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A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider? A The client has a fundal height of 38 cm B The client has a fasting blood glucose of 90 mg/dL C The client reports 12 fetal movements in 1 hr D The client has nonpitting pedal edema
A The client has a fundal height of 38 cm
A nurse is providing discharge instructions to a client who is 24 hours postpartum and has decided not to breastfeed.Which of the following instructions should the nurse include in the teaching? A. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule." B. "Shower daily, allowing warm water to run directly over your breasts." C. "Wear a loose-fitting nonbinding bra for 72 hours." D. "Pump your breasts twice daily to relieve discomfort from engorgement."
A. "Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule."
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound.Which of the following statements by the client indicates an understanding of the teaching? A. "I will drink water before the test until my bladder feels full." B. "I can't have anything to eat after midnight." C. "I won't apply perfumed lotion to my abdomen before the test." D. "I need to take a stool softener the night before the test."
A. "I will drink water before the test until my bladder feels full."
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake.The nurse should instruct the client that which of the following foods has the highest amount of calcium? A. 1 cup cooked broccoli. B. 1 large banana. C. 1/2 cup cubed avocado. D. 1 medium potato.
A. 1 cup cooked broccoli.
a nurse is caring for a client who is receiving prenatal care and is at her 24 week appointment. which of the following laboratory tests should the nurse plan to conduct? A. 1 hr glucose tolerance test B. rubella titer C. group b strep culture D. blood type and RH
A. 1 hr glucose tolerance test
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs? A. 6 contractions in 10 min. B. Contractions last 60 seconds. C. Moderate variability of the fetal heart rate. D. Nonrepetitive early decelerations.
A. 6 contractions in 10 min.
A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication? A. Urine output 20 mL/hr. B. Hypertension. C. Hyperglycemia. D. Respiratory rate 16/min.
A. Urine output 20 mL/hr.
a nurse in a prenatal clinic is reviewing the lab results for a client who is at 12 weeks of gestation? which of the following actions should the nurse take? A. administer ceftriaxone IM B. administer rubella vaccine C. obtain a maternal serum alpha-fetoprotein specimen D. obtain a blood culture
A. administer ceftriaxone IM
A nurse is performing an inital assessment of a newborn who was delivered with a nuchal cord. which of the following clinical findings should the nurse expect? A. facial petechiae B. periauricular papillomas C. telangiectic nevi D. erythema toxicum
A. facial petechiae
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. Which of the following actions should the nurse plan to take when performing a fundal massage (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Ask the client to lie on her back with her knees flexed Place a hand just above the client's symphysis pubis Position a hand around the top of the client's fundus Rotate the upper hand to massage the client's uterus Use slight downward pressure to compress the client's fundus. observe the clients perineum for the passage of clots and amount of bleeding
A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate? A. "This medication stabilizes the fetal heart rate." B. "This medication prevents seizures." C. "This medication increases cardiac output." D. This medication improves tissue perfusion."
B. "This medication prevents seizures."
A nurse is caring for a client who is in the latent phase of the first stage of labor and is in pain.Which of the following nursing interventions are appropriate to reduce pain? (Select all that apply.) A. Perform Leopold maneuvers. B. Apply counterpressure to the sacral area C. Ambulate the client in the hallway D. Administer 70-90% nitrous oxide mixed with oxygen
B. Apply counterpressure to the sacral area C. Ambulate the client in the hallway D. Administer 70-90% nitrous oxide mixed with oxygen
A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization.Which of the following client statements indicates understanding of the teaching? A. "I will receive a series of three immunizations and each one will be a month apart." B. "I will report joint pain that develops after the immunization to my provider immediately." C. "I should avoid becoming pregnant for at least 1 month following the immunization." D. "I should avoid breastfeeding for 2 weeks following the immunization."
C. "I should avoid becoming pregnant for at least 1 month following the immunization."
A nurse in a newborn nursery is receiving change-of-shift report for four newborns.Which of the following newborns should the nurse assess first? A. A newborn who is 24 hr old and has not had a meconium stool. B. A newborn who has a short frenulum and is having difficulty breastfeeding. C. A newborn who is 10 hr old and has onset tachypnea. D. A newborn who is 30 hr old and has blood-tinged discharge in her diaper.
C. A newborn who is 10 hr old and has onset tachypnea.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take? A. Place the client in a semi-Fowler's position for 1 hr after administration. B. Instruct the client to avoid urinary elimination until after administration. C. Verify that informed consent is obtained prior to administration. D. Allow the medication to reach room temperature prior to administration.
C. Verify that informed consent is obtained prior to administration.
A nurse is caring for a client who is at 30 weeks of gestation. the nurse should plan to immunize the client which of the following vaccines? select all that apply A. varicella B. Human papillomarvirus C. diphtheria-acellular pertussis D. inactivated influenza E. measles, mumps, influenza
C. diphtheria-acellular pertussis D. inactivated influenza
A nurse is using Nageles rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was july 28th which of the follow should the nurse document as a client expected delivery date? A. april 21st B. april 4th C. may 5th D. may 21st
C. may 5th
a nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider? A. blood glucose 58mg/DL B. hematocrit 48% C. platelets 100,00/mm3 D. hemoglobin 16G/.DL
C. platelets 100,00/mm3
A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make? A. "You should name the baby so she can have an identity." B. "If you don't hold the baby, it will make letting go much harder." C. "I'm sure you will be able to have another baby when you're ready." D. "You can bathe and dress your baby if you'd like to."
D. "You can bathe and dress your baby if you'd like to."
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository? A. Abdominal distention B. Afterpains C. Vaginal candidiasis D. Third-degree perineal laceration.
D. Third-degree perineal laceration.
A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate? A. Urine culture B. Rapid plasma reagin C. Prothrombin time D. Urine ketones
D. Urine ketones
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. which of the following recommendations should hte nurse make> A. avoid eating snacks before bedtime B. eat high-fat snack before getting out of bed C. drink additional liquids with each meal D. consume food served at cool temperature
D. consume food served at cool temperature
A nurse is caring for a client who has preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following lab values should the nurse review during tocolytic therapy? A. indirect Coombs test B. liver enzymes C. uric acid level D. serum medication level
D. serum medication level
A nurse is caring for a newborn.Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? A. The newborn's respiratory rate is 32/min. B. The newborn's respiratory rate is irregular. C. The newborn is beginning to cough. D. The newborn's pulse oximetry is 91. E. None of the above
E. None of the above
A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care? a. Administer broad-spectrum antibiotics b. cleanse the site with Povidone iodine c. monitor the rectal temperature every 4 hours d. prepare for surgical closure after 72 hours
a. Administer broad-spectrum antibiotics
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care? a. Use a fetal scalp electrode during labor and delivery b. Bathe the newborn before initiating skin to skin contact c. instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation d.administer pneumococcal immunization to the newborn within 4 hours following birth
b. Bathe the newborn before initiating skin to skin contact
A nurse is caring for four enter-partum clients. Which of the following clients should the nurse assess first? a. A client who is at 7 weeks of gestation and reports urinary frequency b. a client who is at 32 weeks of gestation and reports seeing floating spots c. a client who is 38 weeks of gestation and reports leg cramps d. a client who is at 20 weeks of gestation and reports periodic numbness in her fingers
b. a client who is at 32 weeks of gestation and reports seeing floating spots
A nurse is assessing a client who is in preterm labor and has a new prescription or terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse Withhold the medication and Report to the provider? a. fasting blood glucose 75 mg / DL b. blood pressure 88/58 mmhg c. urinary output 40 ml /hr d. FHR 120/min
b. blood pressure 88/58 mmhg
A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother States "No the baby is too tired to be held, Which of the following actions should the nurse take? A. Insist that the mother pick up the newborn to feed him. B. Demonstrate how to hold the newborn and allow the client to practice. C. Persuade the client to breastfeed the newborn to promote bonding. D. Offer to take the newborn to the nursery to finish his feeding.
b. demonstrate how to hold a newborn and allow the client to practice
A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take? a. Administer 50 mL of dextrose solution IV b. obtain a blood sample of serum glucose level c. reassess the blood glucose level prior to the next feeding d. Feed the newborn immediately
c. reassess the blood glucose level prior to the next feeding
A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include? A. "You will be asked to change your password once per year.". B. "Documentation of sensitive material is performed by the charge nurse.". C. "You will be given access to the medical records of every client in the facility.". D. "Information Technology will install a firewall to secure client information.".
A. "You will be asked to change your password once per year.".
A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation.Which of the following findings should indicate to the nurse the need for further diagnostic testing? A. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period. B. No late decelerations noted with three uterine contractions of 60 seconds in C. duration within a 10-min testing period. D. Irregular contractions of 10 to 20 seconds in duration that are not felt by the client.
A. An increase in fetal heart rate to 150/min above the baseline of 140/min lasting 10 seconds in response to fetal movement within a 40-min testing period.
A nurse is providing dietary teaching to a client who is at 32 weeks of gestation and has cholelithiasis.Which of the following foods should the nurse recommend for the client to include in her diet? A. Baked chicken. B. French fries. C. Whole milk. D. Bacon cheeseburger.
A. Baked chicken.
A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? A. Blood pressure 80/50 mm Hg .B. Respiratory rate 55/min. C. Heart rate 72/min. D. Temperature 36.5°C (97.7°F).
A. Blood pressure 80/50 mm Hg
A nurse is caring for a client who is in active labor and has gonorrhea.For which of the following potential complications of gonorrhea should the nurse monitor? A. Chorioamnionitis. B. Vaginal laceration during birth. C. Oligohydramnios. D. Excessive bleeding after birth.
A. Chorioamnionitis.
A nurse is caring for a client who is postpartum and experiencing hypovolemic shock.Which of the following findings should the nurse expect? A. Cool, clammy skin. B. Urinary output 30 mL/hr. C. Bounding pulses. D. Respiratory rate 18/min.
A. Cool, clammy skin.
A nurse is performing an assessment of a newborn's Babinski reflex. Which of the following findings should the nurse expect? A. Eversion of the great toe B. Flexion of the forearm C. Downward curl of the toes D. Extension of the leg
A. Eversion of the great toe
A nurse in a provider's office is caring for a 20-year-old client at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make? A. this procedure determines if your baby has genetic or congenital disorders B. your provider scheduled a chronic villus sampling to determine the sex of your baby C. you cannot have an amniocentesis until you are at least 35 years of age D. we can schedule the procedure for later today if you'd like
A. this procedure determines if your baby has genetic or congenital disorders
a nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia., which of the following findings should the nurse report to the provider? A. hemoglobin 14.8 g/dl B. platelet count 60,000 C. creatine 0.8 mg/dL D. urine protein
B. platelet count 60,000
A nurse is planning care for a client following a chorionic villus sampling. The nurse should recognize that the client is at risk for developing which of the following complications? A. Anemia B. Infection C. Late decelerations D. Placental insufficiency.
B. Infection
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection? A. Midline episiotomy B. Meconium-stained fluid C. Gestational hypertension D. Placenta previa
B. Meconium-stained fluid
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? A. Incompetent cervix. B. Postpartum hemorrhage. C. Ectopic pregnancy. D. Hyperemesis gravidarum.
B. Postpartum hemorrhage.
A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? A. Puncture the heel on the inner aspect of the foot. B. Use an automatic puncture device on the heel. C. Cleanse the newborn's heel with an alcohol swab after the procedure. D. Place an ice pack on the newborn's heel 5 min before the procedure.
B. Use an automatic puncture device on the heel.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. which of the following instructions should the nurse include A. expect 2 to 4 wet diapers every 24hrs B. allow the baby to feed at least every 3 hours C. offer the newborn 30ml (1oz) a water between feedings D. Feed the newborn 5 to 10 minutes per breast
B. allow the baby to feed at least every 3 hours
a nurse is caring for a client who is 36 weeks gestation and has MRSA which of the following isolation precautions should the nurse initate A. droplet B. contact C. airborne D. protective environment
B. contact
a nurse is caring for a client who received epidural analgesia during labor is 4 hours postpartum. which of the following client reports should the nurse address first? A. itching B. inabiltiy to void C. abdominal cramps D. tingling in the legs
B. inabiltiy to void
a nurse is caring for a client who has gestational diabetes mellitus. which of the following clinical findings should indicate to the nurse the client has hyperglycemia? A double vision B. increased urination C. sweating D. dizziness
B. increased urination
a nurse is caring for a client who reports spontaneous rupture. the nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. after calling for assistance and notifying the provider. which of the following should the nurse take next A. initiate an infusion of IV fluids for the client B. perform vaginal examination by applying upward pressure on the presenting part C. administer oxygen via non rebreather mask at 8L/min D. cover the umbilical cord with ste
B. perform vaginal examination by applying upward pressure on the presenting part
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report? A. Increased fetal movement. B. Increased urinary output. C. Increased muscle weakness. D. Increased respiratory rate.
C. Increased muscle weakness.
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion.Which of the following findings should the nurse report to the provider? A. Decrease in frequency of contractions. B. Urinary output 35 mL/hr. C. Absent deep-tendon reflexes. D. BP 150/100 mm Hg.
C. Absent deep-tendon reflexes.
A nurse is caring for a newborn following delivery. Which of the following actions should the nurse take first? A. Obtain the newborn's weight. B. Administer IM vitamin K. C. Apply identification bands to the newborn. D. Apply prophylactic eye ointment.
C. Apply identification bands to the newborn.
A nurse is caring for a newborn who has exstrophy of the bladder.Which of the following actions should the nurse take prior to the beginning of surgical correction? A. Restrict the newborn's fluid intake. B. Keep the newborn in a side-lying position. C. Cover the newborn's bladder with a sterile, non-adherent dressing. D. Exert gentle pressure on the newborn's bladder with sterile gauze.
C. Cover the newborn's bladder with a sterile, non-adherent dressing.
A nurse is assessing a newborn who was exposed to cocaine in utero. Which of the following findings should the nurse expect? A. Hypotonicity B. Decreased startle response C. High-pitched cry D. Increased head circumference
C. High-pitched cry
a nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. which of the following statements by the client indicates an understanding of the teaching> A. I should discontinue the medication if i experience spotting B. I will need to return to the clinic in the next eighth weeks for my next injection C. I should increase my calcium intake while taking this medication D. I will get two shots each time I receive this medication
C. I should increase my calcium intake while taking this medication
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider? A. Rust-stained urine. B. Single palmar creases. C. Subconjunctival hemorrhage. D. Transient circumoral cyanosis.
C. Subconjunctival hemorrhage.
A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect? A. Temperature 37.4°C (99.3°F) B. Scant lochia C. Uterine tenderness D. WBC count 9,000/mm³
C. Uterine tenderness
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? A. "Lesions are visible on the mother's genitalia." B. "Mothers will receive prophylactic treatment with acyclovir prior to delivery." C. "This infection requires that airborne precautions be initiated for the newborn." D. "Transmission can occur via the saliva and urine of the newborn."
D. "Transmission can occur via the saliva and urine of the newborn."
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase her intake of vitamin B12. Which of the following foods should the nurse recommend? A. Fresh citrus fruits. B. Brown rice. C. Raw carrots. D. Fortified soy milk.
D. Fortified soy milk.
A nurse is conducting a class for a group of clients about birth control.Which of the following information should the nurse include in the teaching? A. You should use spermicide 3 hours prior to sexual intercourse. B. Your fertility will return 6 months after your provider removes your IUD. C. You will not need to use birth control for 1 month after receiving emergency contraception. D. You should have an annual examination to assess your diaphragm.
D. You should have an annual examination to assess your diaphragm.
a nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. which of the following instructions should the nurse include? A. you should use an oil based vaginal lubricant when inserting your diaphragm B. you should store your diaphragm in sterile water after each use C. you should keep the diaphragm in place for at least 4hrs after intercourse D. you should have your provider refill you for a new diaphragm
D. you should have your provider refill you for a new diaphragm
a nurse is teaching a client and her partner about the technique of counter pressure during labor? which of the following statements by the nurse is appropriate? A. your partner will apply upward pressure on your lower abdomen between contractions B. your partner will apply continuous pressure between your thumb and index finger C. your partner will apply pressure to the top of your uterus during contractions D. your partner will apply steady pressure with a tennis ball to your lower back
D. your partner will apply steady pressure with a tennis ball to your lower back
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (cmv) infection during pregnancy. The newborn acquired cmv transplacentally. Which of the following findings should the nurse expect the newborn to exhibit? a. cataract b. hearing loss c. macrosomia d. urinary tract infection
b. hearing loss
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect? a. Firm rigid abdomen b. painless, vaginal bleeding c. uterine hypertonicity d. persistent headache
b. painless, vaginal bleeding
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include? a. Apply a thin layer lotion to the newborn skin every 8 hours b. trust in you born in a thin layer clothing during the therapy c. ensure the newborn's eyes are closed beneath the shield d. give the newborn 1 oz of glucose water every 4 hours
c. ensure the newborn's eyes are closed beneath the shield
A client who is 16 weeks of gestation asks the nurse how to prepare her toddler for a younger sibling. Statements should the nurse make? a. You should hold your newborn in your arms when you introduce him to your toddler b. you should move your toddler out of her crib 2 weeks prior to your due date c.you should give your toddler a gift from the baby when she visit you in the facility d. You should place your toddler in timeout if she exhibits regressive Behavior after the baby is born
c.you should give your toddler a gift from the baby when she visit you in the facility
A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5- day old male newborn at home. Which of the following statements should the nurse make to the client? a. Retract the foreskin to clean your baby's during each bath b. use triple antibiotic ointment on your baby's umbilical cord twice per day c. Swaddle your baby tightly with legs extended before laying him down to sleep d. notify your baby's pediatrician if he urinates less than 6 times per day
d. notify your baby's pediatrician if he urinates less than 6 times per day
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following? - A. the plastibell will be removed 4 hours after the procedure b. notify the provider is the end of your penis appears dark red c. make sure the newborn's diaper is snug d. yellow exudate will form at the surgical site in 24 hours
d. yellow exudate will form at the surgical site in 24 hours
