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A nurse is providing dietary teaching with a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?

"I should eat to taste instead of trying to balance my meal

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

"I will have blood tests because my potassium might decrease."

A nurse is conducting an initial prenatal visit for a client who is at 6 weeks of gestation. Which of the following laboratory tests should be performed at this time?

Rubella titer

A nurse is providing education for a client who is in her third trimester and is scheduled for a biophysical profile. The nurse should tell the client that which of the following variables is included in the test?

Amniotic fluid index

A nurse is caring for a client newly admitted to the PACU following a cesarean birth. Which of the following is the priority nursing assessment?

Amount of postpartum lochia

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following assessment findings by the nurse should be reported to the provider?

BUN 25 mg/dL

nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following assessment findings by the nurse should be reported to the provider?

BUN 25 mg/dL An elevated BUN can indicate dehydration and should be reported to the provider.

A nurse on the postpartum unit is caring for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following assessment findings should the nurse expect to find?

Decreased platelet count

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following should the nurse include in the plan of care?

Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. So, instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted

Nurse is caring for a client who is postpartum and has a history of preeclampsia. Upon assessment, the nurse observes petechiae and serosanguineous fluid oozing from the IV insertion site. Which of the following findings should be reported to the provider?

Platelet 50,000

A nurse is providing discharge instructions to a client who had a vaginal delivery and is breastfeeding her newborn. Which of the following statements indicates an understanding of the teaching?

"I will need to eat an additional 330 calories a day while I'm breastfeeding.

A nurse is providing discharge instructions to a client whose infant was circumcised using the clamp technique. Which of the following responses by the client indicates an understanding of the teaching?

"I will put petroleum jelly around the glans during each diaper change." When the clamp method is used, petroleum jelly should be applied around the glans during each diaper change.

A nurse is providing teaching to a client of normal weight who is at 10 weeks of gestation. Which of the following client statements should indicate to the nurse that the client is accepting expected body image changes related to pregnancy?

"I will use new positions during intercourse."

A nurse is providing family planning education to a client who has decided to use a diaphragm. Which of the following should the nurse include in the plan of care?

"You should leave the diaphragm in place for at least 6 hours after intercourse."

A nurse is assessing a newborn who has a weak cry and is grimacing. The nurse notes the newborn has a heart rate of 102/min, blueish extremities, and a flaccid muscle tone. Which of the following reflects the appropriate APGAR score?

5

A nurse on an antepartum unit is reviewing the assessment findings of four clients who are in the third trimester of pregnancy. Which of the following assessment findings is the highest priority?

A client who is reporting epigastric pain

nurse on an antepartum unit is reviewing the assessment findings of four clients who are in the third trimester of pregnancy. Which of the following assessment findings is the highest priority?

A client who is reporting epigastric pain

A nurse on the newborn unit is planning discharge for four clients. Which of the following newborns will require care beyond that of a standard follow-up visit with the provider after delivery?

A newborn being sent home 22 hr after birth

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The fetal monitor shows uterine contractions every 6 min, lasting 20 to 25 seconds, and an FHR of 150/min. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?

A reduction in respiratory distress in the newborn

A nurse is caring for a client who is in premature labor at 32 weeks of gestation and is receiving magnesium sulfate 2 g IV for tocolytic therapy. The nurse should report which of the following findings to the provider?

Absent deep tendon reflexes

A nurse is caring for a client in labor who is reporting excessive pain. Which of the following interventions requires the nurse to hold an additional certification or licensure?

Acupuncture Acupuncture, a pain-control technique that involves the insertion of fine needles into specific body areas, should be performed only by a trained, certified therapist. In some states, additional licensure is required

A nurse is caring for a client who is in labor and has ruptured membranes and one inch of the umbilical cord protruding into the vagina. After calling for assistance, which of the following is a priority nursing action?

Apply internal upward pressure to the presenting part

A nurse is caring for a client who is in labor with right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following is an appropriate action for the nurse to take?

Apply sacral counterpressure The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

A nurse is caring for a client who is 1 day post-vaginal delivery. The nurse determines the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

Assist the client to empty her bladder.

A nurse is caring for a client who is in active labor and reports back pain. The nurse performs a vaginal exam and determines the client is 8 cm dilated, 100% effaced, and -2 station. The fetus is in the occiput posterior position. Which of the following is an appropriate nursing intervention?

Assist the client to the hands and knees position.

A nurse is providing teaching about nonpharmacological pain management for a postpartum client who is breastfeeding and has engorgement. Which of the following methods should the nurse recommend?

Cold cabbage leaves The application of cold cabbage leaves is an effective nonpharmacological method to relieve pain associated with engorgement.

A nurse is assessing a fetal heart monitor tracing of a client receiving oxytocin at 10 milliunits/min. Uterine contractions are noted every 60 to 90 seconds. After turning the client to a side-lying position, which of the following actions should the nurse take next?

Discontinue the medication infusion.

A nurse is teaching a client about Rho(D) immunoglobulin (RhoGAM). Which of the following statements by the client indicates an understanding of the teaching?

I will need this medication if I have an amniocentesis."

A nurse is caring for a client who has a history of rheumatic heart disease, but no physical symptoms prior to pregnancy. The client begins to experience dyspnea, orthopnea, and pulmonary edema. Which of the following physiological alterations explains this change?

Increased blood volume

A nurse is teaching the mother of a newborn about erythromycin ophthalmic ointment 0.5%. Which of the following should be included in the teaching?

It is required by law that newborns receive this treatment.

A nurse is performing an admission assessment on a newborn who is large for gestational age (LGA). Which of the following findings indicates a need for further assessment?

Jitteriness

A client who is pregnant presents to a prenatal clinic for her first visit. She tells the nurse that her last normal menstrual period began Oct 13. Using Nägele's rule, the nurse should determine the client's estimated date of delivery as which of the following?

July 20

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and requires notification of the provider?

Late decelerations Oxytocin is contraindicated based on late decelerations noted on fetal assessment findings. Late decelerations are indicative of uteroplacental insufficiency.

A nurse is observing a mother caring for her newborn who is crying. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior?

Lays the newborn across her lap and gently sways

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

Leopold maneuvers

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following is the priority intervention for the nurse to take?

Monitor the fetal heart rate.

A nurse is assessing a newborn who is 24 hr old. Which of the following is an appropriate action for the nurse to take? (There are three tabs that contain separate categories of data. Look at this data to answer the question.)

Obtain a blood glucose level Assessment data indicates possible hypoglycemia; therefore, this is an appropriate action for the nurse to take.

A nurse is caring for a client who is pregnant and has epilepsy. The nurse observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next?

Oxygen

A nurse is providing education about car seat safety to the parents of a newborn. Which of the following should the nurse include in the teaching?

Position the newborn in the car seat at a 45° angle.

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. This infection places the client at increased risk for which of the following during pregnancy?

Premature rupture of membranes

A nurse is caring for a client who has a vaginal hematoma in the immediate postpartum period. Which of the following assessment findings should the nurse expect to find?

Pressure in the vagina

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?

Swaddle the newborn after the heel puncture.

A client in the transitional phase of labor is using breathing techniques to manage her pain. Which of the following actions by the client should indicate to the nurse that the client's plan of care should be altered?

The client reports tingling sensations in her fingers. Report of tingling sensations in the fingers indicates that the client is hyperventilating. This causes respiratory alkalosis, resulting in dizziness, tingling of the fingers, and circumoral numbness. This can be reversed by having the client breathe into her cupped hands or placing a paper bag tightly around her mouth and nose to breathe carbon dioxide.

A nurse is caring for a client who is at 38 weeks of gestation and is in labor. The nurse notes late decelerations on the fetal monitor. (Order the steps of the process by placing the letters in the correct sequence.)

The nurse should first reposition the client on her side, increase the maintenance IV solution per protocol or the provider's prescription, palpate the uterus to assess for tachysystole, and then administer oxygen via face mask at 8 L/min.

A nurse in a provider's office is assessing a client who is breastfeeding and reports a fever and body aches. Which of the following additional clinical findings is associated with mastitis?

Unilateral breast pain with tenderness Sudden onset of fever, chills, body aches, and unilateral breast pain with tenderness are clinical findings associated with mastitis.


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