. Wear well-fitting bra continuously for first 24 hours after birth. 5. Wash hands before breastfeeding.

1. Apply warm compresses to breast just prior to breastfeeding. 3. Massage breasts during feeding. 5. Wash hands before breastfeeding. (1., 3., & 5. Correct: Applying warm compresses or taking a warm shower prior to breastfeeding will help the let-down reflex. Massaging breasts during feeding can help with emptying. Emphasize the importance of hand hygiene prior to breastfeeding to prevent infection. 2. Incorrect: Allow newborns to nurse on demand. Allow newborns to feed 15-20 minutes per breast or until the breast softens. Begin the next feeding session on the breast that was not completely emptied. 4. Incorrect: Wear well fitting bra continuously for at least 72 hours after birth to avoid milk stasis.)

The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? Select all that apply 1. Birth weight regained in 14 days 2. Fontanels soft and depressed 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings

1. Birth weight regained in 14 days 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings (1., 3., 4. & 5. Correct: Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breast feeding. 2. Incorrect: Fontanels should be soft, firm and flat. A depressed or sunken fontanel may indicate dehydration. Dehydration is one of the major causes of sunken fontanels.)

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

1. C-section delivery (1. Correct: A client with a surgical wound is at risk for hemorrhage and is at greater risk than birth from a vaginal delivery. The surgical opening of the abdomen and the uterus makes this the highest risk. 2. Incorrect: If the placenta is removed and the fundus massaged properly, risk of hemorrhage decreases. The risk of hemorrhage goes up with multiple births, such as twins, as compared with a single birth, but it is still not as high a risk as a c-section. 3. Incorrect: Premature does not place the client at higher risk of bleeding. The premature newborn is generally smaller with less risk of damage to the uterus and perineum of mom. 4. Incorrect: A precipitous delivery could make you think tear, but the client is Gravida 5. Tearing is less likely after having 5 children.)

In which client should the nurse question a prescription for a contraction stress test? Select all that apply 1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 3. Client at 38 weeks with gestational diabetes. 4. Client at 37 weeks gestation. 5. Client with placenta previa.

1. Client at 26 weeks gestation. 2. Client with a history of 4 Cesarean section deliveries. 5. Client with placenta previa. (1., 2., & 5. Correct: 26 weeks is too early to stimulate contractions. This could lead to a preterm delivery. Stimulating contractions in a client with previous cesarean deliveries is not recommended. This may lead to uterine rupture. Stimulating contractions in a client with placenta previa is not recommended. This may lead to hemorrhage. 3., & 4. Incorrect: There is no reason to suspect complications from a contraction stress test for this client.)

A client who is 36 weeks gestation has been admitted to the labor and delivery area for evaluation due to worsening signs of pregnancy induced hypertension (PIH). The BP upon arrival is 168/96. While being monitored, she reports a sudden onset of severe abdominal pain. Further nursing assessment reveals vaginal bleeding, abdominal rigidity, and a fetal heart rate of 90/min on the fetal monitor. What nursing actions would be appropriate for this client? Select all that apply 1. Continuously monitor the client's vital signs. 2. Keep the mother informed of the fetus' condition. 3. Careful monitoring of the fetal heart rate electronically. 4. Accurate measurement of I&O. 5. Prepare for emergency vaginal delivery. 6. Monitor for restlessness and decreased level of consciousness (LOC).

1. Continuously monitor the client's vital signs. 2. Keep the mother informed of the fetus' condition. 3. Careful monitoring of the fetal heart rate electronically. 4. Accurate measurement of I&O. 6. Monitor for restlessness and decreased level of consciousness (LOC). (1., 2., 3., 4., and 6. Correct: The nurse recognizes that the client is demonstrating signs of placental abruption (abruptio placentae), most likely due to the presence of PIH. Due to the risk of shock, the maternal vital signs are checked immediately and continuously monitored. The mother will be aware of the emergent nature of her situation. She will need to be informed of what is occurring and kept informed of the status of the fetus. Accurate measurement of I&O, in addition to assessing the amount of vaginal blood loss, will be crucial in determining fluid volume status. Restlessness and decreasing level of consciousness would indicate poor cerebral perfusion as a result of decreased vascular volume and decreased cardiac output. Fluid and blood replacement would be indicated. 5. Incorrect: The infant is already demonstrating signs of distress (bradycardia), and the mother is considered unstable. The nurse would need to prepare her for an emergency delivery by cesarean, not a vaginal delivery.)

The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.

1. Discuss with healthcare provider your current exercise regimen and history. (1. Correct: Best advice for pregnant women. The healthcare provider can individualize according to the physical condition of the woman and the stage of pregnancy. 2. Incorrect: As pregnancy progresses, the exercise program may need modification because the change in the woman's center of gravity makes her more prone to falls. Therefore, an activity that is safe in the first trimester may not be safe in the third trimester. Those women who have been exercising strenuously before pregnancy should consult the healthcare provider but may be able to continue much of their usual routine. Recreational sports generally can be continued if no risk of falling or abdominal trauma exists. 3. Incorrect: Exercise during pregnancy is generally beneficial and can strengthen muscles, reduce backache, reduce stress and provide a feeling of well-being. The amount and type of exercise recommended depend on the physical condition of the woman and the stage of pregnancy. 4. Incorrect: Women who have no medical or obstetric complications should exercise in moderation each day for 30 minutes or more during pregnancy.)

A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? Select all that apply 1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 4. Administer propranolol for BP > 100 diastolic. 5. Initiate external fetal heart monitoring.

1. Monitor for headache. 2. Place client in left recumbent position. 3. Insert indwelling urinary catheter. 5. Initiate external fetal heart monitoring. (1., 2., 3., & 5. Correct: Headache is a sign of increasing BP and increasing ICP. The left recumbent position moves the fetus off the mom's aorta and will help decrease the BP. This client needs to have UOP closely monitored because of the fluid volume excess (FVE), so an indwelling urinary catheter is needed. The fetus needs to be monitored for complications, and the fetal heart rate (FHR) should be 120-160/minute so close monitoring is required. 4. Incorrect: Propranolol, a beta blocker, is not given during pregnancy as it decreases HR and the amount of blood pumped by the heart. This can cause fetal bradycardia, decreased cardiac output, and potential for fetal demise.)

A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? Select all that apply 1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. 4. Place an oral airway into the client's mouth. 5. Administer diazepam.

1. Place the client's head in the nurse's lap. 2. Administer oxygen. 3. Monitor tonic-clonic activity. (1., 2. & 3. Correct: This client in triage experiencing a seizure should be gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and body part affected. 4. Incorrect: Never place an object in a client's mouth who is experiencing a seizure. 5. Incorrect: Magnesium sulfate is administered to control BP and decrease seizures. Magnesium sulfate leads to fewer maternal deaths and fewer future seizures when given for eclamptic seizures. Diazepam is contraindicated for use in pregnancy.)

The nurse is planning to teach a group of young women who want to become pregnant. What information should be included as recommendations to increase the chances of having a healthy baby? Select all that apply 1. Take 400 micrograms of folic acid every day. 2. Limit alcohol to 1 glass per day. 3. Avoid smoking. 4. Take the flu vaccine during flu season. 5. Start prenatal care by 3 months of pregnancy

1. Take 400 micrograms of folic acid every day. 3. Avoid smoking. 4. Take the flu vaccine during flu season. (1., 3., & 4. Correct: Folic acid is a B vitamin. If a woman has enough folic acid in her body at least a month before and during pregnancy, it can help prevent neural tube defects. Smoking can lead to premature birth, cleft lip or cleft palate, and infant death. The flu shot given during pregnancy has been shown to protect mom and baby (up to 6 months old) from flu. 2. Incorrect: When a woman drinks alcohol, so does her unborn baby. This can cause the baby to be born with fetal alcohol spectrum disorder. 5. Incorrect: A woman should be certain to see her healthcare provider when planning pregnancy and start prenatal care as soon as she thinks she is pregnant.)

A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? Select all that apply 1. Take initial vital signs. 2. Measure cervical dilation. 3. Check fundal height and fetal heart rate (FHR). 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.

1. Take initial vital signs. 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia. (1, 4, & 5. Correct: The LPN scope of practice varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse. 2. Incorrect: Measuring cervical dilation is an invasive assessment not within the LPN scope of practice. An experienced registered nurse or primary healthcare provider must be specifically trained to perform this procedure. 3. Incorrect: Fundal height is a determination of uterine size to assess fetal growth and development which cannot be delegated to an LPN. Additionally, determining fetal heart rate involves assessment of fetal well being and not within the LPN scope of practice.)

The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should be assigned to the medical surgical nurse? Select all that apply 1. Total abdominal hysterectomy (TAH). 2. Client post C-section to be discharged home. 3. Breast Reduction. 4. Vaginal delivery of fetal demise. 5. 28 week gestation of bed rest. 6. Bladder suspension with anterior and posterior repair.

1. Total abdominal hysterectomy (TAH). 3. Breast Reduction. 6. Bladder suspension with anterior and posterior repair. (1., 3. and 6. Correct: When a nurse is pulled to another unit, always assign them like a brand new nurse. A client with a TAH, Breast reduction or bladder suspension require basic post-operative care. These are within the scope of knowledge of a brand new nurse with medical-surgical knowledge. 2. Incorrect: This client is going to require specific discharge teachings related to her care, medication and care of the newborn. Specialized training is necessary here. 4. Incorrect: The nurse caring for this client needs to have skills related to postpartum care as well as psychological care of this type of loss. A pulled nurse from the medical-surgical floor will not be prepared to assist this client with all her needs. 5. Incorrect: This client is on bedrest for a reason and is hospitalized for a reason. Skilled assessment to identify change in status or denote impending complications is essential. This is not appropriate for the pulled medical-surgical nurse.)

A client comes into the emergency department (ED) with intense abdominal pain. The nurse completes a physical assessment and evaluates the vital signs and lab work. Based on the information gathered, the nurse expects which diagnostic test will be priority? 16 year old female admitted to treatment room 3, reporting "intense abdominal pain" at 10/10. States, "pain started 3 days ago, but got worse this morning". Confirms no injury to abdominal area. Rigid, board-like abdomen noted. Last menstrual cycle "6 weeks ago." Temperature - 100 degrees F (37.77 degrees C) Heart rate - 110/min Respirations - 28/min Blood Pressure - 90/62 Hemoglobin - 10 grams/dL (100 grams/L) Hematocrit - 32% (0.32) serum hcg - 27 mIU/mL 1. Transvaginal ultrasound 2. Esophagogastroduodenoscopy (EGD) 3. CAT Scan of the abdomen 4. KUB (Kidney, Ureter, and Bladder)

1. Transvaginal ultrasound (1. Correct: The serum hCG indicates that the client is pregnant. The Hgb and Hct along with a BP of 90/62, and a rigid board like abdomen indicates bleeding in the peritoneum. Intense pain at 10/10 without injury can lead the nurse to thinking tubal pregnancy. How do determine if the client has a tubal pregnancy? With an ultrasound. A transvaginal ultrasound is a type of pelvic ultrasound used to examine the uterus, fallopian tubes, ovaries, cervix, and vagina. 2. Incorrect: No, an EGD looks into the stomach and small intestine. All clues lead to tubal pregnancy. 3. Incorrect: No, tubal pregnancy can be seen quickly by ultrasound. 4. Incorrect: Kidney, Ureter, and Bladder-general picture of the abdomen-less specific than the Ultrasound. The focus is not on the fallopian tubes.)

A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? Select all that apply 1. Turn the client to the left side. 2. Administer oxygen. 3. Start an intravenous line. 4. Prep the mother for cesarian section. 5. Notify the primary healthcare provider.

1. Turn the client to the left side. 2. Administer oxygen. 5. Notify the primary healthcare provider. (1., 2. & 5. Correct: Late fetal heart rate decelerations are associated with fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increases maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary healthcare provider are deviations from the standard of care. 3. Incorrect: Intravenous line would already be in place. This will not help the fetus. 4. Incorrect: Prepping the client for caesarian section is premature.)

A client with a history of cardiac disease has safely delivered a full term infant. When discussing discharge instructions, the nurse knows the teaching was successful when the client makes what statement? 1. "Now that the baby is born, I can eat more salt." 2. "I must include lots of fiber to prevent constipation." 3. "I should return to my previous dose of cardiac medication." 4. "I will need extra fluids to help with breast feeding needs."

2. "I must include lots of fiber to prevent constipation." (2. Correct: Pregnancy stresses an impaired cardiovascular system and requires careful monitoring even after delivery of the infant. The heart needs time to recover from the strain to the body. Constipation can be a problem after delivery, caused by relaxed muscle tone, hemorrhoids, or surgical repair. Increasing fiber in the diet, along with mild exercise, can prevent constipation. 1. Incorrect: Salt is not restricted during pregnancy because the fetus needs iodine for brain and nervous system development. But increasing salt after delivery would result in unhealthy amounts of sodium in the diet, which is unsafe for cardiac clients. 3. Incorrect: Since this client's cardiac medications would have been altered during the pregnancy, it is important to meet with the cardiologist following delivery to evaluate current medication needs. Simply returning to pre-natal medications or dosages would not be appropriate due to extreme changes in the client's overall health status and postpartum condition. 4. Incorrect: Even though adequate fluids are necessary for breast-feeding mothers, clients with cardiac issues must be cautious of overloading the heart with large amounts of fluids. The risk of post-partum cardiac complications will continue for several months, including the possibility of cardiomyopathy or a myocardial infarction. Breast feeding mothers need an extra 300 - 500 calories, particularly foods rich in calcium, and not excessive amounts of fluid.

The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn.

2. Assess the five minute APGAR of a newborn. (2. Correct: The APGAR is done to determine whether a newborn needs help breathing or is having heart trouble. It looks at the newborn's breathing effort, HR, muscle tone, reflexes, and skin color and is the most important initial assessment for a newborn. 1. Incorrect: This task is not emergent and can be performed later at an appropriate time. 3. Incorrect: This task is not emergent and can be performed later at anytime during the transition stage of the newborn's nursery care. 4. Incorrect: This task is not emergent and can be performed at anytime between 24 hours and 7 days old. Typically it is done before the newborn is discharged home.)

A client at 28 weeks gestation reports swollen hands and feet during her prenatal visit. Which additional signs/symptoms would be of concern to the nurse? Select all that apply 1. Decreased deep tendon reflexes 2. Blurred vision 3. Blood glucose 120mg/dL (6.7 mmol/L) 4. Muscle spasms 5. Headache

2. Blurred vision 4. Muscle spasms 5. Headache (2., 4., & 5 Correct: Muscle spasms indicating nerve/muscle irritation. Headache and blurred vision are indicators of increasing blood pressure. This client is going into preeclampsia. 1. Incorrect: No, the deep tendon reflexes will be hyperactive (increased) with preeclampsia. 3. Incorrect: Mild blood sugar elevation is not related to preeclampsia.)

A nurse is teaching a group of women about human papillomavirus (HPV). What should the nurse tell the women that human papillomavirus puts women at risk for? 1. Human immunodeficiency virus 2. Cervical cancer 3. Hepatitis B 4. Cirrhosis

2. Cervical cancer (2. Correct: Women who have had human papillomavirus are at increased risk for developing cervical cancer. 1. Incorrect: HPV does not increase the risk of developing HIV. HPV increases the risk for developing cervical cancer. 3. Incorrect: HPV does not contribute to Hepatitis B. HPV increases the risk for developing cervical cancer. 4. Incorrect: HPV does not contribute to Cirrhosis. HPV increases the risk for developing cervical cancer.)

Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client? 1. Onset of nausea and vomiting 2. Contraction every 90 seconds lasting 70 seconds 3. Maternal blood pressure 140/90 4. Early decelerations in the fetal heart rate

2. Contraction every 90 seconds lasting 70 seconds (2. Correct: These contractions are too long and too often. 1. Incorrect: Many laboring clients become nauseated and vomit during labor. Also, common side effects of oxytocin include nausea and vomiting. This would not require the discontinuation of oxytocin. 3. Incorrect: Maternal hypotension requires discontinuation of oxytocin. This BP is not worrisome. 4. Incorrect: Early decels are generally not harmful and happen as baby is descending through the birth canal during the later stages of labor. These are not related to the oxytocin infusion.)

A nurse is helping a client to maintain normal voiding habits while recovering from a cesarean section. What methods should the nurse initiate? Select all that apply 1. Have the client recline slightly while using bedside commode. 2. Encourage the client to push over the pubic area with hands. 3. Suggest the client read or listen to music. 4. Pour warm water over the perineum. 5. Stay and talk with client while waiting for urge to void.

2. Encourage the client to push over the pubic area with hands. 3. Suggest the client read or listen to music. 4. Pour warm water over the perineum. (2., 3., 4. Correct: Encourage the client to push over the pubic area with the hands or lean forward to increase intraabdominal pressure and external pressure on the bladder. Reading or listening to music will help to decrease anxiety and tension. Pouring warm water over the perineum promotes muscle relaxation. 1. Incorrect: Assist the client to a normal position for voiding. For males, standing. For females, squatting or leaning slightly forward when sitting. These positions enhance movement of urine through the tract by gravity. 5. Incorrect: Provide privacy. Many people cannot void in the presence of another person.)

When assessing a newborn following a breech delivery, what physical findings should the nurse report to the primary healthcare provider as positive indications of congenital hip dysplasia (CHD)? Select all that apply 1. Symmetrical gluteal folds. 2. Limited abduction of one leg. 3. Pain with the Barlow maneuver. 4. Presence of an Ortolani click. 5. Confirmed stepping reflex.

2. Limited abduction of one leg. 4. Presence of an Ortolani click. (2 & 4. Correct: When assessing a newborn, the nurse must determine which findings are normally expected at birth versus abnormal findings that should be reported to the primary healthcare provider. Two expected findings suggestive of congenital hip dysplasia (CHD) include limited abduction of one leg and the presence of an Ortolani click when the affected hip is placed into the "frog-leg" position. 1. Incorrect: Symmetrical gluteal folds are an expected, normal finding when the newborn is placed in the prone position. In an infant with suspected CHD, gluteal folds are notably asymmetrical. 3. Incorrect: During evaluation for congenital hip dysplasia, there is no pain during any assessment procedures. The Barlow procedure, in which one leg is adducted across the body, is currently used, in addition to other examination techniques, to determine any abnormalities with hip/socket placement. 5. Incorrect: The stepping reflex is part of the neurologic evaluation and is a normal finding at birth. When held upright with the soles of the feet lightly touching the table, the infant appears to lift alternate feet as if walking. This reflex disappears in about 2 to 3 months, but will return when the child begins learning to walk.)

A client who delivered a 9-pound 12-ounce (4.17 kg) baby 1 hour ago, has saturated 2 peri-pads in 15 minutes. Which nursing action should take priority? 1. Notify the primary healthcare provider. 2. Massage the fundus. 3. Obtain a blood pressure. 4. Begin an infusion of oxytocin.

2. Massage the fundus. (2. Correct: This is the only answer that will stop bleeding. The fundus is boggy. 1. Incorrect: Doesn't stop the bleeding. Since it says priority you have to say, if I could only do ONE thing. If you choose this answer you have not stopped the bleeding. 3. Incorrect: This is good, but how will it stop the bleeding? 4. Incorrect: The most common reason for saturating 2 peri-pads is a boggy fundus. The priority is to massage the fundus and stop the bleeding! If post partum hemorrhage continues, an infusion of oxytocin may be initiated.)

A primagravida asks the nurse about the purpose of the RhoGam injection. What would be the best explanation by the nurse? 1. RhoGam changes the RH positive fetus to Rh negative. 2. RhoGam prevents the mother from forming Rh antibodies. 3. RhoGam inhibits Rh antibodies in the newborn infant. 4. RhoGam destroys antibodies in the RH positive mother.

2. RhoGam prevents the mother from forming Rh antibodies. (2. Correct: RhoGam is an immunoglobulin given via injection to an Rh negative mother following the birth of an Rh positive infant. The mixing of mother and fetal blood during birth causes the mother to develop antibodies which can be fatal to the next fetus. RhoGam prevents the formation of these antibodies in the mother. 1. Incorrect: RhoGam has no effect on the Rh factor in the fetus. RhoGam is administered to the mother and does not alter the Rh factor at all. RhoGam works to prevent antibody formation in the mother. 3. Incorrect: RhoGam is never given to an infant because the fetus does not form RH antibodies. Only the mother will form antibodies. 4. Incorrect: RhoGam does not "destroy" antibodies; rather, it prevents the actual formation of antibodies in the mother. Also, RhoGam is only given to Rh negative mothers.)

What does a non-stress test tell the nurse about a pregnant client? 1. That the baby is going to be a boy or girl 2. The baby is doing well and the placenta is providing enough oxygen at this time 3. That the baby's heart is healthy and there are no birth defects 4. That the mother is strong enough to undergo vaginal delivery

2. The baby is doing well and the placenta is providing enough oxygen at this time (2. Correct: The non-stress test identifies whether an increase in the fetal heart rate (FHR) occurs when the fetus moves, indicating adequate oxygenation, a healthy neural pathway from the fetal central nervous system to the fetal heart and the ability of the fetal heart to respond to stimuli. 1. Incorrect: The sex is not determined by this test. 3. Incorrect: Birth defects are not determined from a non-stress test. 4. Incorrect: We can't determine if the mother is strong enough to undergo vaginal delivery from a non-stress test.)

A primigravida client at 35 weeks gestation has been diagnosed with human papillomavirus (HPV). The nurse knows that the most important information to discuss with this client is what? 1. The infant will not be able to breast feed. 2. The mother will need frequent follow up Pap smears. 3. The fetus will need to be delivered by C-section. 4. The mother must start metronidazole immediately.

2. The mother will need frequent follow up Pap smears. (2. Correct: HPV is a sexually transmitted viral infection that can cause genital warts or even precancerous lesions. This virus is spread by direct contact with infected mucous membranes and is transmitted through sexual contact. Although HPV generally clears itself through the human immune system, clients diagnosed with this infection are recommended to have a follow-up Pap smear every six months for the first year, particularly if infected with HPV 16 or HPV 18. 1. Incorrect: The risk of transmitting HPV in breast milk is extremely minimal. Research has shown that the miniscule amounts of HPV which could be transmitted do not outweigh the benefits of allowing the infant to breastfeed. 3. Incorrect: The chance of transmitting HPV during vaginal birth is small. Even in the presence of non-cancerous genital warts, the greatest concern is whether the birth canal is blocked by these growths. The existence of warts does not mean the client will automatically need a cesarean section. 4. Incorrect: The primary healthcare provider will treat the mother and all sexual partners for the HPV, usually with a medication such as metronidazole. However, this information is not the most important topic for the nurse to discuss with the client at this time.)

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary healthcare provider immediately? 1. Deep tendon reflexes of plus three. 2. Urine output of 80 mL over four hours. 3. Respiratory rate of 24 breaths/minute. 4. Severe headache with blurred vision.

2. Urine output of 80 mL over four hours. (2. Correct: Preeclampsia is a condition in which the client's blood pressure is consistently elevated, with a systolic greater than 140 mm Hg and a diastolic above 90 mm Hg. The greatest main concern is decreased perfusion to the placenta, endangering mother and fetus, potentially accompanied by seizures, kidney or liver failure. This client has had only 80 mL of urine in four hours, indicating an output less than the minimum required of 30 mL per hour. This indication of possible kidney failure should be reported to the primary healthcare provider immediately. 1. Incorrect: Deep tendon reflexes (DTR'S) range from 0 to +5 and are used to assess the neurologic integrity of the body. Normal reflexes for the body range around +2 but become elevated in preeclampsia. The possibility of seizures increases as DTR's increase over the normal range. This symptom is serious but expected in a client with preeclampsia. The nurse should continue monitoring this. 3.Incorrect: As blood pressure increases in the preeclampsic client, both respirations and heart rate would also begin to elevate. The client may display excessive swelling of hands and feet, occasionally accompanied by facial swelling. Although a respiratory rate of 24 is a bit elevated, it is nothing the nurse needs to report immediately. 4. Incorrect: The combination of increased blood pressure and swelling in preeclampsia frequently results in severe headaches and blurred vision. If the blood pressure reaches life-threatening levels, clients have been known to develop blindness because of retinal response to the decreased body perfusion. Although headache and blurred vision are serious symptoms, this is not completely unexpected and therefore does not need to be reported to the primary healthcare provider immediately.)

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy.

3. Call the primary healthcare provider immediately. (3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. 1. Incorrect: Not a concern as much as impending seizure symptoms. Administering an antacid will not fix the problem if PIH is worsing. This is delaying care. 2. Incorrect: Not a concern as much as impending seizure symptoms. Checking the client's blood pressure is not the priority in this situation. It will not fix the problem. 4. Incorrect: Not in this situation. Heartburn is a normal discomfort or right upper quadrant pain in a client with PIH may indicate impending rupture of the liver capsule which is a life threatening complication.)

While the postpartum nurse was in report, four clients called the nurse's station for assistance. Which client should the nurse see first? 1. Client with three dime sized clots on her perineal pad. 2. Breastfeeding client who is reporting uterine cramping. 3. Client reporting blood running down legs upon standing. 4. Client who had an epidural and is now reporting a headache.

3. Client reporting blood running down legs upon standing. (3. Correct: A new nurse should assess this client first because we are worried about hemorrhage. If the fundus is boggy, a fundal massage will need to be done. Assess vital signs for hemorrhage. 1. Incorrect: Clots smaller than a silver dollar are normal. However, do not ignore any bleeding. Always assess the client with any signs of bleeding to determine that the problem is significant. 2. Incorrect: Breastfeeding causes the release of endogenous oxytocin from the pituitary, which causes the uterus to contract. When the uterus contracts, the client may call this discomfort, cramping. This is a normal process necessary for the uterus to return to normal. 4. Incorrect: A post epidural headache can be an indication of inadvertent puncture of the dural membrane. This client will need to be positioned prone, push fluids, given caffeine and may need a blood patch to seal the dural leak.)

A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is most appropriate at this time? 1. Lie on left side and take slow, deep breaths. 2. Call an ambulance and go to emergency room. 3. Come to the clinic for assessment and evaluation. 4. Go directly to the hospital emergency room.

3. Come to the clinic for assessment and evaluation. (3. Correct: This client is full term and the expulsion of large amounts of fluid indicates the client has experienced a rupture of membranes. The next step would be to evaluate the client for effacement and dilation as well as fetal heart tones. The best approach would be for the client come to the clinic for a quick evaluation and assessment. 1. Incorrect: This is neither safe nor appropriate. The client should be examined by the primary healthcare provider as soon as possible. Lying on the left side and taking deep breaths would be a delay of the appropriate treatment. 2. Incorrect: There is no indication the client is experiencing a situation serious enough to warrant an ambulance trip to the emergency room. The question suggests normal rupture of membranes, and while the client should be assessed, this can be accomplished without a trip to the emergency room. 4. Incorrect: It is not necessary for the client to go directly to the emergency room. Because the clinic is still open, the client could be examined by the primary healthcare provider to determine the stage of labor as well as dilation. If the client had called the clinic after hours, the nurse might have recommended a trip to the labor & delivery unit.)

A client has just found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected date of confinement? 1. December 3 2. December 7 3. December 10 4. December 13

3. December 10 (3. Correct: The most common method of determining the expected date of confinement is by Nagele's rule. To use this method begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10. 1. Incorrect: To use Nagele's rule begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10. 2. Incorrect: To use Nagele's rule begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10. 4. Incorrect: To use Nagele's rule begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10.)

Which nursing action takes priority once a term infant has delivered vaginally? 1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints

3. Dry the baby (3. Correct: Cold stress is the biggest danger to a newborn. A newborn is wet, and evaporation will rapidly cool the baby, which can cause hypoglycemia and respiratory distress. The stimulus of drying the skin also promotes vigorous crying and lung expansion in most healthy infants. 1. Incorrect: A task that needs to be done before the baby leaves the delivery room, but is not immediate priority. 2. Incorrect: Eye prophylaxis may be delayed until the end of the first hour after birth without adverse effects. Because the ointment may temporarily blur the infant's vision, parents may wish to delay treatment for a short time during initial bonding. 4. Incorrect: A task that needs to be accomplished before the baby leaves the delivery room, but is not immediate priority.)

A client's membranes spontaneously rupture at 10 cm dilation and +2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? 1. Emergency cesarean delivery 2. Immediate high forceps delivery 3. Equipment for immediate suctioning of the newborn 4. Administration of IV oxytocin

3. Equipment for immediate suctioning of the newborn (3. Correct: Green stained fluid indicates fetal passage of meconium. The fetus must be suctioned by the healthcare provider when the head is still on the perineum and before the baby takes its first breath. This will remove any particulate matter from the meconium that may cause aspiration. 1. Incorrect: Delivery will probably occur soon and vaginal delivery is preferable to cesarean. This is an unrealistic and inappropriate action for this client. 2. Incorrect: High forceps are never indicated and would not provide safe delivery for the baby. The concern is the meconium stained fluid and potential aspiration for the baby. 4. Incorrect: The meconium passage is an indicator of fetal stress, and increased uterine contractions may stress the fetus further. This would not be safe for the baby or the mother at this stage of labor.)

A client is admitted to the hospital at 36 weeks gestation with a diagnosis of placental abruption. Following an initial assessment, what action by the nurse is most important? Pulse - 120 and regular Respirations - 26, non-labored Blood pressure - 90/50 Fetal heart rate - 110 1. Apply the fetal monitor. 2. Complete an abdominal prep. 3. Insert large bore intravenous line. 4. Have client sign the consent form.

3. Insert large bore intravenous line. (3. Correct: The exhibit shows the client's blood pressure is dangerously low, most likely due to loss of blood, placing the client at risk for hypovolemic shock. When the mother's blood pressure drops, the fetal heart rate also drops. The priority is to immediately place a large intravenous line to administer fluids or medications. 1. Incorrect: A fetal monitor would most likely already be in place; however, if not, the placement of a fetal monitor is not the initial priority. The priority should focus on the client; in this case, it is the mother, whose well being will directly affect fetal outcome. 2. Incorrect: Because the fetus is being affected by the mother's low blood pressure, an emergency cesarean section may need to be performed. But an abdominal prep is not a priority, and could, in fact, be completed in the operating room. 4. Incorrect: It is not the nurse's responsibility to get the consent form signed. That is the duty of the primary healthcare provider or surgeon performing the procedure. Because this is a medical emergency, even a family member could sign the form later.)

A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What information should the nurse provide the client about spermicidal agents? 1. Effectively reduces vaginal fungal infections such as Candida albicans. 2. Eliminates bacterial and viral sexually transmitted infections. 3. Most effective when used in conjunction with barrier methods, such as a diaphragm. 4. Causes few side effects.

3. Most effective when used in conjunction with barrier methods, such as a diaphragm. (3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival. 1. Incorrect: They do not kill fungi such as Candida albicans, even in high concentrations. 2. Incorrect: Spermicidal agents do not eliminate bacterial and viral STIs. 4. Incorrect: Spermicidal agents are used only when sexual intercourse is expected, but side effects include vaginal and penile irritation, lesions, and ulcerations due to the detergent effect. Disruption of normal protective vaginal flora results in an increased risk of opportunistic vaginal infections and urinary tract infections.)

Which postpartum client should the nurse assign to the last private room in the Women's Health Center? 1. Placenta abruption during delivery 22 hours ago 2. Boggy fundus five hours post-delivery 3. Pre-eclamptic prior to delivery 30 hours ago 4. WBC count is 12,000/mm³ (12 x 10⁹​/L) at 24 hours postpartum

3. Pre-eclamptic prior to delivery 30 hours ago (3. Correct: This pre-eclamptic client delivered 30 hours ago. The client must have a private room because any stimulus can still precipitate a seizure. 1. Incorrect: People who are at risk for bleeding and shock do not require private rooms. 2. Incorrect: Boggy fundus doesn't have anything to do with a private room. 4. Incorrect: This is the one most people jump on.... Most postpartum clients have elevated white counts post-delivery. Normal white count is 5,000-10,000/mm³ or 5-10 x 10⁹​/L)

The nurse is instructing expectant first-time mothers about the process of rooming-in while at the hospital. After discussing security protocols, one client asks the nurse what to do if no staff is available when toileting or showering assistance is needed. The nurse knows teaching was successful when another client responds with what statement? 1. "Only hand the baby to individuals wearing proper hospital I.D." 2. "Ask family member to watch infant while you're in the bathroom." 3. "Showering is not necessary since discharge is within 24 hours." 4. "Push baby in bassinet with you into bathroom if no one available."

4. "Push baby in bassinet with you into bathroom if no one available." (4. Correct: There are many safety and security measures implemented to diminish the potential for newborn abductions. At no time should a newborn ever be left alone, even in the mother's room. In the unlikely event no authorized staff can assist the client in the bathroom, the newborn should be wheeled by the mother into the bathroom and kept in view at all times. 1. Incorrect: The wearing of an official facility identification badge does not guarantee security or even whether the individual is actually an employee. Because of the potential for fake I.D.'s, the newborn should never be handed to anyone just because they are wearing facility identification. 2. Incorrect: Having to rely on family anytime the mother needs to use the bathroom is impractical and inconvenient since family may not always be present or available. The mother and infant are the responsibility of staff. A more timely solution is needed. 3. Incorrect: Not all mothers are discharged within 24 hours, depending on the mode of delivery and condition of the client. More importantly, length of time in facility does not negate the mother's right to have a shower any time if prescribed.)

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? 1. "The medication permits safe breastfeeding after delivery." 2. "It protects you against other infections during pregnancy." 3. "This drug prevents transmission of HIV to your partner." 4. "ZDV decreases the chance the baby will contract HIV."

4. "ZDV decreases the chance the baby will contract HIV." (4. Correct: New advances in the treatment of HIV have decreased the chances of transmitting the HIV virus from mother to fetus from 25% without treatment to less than 2 % with treatment. Several HIV medications have been shown to be safe for both the fetus and mother, including ZDV. The nurse is presenting the most complete, accurate information with this statement. 1. Incorrect: Even with treatment, most primary healthcare providers discourage breast-feeding after birth since the HIV virus has been shown to be transmitted through breast milk. The use of ZDV or other antiviral medications cannot completely eradicate the virus from breast milk, though some pediatricians allow breastfeeding under certain circumstances. 2. Incorrect: The use of antiviral medications, including ZDV, does not protect the client from contracting other acquired infections. The medication is strictly for the purpose of decreasing the chances of passing HIV to the fetus, and requires the mother to precisely follow the dosing regime and other healthy habits to increase its effectiveness. 3. Incorrect: While the use of antiviral medications during pregnancy can decrease the chances of the mother passing the virus to the fetus, the medication does not prevent transmission of the disease to the client's partner. This statement is incorrect.)

What room assignment would be best for the nurse to make for a primigravida with gestational diabetes who was admitted for glycemic control? 1. A private room near the nurses' station. 2. A room with a client admitted with a placenta previa. 3. A room with a client in preterm labor. 4. A room with a client admitted with pregestational diabetes.

4. A room with a client admitted with pregestational diabetes. (4. Correct: Placing clients with similar diagnoses together can result in information sharing and emotional support. It is ok to put these two clients together. 1. Incorrect: A private room is not required since the client has no emotional or infection control issues. Also, it is not necessary to place them near the nursing station because they do not need monitoring on that close of a level. 2. Incorrect: A client with placenta previa is in an unstable state and can have emotional issues concerning this diagnosis. The client would be best in a private room. 3. Incorrect: The client in preterm labor needs a private room that is quiet with limited visitors, she is having issues herself and concerned about her unborn child.)

The nurse is caring for a client in the 8th week of pregnancy. The client is spotting, has a rigid abdomen and is on bedrest. What is the most important assessment at this time? 1. Protein in the urine 2. Fetal heart tones 3. Cervical dilation 4. Hemoglobin and hematocrit levels

4. Hemoglobin and hematocrit levels (4. Correct: The client may be bleeding, and that is an emergency! Common causes of hemorrhage during the first half of pregnancy include abortion and ectopic pregnancy. Ectopic pregnancy is a significant cause of maternal death from hemorrhage and the classic signs of ectopic pregnancy include positive pregnancy test, abdominal pain and vaginal "spotting". Remember that in the ruptured ectopic pregnancy, bleeding may be concealed and severe pain could be the only symptom. 1. Incorrect: Protein in the urine indicates preeclampsia, which is a condition in which hypertension develops during the last half of pregnancy. 2. Incorrect: We can't hear them yet because the client is just 8 weeks pregnant. It may be possible to detect heart beat with a Doppler transducer at 10 weeks, but this client is only in the eighth week of pregnancy. 3. Incorrect: A vaginal exam may stimulate heavier bleeding and will not provide information about concealed bleeding. A transvaginal ultrasound will be performed to determine whether a fetus is present and if so, whether it is alive.)

The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia

4. Hypokalemia (4. Correct: Hyperemesis gravidarum is characterized by persistent severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting. 1. Incorrect: Hypocalcemia results from any condition that causes a decrease in the production of parathyroid hormone (PTH). Hyperemesis gravidarum does not affect PTH. 2. Incorrect: The lower GI tract has a lot of magnesium; this client is at risk for hypomagnesemia, but not more than hypokalemia. The client with hyperemesis gravidarum is losing upper GI contents. 3. Incorrect: The client with hyperemesis gravidarum is at high risk for being dehydrated. The electrolyte imbalance associated with dehydration is hypernatremia, not hyponatremia. Remember, this client's blood will be concentrated, and concentrated makes numbers go up i.e. sodium, hematocrit and specific gravity.)

A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention? 1. Ambulate in the room 2. Perform crede' exercises 3. Reassess the fundus in 30 minutes. 4. Massage the fundus.

4. Massage the fundus. (4. Correct: If the fundus is boggy and soft, massaging the fundus until firm will increase uterine tone and decrease bleeding. This is the only option that will fix the problem. 1. Incorrect: Ambulation will not fix a boggy fundus and would not be safe. 2. Incorrect: Crede' exercises are for bladder tone. Although urinary retention will prevent uterine contraction, the appropriate nursing intervention in the case of a full bladder is to have the client empty her bladder or to catheterize her if she is unable to void. 3. Incorrect: Postponing care could make the bleeding worse. This is delaying care.)

A term primipara is admitted in active labor and with rupture of membranes. Her last vaginal exam one hour ago revealed that she was dilated to 6 centimeters, 100% effaced, and at -1 station. The client calls out "My belly really hurts. I feel like I have to have a bowel movement!" Which action should the nurse perform first? 1. Offer her a bedpan. 2. Call the primary healthcare provider. 3. Prepare for epidural administration. 4. Perform a sterile vaginal exam.

4. Perform a sterile vaginal exam. (4. Correct: Labor can progress rapidly even in a primipara. As the fetal presenting part descends, pressure is placed on the rectum and many women report that it feels as though they need to have a bowel movement. The symptoms described indicate that the client has fully dilated and is at +1 or better station, and delivery may be imminent. 1. Incorrect: The nurse should first determine labor progress with a vaginal exam since this complaint is a common symptom of labor progressing and the fetus descending through the birth canal. Often, the client has had an enema to cleanse the colon prior to delivery so there usually is no fecal material present. 2. Incorrect: First determine labor progress with a vaginal exam. This might be necessary later, but is not the first action to perform. 3. Incorrect: First determine labor progress with a vaginal exam prior to preparing the client for anesthesia.)

What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero? 1. Grasps nurse's finger when placed in neonate's hand. 2. Toes curl downward when soles of feet stroked. 3. Turn's toward nurse's finger when cheek is touched. 4. Extends arms when nurse claps hands.

2. Toes curl downward when soles of feet stroked. (2. Correct: If the neonate's toes curl downward when the soles of the feet are stroked, it may be evidence that neurologic damage from asphyxia has occurred. A normal response would be for the toes to curl fan out when the soles of the feet are stroked. 1. Incorrect: This is a normal response seen in the neonate. 3. Incorrect: This is a normal response seen in the neonate. 4. Incorrect: This is a normal response seen in the neonate.)

A pregnant client's initial blood work shows a negative rubella titer. The nurse is aware this result indicates what important course of action? 1. Client needs to be isolated until delivery. 2. Client is immune to rubella currently. 3. Client should be given rubella vaccine after delivery. 4. Client has never been exposed to rubella.

3. Client should be given rubella vaccine after delivery. (3. Correct: A negative titer indicates the client has no rubella antibodies present currently. But because the rubella vaccine contains a live virus, the client cannot be safely vaccinated until after delivery. 1. Incorrect: Although the client may be cautioned about being around groups of children until after delivery, there is no need for total isolation for the duration of the pregnancy. 2. Incorrect: If the client were immune to rubella, the titer would have been positive, indicating the presence of rubella antibodies. This client is not immune currently. 4. Incorrect: Whether the client has ever been exposed to rubella cannot be determined from the information presented in this question.)

A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring? Select all that apply 1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby 5. Allows baby to cry vigorously for 15 minutes

1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby (1., 2., 3., & 4. Correct: Positive behaviors that would indicate that maternal-infant bonding is occurring include making eye contact, assuming en face position when holding the infant, pointing out common features, smiling and gazing at the infant, touching infant, progressing from fingertips to holding, speaking soft, high-pitched tones and speaking positively about the infant. 5. Incorrect: Crying vigorously for 15 minutes is an indication that the baby has a need that the mom is ignoring. This is not a common behavior promoting maternal-infant bonding.)

Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the nurse takes priority? 1. Elevate the head of the bed 2. Administer oxygen by face mask 3. Position client side-lying 4. Begin dopamine 5 mcg/kg/min

3. Position client side-lying (3. Correct: When you turn them on their side, this relieves pressure on the vena cava and the BP will go UP. 1. Incorrect: This will drop the pressure more. 2. Incorrect: O₂ doesn't bring up the BP. 4. Incorrect: Stay away from drugs as long as you can.)