OB Final SSE

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75. A primiparous client with a neonate who is 36hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which of the following? 1. An immature cardiac sphincter. 2. A defect in the gastrointestinal system. 3. Burping the infant too frequently. 4. Moving the infant during the feeding.

1. An immature cardiac sphincter.

54. Three days after admission of a neonate born at 30 weeks' gestation, the neonatologist plans to assess the neonate for intraventricular hemorrhage (IVH). The nurse should plan to assist the neonatologist by preparing the neonate for which of the following? 1. Cranial ultrasonography. 2. Arterial blood specimen collection. 3. Radiographs of the skull. 4. Complete blood count specimen collection.

1. Cranial ultrasonography.

During labor, the nurse determines that a full term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order) a. Provide oxygen via face mack b. Reposition the client c. Increase IV fluid d. Call the healthcare provider

1. Reposition the Client 2. Provide oxygen via face mask 3. Increase IV fluid 4. Call the healthcare provider

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order) a. Provide oxygen via face mask b. Reposition the client c. Increase IV fluid d. Call the healthcare provider

1. Reposition the Client - b. 2. Provide oxygen via face mask - a. 3. Increase IV fluid - c. 4. Call the healthcare provider - d.

pregnant woman of 39 which dates is need to report :

101. 2 F oral temp

The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and a 12- year-old sibling are the child bedside. Which instruction best supports this family?

" While waiting for the healthcare provider, only one visitor may stay with the child"

A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? -Bruising. -Oral intake. -Hemoglobin. -Bilirubin.

-Bilirubin.

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? -Provide tactile stimulation. -Administer flow by 100% oxygen. -Asses the functionality of the monitoring device. -Evaluate the newborn's color and respirations.

-Evaluate the newborn's color and respirations.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery? -April 25, 2007. -May 9, 2007. -May 29, 2007. -June 2, 2007.

-May 9, 2007.

The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer?

0.3

Match the degree of tear or episiotomy to its description A. Laceration that goes through the anal sphincter and the rectal wall B. a tear through part or all of the perineal muscles C. small nick in the perineum, not involving muscle D. Laceration through part or all of anal sphincter muscle 1st degree 2nd degree 3rd degree 4th degree

1st degree = C. small nick in the perineum, not involving muscle 2nd degree = B. a tear through part or all of the perineal muscles 3rd degree = D. Laceration through part or all of anal sphincter muscle 4th degree = A. Laceration that goes through the anal sphincter and the rectal wall

58. Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching? 1. "BPD is an acute disease that can be treated with antibiotics." 2. "My baby may require long-term respiratory support." 3. "Bronchodilators can cure my baby's condition." 4. "My baby may have seizures later on in life because of this condition."

2. "My baby may require long-term respiratory support."

77. A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age? 1. 2 months. 2. 6 months. 3. 8 months. 4. 10 months.

2. 6 months.

94. During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which of the following? 1. Postpartum "blues." 2. Uterine atony. 3. Intrauterine infection. 4. Urinary tract infection.

2. Uterine atony.

estimate the date of delivery for Nagele rules 15 February first day last menstruation

22 NOV

A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus?

3 cm below the umbilicus

55. Which of the following would the nurse most expect to assess in a neonate born at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)? 1. Increased muscle tone. 2. Hyperbilirubinemia. 3. Bulging fontanels. 4. Hyperactivity.

3. Bulging fontanels.

65. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following? 1. Apply an ice cube to the nipples. 2. Rub her nipples gently with lanolin cream. 3. Express a small amount of breast milk. 4. Offer the neonate a small amount of formula.

3. Express a small amount of breast milk.

In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.)

3. The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement? 1. "If the fetus is becoming less active than before." 2. "If it takes longer each day for the fetus to move 10 times." 3. "If the fetus stops moving for 12 hours." 4. "If the fetus moves more often than 3 times an hour."

4. "If the fetus moves more often than 3 times an hour." Daily fetal movement counting is part of all high-risk assessments and is a noninvasive, inexpensive method of monitoring fetal well-being. The health care provider should be notified if there is a gradual slowing over time of fetal activity, if each day it takes longer for the fetus to move a minimum of 10 times, or if the fetus stops moving for 12 hours or longer.

59. A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following? 1. Placement of the neonate on a ventilator. 2. Administration of bronchodilators through the nares. 3. Suctioning of the neonate's nares with wall suction. 4. Insertion of a chest tube into the neonate.

4. Insertion of a chest tube into the neonate.

81. When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently? 1. Dehydration. 2. Nausea and vomiting. 3. Iron-deficiency anemia. 4. Tachycardia.

4. Tachycardia.

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take? A) Call for help and Notify the care provider immediately B) Start pitocin C) Have her empty her bladder D) Insert a Foley catheter

A) Call for help and Notify the care provider immediately

3) Which basic type of pelvis includes the correct description and percentage of occurrence in women? A) Platypelloid: flattened, wide, shallow; 3% B) Anthropoid: resembling the ape; narrower; 10% C) Android: resembling the male; wider oval; 15% D) Gynecoid: classic female; heart shaped; 75%

A) Platypelloid: flattened, wide, shallow; 3%

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes and hyperclonus. B. Periorbital edema, flashing lights, and aura. C. Epigastric pain in the third trimester. D. Recent decreased urinary output.

A. 3+ deep tendon reflexes and hyperclonus.

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the LPN/LVN perform first? A. Bathe the infant with an antimicrobial soap. B. Measure the head and chest circumference. C. Obtain the infant's footprints. D. Administer vitamin K (AquaMEPHYTON).

A. Bathe the infant with an antimicrobial soap.

5. A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied. B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C. Breastfeed on the unaffected breast only until the mastitis subsides. D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.

A. Breastfeed the infant, ensuring that both breasts are completely emptied.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? A. Describe diet changes that can improve the management of her diabetes. B. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. C. Demonstrate self-administration of insulin. D. Evaluate the client's ability to do glucose monitoring

A. Describe diet changes that can improve the management of her diabetes.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next? A. Initiate positive pressure ventilation. B. Intervene after the one minute Apgar is assessed. C. Initiate CPR on the infant. D. Assess the infant's blood glucose level.

A. Initiate positive pressure ventilation.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the LPN/LVN perform next? A. Initiate positive pressure ventilation. B. Intervene after the one minute Apgar is assessed. C. Initiate CPR on the infant. D. Assess the infant's blood glucose level.

A. Initiate positive pressure ventilation.

Which nursing intervention is helpful in relieving"afterpains" (postpartum uterine contractions)? A. Using relaxation breathing techniques. B. Using a breast pump. C. Massaging the abdomen. D. Giving oxytocic medications.

A. Using relaxation breathing techniques.

The LPN/LVN is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs A. two weeks before menstruation. B. immediately after menstruation. C. immediately before menstruation. D. three weeks before menstruation.

A. two weeks before menstruation.

The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drip to augment a clients labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin? A) uterus is soft B) contraction duration of 100 seconds C) four contractions in 10 minutes D) Early deceleration of fetal heart rate

B) contraction duration of 100 seconds

The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client's teaching plan? A) Insulin production is decreased during pregnancy B) increase daily caloric intake is needed C) injection requirements remain the same D) Blood sugars need less monitoring in the first trimester

B) increase daily caloric intake is needed

A woman who is 38 weeks' gestation is receiving magnesium sulfate for severe preeclampsia Which assessment finding warrants immediate intervention by the nurse A- dizziness when standing B-Absent patellar reflexes C-Sinus tachycardia D- Lower back pain

B-Absent patellar reflexes

A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform?

Babinski's reflex.

A woman in labor has just received an epidural block. The most important nursing intervention is to: A) Limit parenteral fluids. B) Monitor the fetus for possible tachycardia C) Monitor the maternal blood pressure for possible hypotension. D) Monitor the maternal pulse for possible bradycardia

C) Monitor the maternal blood pressure for possible hypotension.

Which of the following is NOT a reason to come to labor and birth. A) The patient is 39 weeks with second baby. She has been having contractions for 2 hours. Contractions are getting longer and stronger and closer together. B) The patients says she has noticed greenish fluid leaking from her vagina. She is 41.5 weeks pregnant and not having contractions. C) The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours. D) The patient has not felt the baby move for 8 hours, despite drinking cold fluids, and nudging the baby with her hand.

C) The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours.

The LPN/LVN providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by: A) Altered cerebral blood flow B) Spontaneous rupture of membranes C) Uteroplacental insufficiency D) Umbilical cord compression

C) Uteroplacental insufficiency

A client at 32-weeks gestation is hospitalized with severe pregnancy induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? A. 4+ reflexes. B. Urinary output of 50 ml per hour. C. A decrease in respiratory rate from 24 to 16. D. A decreased body temperature.

C. A decrease in respiratory rate from 24 to 16.

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? A. 4+ reflexes. B. Urinary output of 50 ml per hour. C. A decrease in respiratory rate from 24 to 16. D. A decreased body temperature.

C. A decrease in respiratory rate from 24 to 16.

The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? A. Provide phototherapy for 30 minutes q8h. B. Feed the newborn sterile water hourly. C. Encourage the mother to breastfeed frequently. D. Assess the newborn's blood glucose level.

C. Encourage the mother to breastfeed frequently.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again.

C. Encourage the mother to stop feeding for a few minutes and comfort the infant.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness? A. Wear a cotton bra with nonbinding support. B. Increase nursing time gradually over several days. C. Ensure that the baby is positioned correctly for latching on. D. Manually express a small amount of milk before nursing.

C. Ensure that the baby is positioned correctly for latching on.

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes. B. Periorbital edema. C. Epigastric pain. D. Decreased urine output.

C. Epigastric pain.

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take? A. Instruct the client to go to the emergency room. B. Recommend vaginal douching. C. Explain this is a normal finding. D. Determine if ovulation has occurred.

C. Explain this is a normal finding.

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A. Maternal blood pressure B. Maternal temperature C. Fetal heart rate (FHR) D. White blood cell count (WBC)

C. Fetal heart rate (FHR)

The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds at 36- weeks' gestation. This amniocentesis is being performed to obtain which information? A. Presence of a neural tube defect B. Gender of the fetus C. Fetal lung maturity D. Chromosomal abnormalities

C. Fetal lung maturity

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis

C. Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against option A, B, or D.

The LPN/LVN is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse ly calculates that the woman's next fertile period is A. January 14-15. B. January 22-23. C. January 30-31. D. February 6-7.

C. January 30-31.

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is A. January 14-15. B. January 22-23. C. January 30-31. D. February 6-7.

C. January 30-31.

The LPN/LVN assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A. Insert an internal fetal monitor. B. Assess for cervical changes q1h. C. Monitor bleeding from IV sites. D. Perform Leopold's maneuvers.

C. Monitor bleeding from IV sites.

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A. Insert an internal fetal monitor. B. Assess for cervical changes q1h. C. Monitor bleeding from IV sites. D. Perform Leopold's maneuvers.

C. Monitor bleeding from IV sites.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in the diet. C. Move about every hour. D. Avoid constrictive clothing.

C. Move about every hour.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? A. This is not an unusual shaped head, especially for a first baby. B. It may look funny to you, but newborn babies are often born with heads like your baby's. C. That is normal; the head will return to a round shape within 7 to 10 days. D. Your pelvis was too small, so the baby's head had to adjust to the birth canal

C. That is normal; the head will return to a round shape within 7 to 10 days.

Primipara patient. What is the pet to share time a, home that is not recommended?

CAT

A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet?

Chicken.

4 postpartum client who is priority to see for possible problems psychosocial

Client to immigrant to United states recent with spouse

pregnancy with gestational diabetes has religious beliefs teaching to use insulin:

Collaborate to physician to alternative insulin schedule

During a routine clinic visit, the nurse determines that a 5-year-old boy's blood pressure is 112/70. When calculating the child's blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next?

Compare the child's blood pressure with readings from previous visits.

During a well-child visit for their child, one of the parents who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder." How should the nurse respond?

Confirm that there is a 50% chance of their future children inheriting the disorder.

A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time?

Contractions decrease with walking.

A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulations?

Counter pressure

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Cries vigorously when stimulated.

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Cries vigorously when stimulated.

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Cries vigorously when stimulated.

When assessing a pregnant woman at 39-weeks gestation who is admitted to labor and delivery, which finding is most important to report to the health care provider? A) +1 proteinuria B) 130/70 blood pressure C) +1 pedal edema D) 101.2 F oral temperature

D) 101.2 F oral temperature

Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority?

D. Have a meconium aspirator available at delivery.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.

D. Obtain a serum glucose level.

A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? A. Tell the older child that he is a big boy now and should love his new sister. B. Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. C. Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn. D. Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

D. Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority?

Have a meconium aspirator available at delivery.

Artificial rupture of the membranes of a laboring client reveals meconiumstained fluid. What intervention has the greatest priority?

Have a meconium aspirator available at delivery.

newborn with 4 lb, 18 inch , what condition is of first priority:

Hypoglycemia

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which the following potential complications associated with prematurity?

Intraventricular hemorrhage

postpartum client shot rubella vaccine ; recommendation

No contact sexual 28 days

The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?

Reduce cerebral edema and lower intracranial pressure.

A nurse is care for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?

Renal agenesis

A nurse is assessing the moro response of a newborn. Which of the following findings should the nurse expect?

The legs move in a similar pattern of response to the arm

A nurse is caring for a newborn who has a prescription of phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make?

The light will help lower your baby's bilirubin level

A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? a. Complete a sterile vaginal exam b. Take maternal temperature every 2 hours c. Prepare for an immediate cesarean birth d. Obtain sterile suction equipment

a. Complete a sterile vaginal exam A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord.

The nurse's assessment of a preterm infant reveals decreased muscle tone, sign of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first? a. Position a radiant warmer over the crib b. Place the infant in a side-lying position c. Assess the infant's blood glucose test d. Nipple feed 1 ounce 5% glucose water

a. Position a radiant warmer over the crib

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? a. edema, basilar rales, and an irregular pulse b. Increased urinary output, and tachycardia c. Shortness of breath, bradycardia, and hypertension d. Regular heart rate, and hypertension

a. edema, basilar rales, and an irregular pulse Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and require immediate intervention.

A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication? a. jaundice b brain damage c. poor appetite d. hypoglycemia

a. jaundice

the nurse see the newborn in a warmer and applied naso oral succion , what is action significant the newborn is vigorous

active movement and lusty cry

When planning care for a laboring client, the nurse identifies the need to withhold solid food while the client is in labor. What is the best intervention?

an increase of aspiration can occur if general anesthesia is need it

A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. What action should the nurse take first? a. Decrease environmental stimuli b. Obtain a blood glucose level c. Administer oxygen d. Feed the infant glucose water (10%)

b. Obtain a blood glucose level

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old infant has gestational age of 42-weeks. Based on this finding, which intervention is most important for the nurse to implement? a. Draw arterial blood gases b. Obtain a capillary blood glucose c. Apply a pulse oximeter to the foot d. Provide blow by oxygen

b. Obtain a capillary blood glucose(salio)

The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision? a. Wrap the infant in warm receiving blankets b. Place petrolatum gauze dressing on the side c. Gave a PRN dose of liquid acetaminophen d. Offer a pacifier dipped in glucose water

b. Place petrolatum gauze dressing on the side

A pregnant client mentions in her history that she changes a cat's litter box daily. Which test should the nurse anticipate the HCP to prescribe? a. Biophysical profile b. TORCH screening c. Fern Test d. amniocentesis

b. TORCH screening

A 39-week gestational multigravida is admitted to labor and delivery with spontaneous rupture of membranes (SCROM) and contractions occurring every 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6 cm, 90% effaced, and the fetus is at a +2 station. During the last 45 minutes the fetal hearth rate "FHR" has range between 170 and 180 beats/minute. What action should the nurse implement? a. Obtain a blood specimen for hemoglobin b. Take an oral maternal temperature c. Straight catharize the client d. Sent amniotic fluid for analysis

b. Take an oral maternal temperature

During a routine health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage? a. Scan the bladder for urinary retention b. Test the fluid with a nitrazine strip c. Palpate suprapubic area for fetal head position d. Insert straight urinary catheter for drain bladder

b. Test the fluid with a nitrazine strip (salio)

when assessing a client the first postpartum day, the nurse finds moderate amount of lochia rubra, with the uterus firm, dextroverted, and three fingerbbreadths above the umbilicus. What action should the nurse take first? a. massage the uterus to decrease atony b. assess the bladder for distention c. provide a stool softner for constipation d. check the hemoglobin to determine uterine hemorrhage

b. assess the bladder for distention

17., A low risk primigravida at 28 weeks gestation arrives for her regular antepartal clinic visit. Which assessment findings should the nurse consider within normal limits for this client? a. 2+ proteninuria b. pulse increase of 10 beats/min c.Ͳ3+ glucosuria d. Fundal height of 36 centimeter

b. pulse increase of 10 beats/min

The nurse is caring for a postpartum client who is complaining of severe pain and feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that the perineal hematoma is beginning. Which assessment finding should the nurse obtain first? a. Hemoglobin and hematocrit b. Abdominal contour and bowel sound c. Heart rate and blood pressure d. Urinary output and IV fluid intake

c. Heart rate and blood pressure

At 0600 while admitting a woman for a scheduled repeat c section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. What action should the nurse take first? a. Ensure preoperative lab results are available b. Start prescribed IV with Lactated Ringers c. Inform the anesthesia care provider d. Contact the client's obstetrician

c. Inform the anesthesia care provider

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and cervix dialed 3cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor? a. Clients hourly blood pressure b. Preparation for emergency cesarean birth c. Intensity, interval, and length of contractions d. Checking the perineum for bulging

c. Intensity, interval, and length of contractions

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her menstrual period was January *. The nurse correctly calculates that the woman's next fertile period is a. January 14-15 b. January 22-23 c. January 30-31 d. February 6-7

c. January 30-31

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? a. Heart rate of 100 beats/minute b. Variable fetal heart rate c. Onset of uterine contractions d. Burning urination

c. Onset of uterine contractions

child with suspected bacterial meningitis, would have a recent history of unrelated bacterial upper respiratory, sinus, or ear infection

ear ache

14 month old, hospitalized

febrile seizures

treatment with herbal medicine for nausea and vomiting in the morning

ginger

history of preeclampsia

high blood pressure

osteomyelitis foods to eat, 6 years old

high protein/high calories, milk shake is best choice

hormone with elevated in pregnancy

human chorionic gonadotropin

Digoxin 3 month old with GHD, miss a dose

if missed in less than 4 hours, gibe dose, if elapsed more than 4 hours, hold and give dose at next scheduled time

pregnancy drink coffee 30 minutes previous labor

inform to anesthetist

action to prevent bleeding in a neonate with 1 hr to birth

injection VIT K ( phytonadione)

rubella vaccine

instruction about use of a reliable method of birth control for 28 days after the rubella vaccine is given

obtain written consent for an emergency cesarean section.

One day after vaginal delivery of a full term baby, a postpartum client's white blood cell count is 15.000/mm. What action should the nurse take first? · Check the differential, since the WBC is normal for this client · Assess the client's temperature, pulse, and respirations q4h · Assess the client's perineal area for signs of a perineal hematoma · Notify the healthcare provider, since this finding is indicative of infection

· Check the differential, since the WBC is normal for this client

A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? · Carrots · Chicken · Yogurt · Cheese

· Chicken

The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and a 12-year-old sibling are the child bedside. Which instruction best supports this family?

" While waiting for the healthcare provider, only one visitor may stay with the child"

The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which answer should the nurse to provide?

" Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider"

The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which answer should the nurse to provide?

" Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider"

The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

"What food does your baby usually eat in a normal day?"

A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? -Document the color of the lochia. -Observe maternal vital signs. -Assist the client to the bathroom. -Notify the healthcare provider.

-Assist the client to the bathroom.

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? -Bathe the infant with an antimicrobial soap. -Measure the head and chest circumference. -Obtain the infant's footprints. -Administer vitamin K (AquaMEPHYTON)

-Bathe the infant with an antimicrobial soap.

A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse have available for signs of potential toxicity? -Oxytocin (Pitocin). -Calcium gluconate. -Terbutaline (Brethine). -Naloxone (Narcan).

-Calcium gluconate.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? -Notify the pediatrician immediately. -Suction the infant's nares, then the oral cavity. -Check the infant's oxygen saturation rate. -Position the infant on the right side.

-Check the infant's oxygen saturation rate.

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? -Choking, coughing, and cyanosis. -Projectile vomiting and cyanosis. -Apneic spells and grunting. -Scaphoid abdomen and anorexia.

-Choking, coughing, and cyanosis.

A pregnant woman who is at 10-week gestation and is 35 years old tell the nurse she is concern about the possibility of having a baby with a down syndrome which information should the nurse provide to a client? -An amniocentesis is conducted at 24 weeks gestation confirm or denies down syndrome in the fetus. -Maternal serum human chorionic gonadotropic (HCG) can identify down syndrome at 6 weeks of gestation -Weekly fundal height measurement a noninvasive method used to check for down syndrome -Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify down syndrome

-Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify down syndrome

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.) -Dark, red vaginal bleeding. -Lower back pain. -Premature rupture of membranes. -Increased uterine irritability. -Bilateral pitting edema. -A rigid abdomen.

-Dark, red vaginal bleeding. -Increased uterine irritability. -A rigid abdomen.

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? -Gravidity and parity. -Time and amount of last oral intake. -Date of last normal menstrual period. -Frequency and intensity of contractions

-Date of last normal menstrual period.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? -Describe diet changes that can improve the management of her diabetes. -Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. -Demonstrate self-administration of insulin. -Evaluate the client's ability to do glucose monitoring.

-Describe diet changes that can improve the management of her diabetes.

A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? -Determine the firmness of the fundus. -Give oxytocin (Pitocin) intravenously. -Inform the healthcare provider of the bleeding. -Assess the vital signs for indicators of shock

-Determine the firmness of the fundus.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? -Which symptom did you experience first? -Are you eating large amounts of salty foods? -Have you visited a foreign country recently? -Do you have a history of rheumatic fever?

-Do you have a history of rheumatic fever?

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? -Gestational diabetes. -Elevated blood pressure. -Urinary tract infection. -Swelling in lower extremities.

-Gestational diabetes.

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is -January 14-15. -January 22-23. -January 30-31. -February 6-7.

-January 30-31.

The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? -August 1. -August 10. -September 3. -September 8.

-September 8.

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is: -shortness of breath. -joint pain. -a persistent cold. -organomegaly.

-a persistent cold.

14, a client whose blood type is o negative delivers an infant who is o positive. Six hours after delivery the client has a negative indirect coombs. Which intervention should the nurse implement? -administer one standard dose of Rhogam within 72 hours of delivery -teach the new mother about incompatibility of blood types and RhoGAM -assess the direct Coombs result of the infant to determine if RhoGAM is necessary -evaluate the father's blood type and Rh to crossmatch the RhoHAM

-administer one standard dose of Rhogam within 72 hours of delivery

At client at 40 weeks'gestation is admitted in active labor, a laboratory finding indicate that she is HIV positive. What action should the nurse plan to perform?

-encourage the mother to bottle feed -Use standard precautions

What nursing intervention is of greatest benefit in preventing postpartum thrombophlebitis? -encourage use of supportive stockings -apply moist heat to varicose veins -encourage early prenatal care -promote early postpartum ambulation

-promote early postpartum ambulation

a client who is bleeding after a vaginal delivery recieves a presciption for methyleergonovine (Methergine) 0.2 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg.ml. What is the maximum dosage in mg that the nurse should administer to this client?

20. A primigravid client with severe preeclampsia exhibits hyperactive, very brisk patellar reflexes with two beats of ankle clonus present. The nurse documents the patellar reflexes as which of the following? 1. 1+. 2. 2+. 3. 3+. 4. 4+.

1. 4+. These findings would be documented as 4+. 1+ indicates a diminished response; 2+ indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are two movements.

53. Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications? 1. Laser therapy. 2. Cromolyn sodium eye drops. 3. Frequent testing for glaucoma. 4. Corneal transplants.

1. Laser therapy.

66. A breast-feeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake? 1. Six to eight wet diapers by the fifth day. 2. Three to four transitional stools on the fourth day. 3. Ability to fall asleep easily after feeding on the first day. 4. Regain of lost birth weight by the third day.

1. Six to eight wet diapers by the fifth day.

76. A primiparous client who will be bottle-feeding her neonate asks, "What is the best position for the baby after feeding?" Which of the following positions should the nurse recommend to aid digestion? 1. Supine position. 2. On the left side. 3. Prone without a pillow. 4. Sitting on the caregiver's lap for 20 minutes.

1. Supine position.

90. The primary health care provider prescribes an amnioinfusion for a primigravid client at term who is diagnosed with oligohydramnios. Which of the following should the nurse include in the client's teaching plan about the purpose of this procedure? 1. To decrease the frequency and severity of variable decelerations. 2. To minimize the possibility of fetal metabolic alkalosis. 3. To increase the fetal heart rate accelerations during a contraction. 4. To raise the amniotic fluid index to more than 15 cm

1. To decrease the frequency and severity of variable decelerations.

A 38-week primigravida client who is positive for Group A Beta Streptococcus receives a prescription for cefazolin 2 grams IV to be infused over 30 minutes. The medications available in 2 grams/100 ml of normal saline. The nurse should program the infusion pump to deliver how many ml/hour?

1.6 ml/hr

the nurse adds 20 units of oxytocin to one liter of lactated ringer, which should infuse over 8 hours for a client who deliver 2 hours ago. How many ml\h should the nurse infuse the pump?

125

A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer?

30. The nurse is teaching a new prenatal client about her iron deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia? 1. "I will need to take iron supplements now." 2. "I may have anemia because my family is of Asian descent." 3. "I am considered anemic if my hemoglobin is below 11 g/dL (110 g/L)." 4. "The anemia increases the workload on my heart."

2. "I may have anemia because my family is of Asian descent." Iron deficiency anemia is caused by insufficient iron stores in the body, poor iron content in the diet of the pregnant woman, or both. Other thalassemias and sickle cell anemia, rather than iron deficiency anemia, can be associated with ethnicity but occur primarily in clients of African or Mediterranean origin. Because red blood cells increase by about 50% during pregnancy, many clients will need to take supplemental iron to avoid iron deficiency anemia. A pregnant client is considered anemic when the hemoglobin is below 11 mg/dL (110 g/dL). In most types of anemia, the heart must pump more often and harder to deliver oxygen to cells.

93. The nurse is caring for a multigravid client who speaks only a foreign language. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next? 1. Tell the client to push between contractions. 2. Provide gentle support to the fetal head. 3. Apply gentle upward traction on the neonate's anterior shoulder. 4. Massage the perineum to stretch the perineal tissues.

2. Provide gentle support to the fetal head.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record? -3-1-2-0-3. -4-1-2-0-3. -2-1-2-1-2. -3-1-1-0-3

3-1-1-0-3

63. After the nurse teaches a primiparous client planning to return to work in 6 weeks about storing breast milk, which of the following client statements indicates the need for further teaching? 1. "I can let the milk sit out in a bottle for up to 10 hours." 2. "I'll be sure to label the milk with the date, time, and amount." 3. "I can safely store the milk for 3 days in the refrigerator." 4. "I can keep the milk in a deep freeze in clean glass bottles for up to 1 year."

3. "I can safely store the milk for 3 days in the refrigerator."

28. A primigravid client at 16 weeks' gestation has had an amniocentesis and has received teaching concerning signs and symptoms to report. Which statement indicates that the client needs further teaching? 1. "I need to call if I start to leak fluid from my vagina." 2. "If I start bleeding, I will need to call back." 3. "If my baby does not move, I need to call my health care provider." 4. "If I start running a fever, I should let the office know."

3. "If my baby does not move, I need to call my health care provider." At 16 weeks' gestation, a primipara will not feel the baby moving. Quickening occurs between 18 and 20 weeks' gestation for a primipara and between 16 and 18 weeks' gestation for a multipara. Leaking fluid from the vagina should not occur until labor begins and may indicate a rupture of the membranes. Bleeding and a fever are complications that warrant further evaluation and should be reported at any time during the pregnancy.

22. A multigravid client will be using medroxyprogesterone acetate (Depo- Provera) as a family planning method. After the nurse instructs the client about this method, which of the following client statements indicates effective teaching? 1. "This method of family planning requires monthly injections." 2. "I should have my first injection during my menstrual cycle." 3. "One possible adverse effect is absence of a menstrual period." 4. "This drug will be given by subcutaneous injections."

3. "One possible adverse effect is absence of a menstrual period." With medroxyprogesterone acetate, irregular menstrual cycles and amenorrhea are common adverse effects. Other adverse effects include weight gain, breakthrough bleeding, headaches, and depression. This method requires deep intramuscular injections every 3 months. The first injection should occur within 5 days after menses.

5. At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches (151.7 cm) has gained a total of 20 lb (9.1 kg), with a 1-lb (0.45-kg) gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia? 1. Total weight gain. 2. Short stature. 3. Adolescent age group. 4. Proteinuria.

3. Adolescent age group. Clients with increased risk for preeclampsia include primigravid clients younger than 20 years or older than 40 years, clients with five or more pregnancies, women of color, women with multifetal pregnancies, women with diabetes or heart disease, and women with hydramnios. A total weight gain of 20 lb (9.1 kg) at 32 weeks' gestation with a 1-lb (0.45-kg) weight gain in the last 2 weeks is within normal limits. Short stature is not associated with the development of preeclampsia. A trace amount of protein in the urine is common during pregnancy. However, protein amounts of 1+ or more may be a symptom of pregnancy-induced hypertension.

18. As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which of the following should the nurse do first? 1. Insert an airway to improve oxygenation. 2. Note the time when the seizure begins and ends. 3. Call for immediate assistance. 4. Turn the client to her left side.

3. Call for immediate assistance. If a client begins to have a seizure, the first action by the nurse is to remain with the client and call for immediate assistance. The nurse needs to have some assistance in managing this client. After the seizure, the client needs intensive monitoring. An airway can be inserted, if appropriate, after the seizure ends. Noting the time the seizure begins and ends and turning the client to her left side should be done after assistance is obtained.

60. Which of the following would alert the nurse to suspect that a neonate born at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration? 1. Hypernatremia. 2. Polycythemia. 3. Hypoproteinemia. 4. Increased urine specific gravity.

3. Hypoproteinemia.

87. A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the client's neonate? 1. Sedation. 2. Hyperbilirubinemia. 3. Low birth weight. 4. Hypocalcemia.

3. Low birth weight.

2. A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and feet. What further information should the nurse obtain to determine if this client is becoming preeclamptic? 1. Headaches. 2. Blood glucose level. 3. Proteinuria. 4. Edema in lower extremities.

3. Proteinuria. The two major defining characteristics of preeclampsia are blood pressure elevation of 140/90 mm Hg or greater and proteinuria. Because the client's blood pressure meets the gestational hypertension criteria, the next nursing responsibility is to determine if she has protein in her urine. If she does not, then she may be having transient hypertension. The edema is within normal limits for someone at this gestational age, particularly because it is in the lower extremities. The preeclamptic client will have significant edema in the face and hands. Headaches are significant in pregnancyinduced hypertension but may have other etiologies. The client's blood glucose level has no bearing on a preeclampsia diagnosis.

8. When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, which of the following types of diet should the nurse discuss? 1. High-residue diet. 2. Low-sodium diet. 3. Regular diet. 4. High-protein diet.

3. Regular diet. For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.

88. A primigravid client who has had a prolonged labor but now is completely dilated has received epidural anesthesia. Which of the following should the nurse include in the teaching plan about pushing? 1. The client needs to push for at least 1 to 3 minutes. 2. Pushing is most effective when the client holds her breath. 3. The client should be urged to push with an open glottis. 4. Pushing is limited to times when she feels the urge.

3. The client should be urged to push with an open glottis.

67. Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? 1. "Wait until you have breast-fed for at least 4 months." 2. "Eliminate the baby's favorite feeding times first." 3. "Plan to omit the daytime feedings last." 4. "Gradually eliminate one feeding at a time."

4. "Gradually eliminate one feeding at a time."

73. A client gave birth 2 days ago and has been given instructions on breast care for bottle-feeding mothers. Which of the following statements indicates that the nurse should reinforce the instructions to the client? 1. "I will wear a sports bra or a well-fitting bra for several days." 2. "When showering, I'll direct water onto my shoulders." 3. "I will use only water to clean my nipples." 4. "I will use a breast pump to remove any milk that may appear."

4. "I will use a breast pump to remove any milk that may appear."

91. The nurse is admitting a primigravid client at 37 weeks' gestation who has been diagnosed with preeclampsia to the labor and birth area. Which of the following client care rooms is most appropriate for this client? 1. A brightly lit private room at the end of the hall from the nurses' station. 2. A semiprivate room midway down the hall from the nurses' station. 3. A private room with many windows that is near the operating room. 4. A darkened private room as close to the nurses' station as possible.

4. A darkened private room as close to the nurses' station as possible.

57. While caring for a neonate born at 32 weeks' gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist? 1. The presence of 1 mL of gastric residual before a gavage feeding. 2. Jaundice appearing on the face and chest. 3. An increase in bowel peristalsis. 4. Abdominal distention.

4. Abdominal distention.

43. After a vaginal birth, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which of the following positions? 1. Left side, with the neck slightly flexed. 2. Back, with the head turned to the left side. 3. Abdomen, with the head down. 4. Back, with the neck slightly extended.

4. Back, with the neck slightly extended. When receiving oxygen by mask, the neonate is placed on the back with the neck slightly extended, in the "sniffing" or neutral position. This position optimizes lung expansion and places the upper respiratory tract in the best position for receiving oxygen. Placing a small rolled towel under the neonate's shoulders helps to extend the neck properly without overextending it. Once stabilized and transferred to an isolette in the intensive care unit, the neonate can be positioned in the prone position, which allows for lung expansion in the oxygenated environment. Placing the neonate on the left side does not allow for maximum lung expansion. Also, slightly flexing the neck interferes with opening the airway. Placing the neonate on the back with the head turned to the left side does not allow for lung expansion. Placing the neonate on the abdomen interferes with proper positioning of the oxygen mask.

100. A multigravid client in active labor at term is diagnosed with polyhydramnios. The primary health care provider has instructed the client about possible neonatal complications related to the polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydramnios is associated with which of the following in the fetus or neonate? 1. Renal dysfunction. 2. Intrauterine growth retardation. 3. Pulmonary hypoplasia. 4. Gastrointestinal disorders.

4. Gastrointestinal disorders.

84. A multigravid client at 39 weeks' gestation diagnosed with insulin-dependent diabetes is admitted for induction of labor with oxytocin. Which of the following should the nurse include in the teaching plan as a possible disadvantage of this procedure? 1. Urinary frequency. 2. Maternal hypoglycemia. 3. Preterm birth. 4. Neonatal jaundice.

4. Neonatal jaundice.

64. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she is aware of a "let-down sensation" in her breasts and asks what causes it. The nurse explains that the let-down sensation is stimulated by which of the following? 1. Adrenalin. 2. Estrogen. 3. Prolactin. 4. Oxytocin.

4. Oxytocin.

71. The triage nurse in the pediatrician's office returns a call to a mother who is breast-feeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? 1. This type of stool indicates the infant may have diarrhea and should be seen in the office today. 2. The stool will transition into a soft brown formed stool within a few days and is appropriate for breast-feeding. 3. The stool results from the gassy food eaten by the mother. Instruct the mother to refrain from eating these foods while breast-feeding. 4. Soft seedy unformed stools with each feeding are normal for this age infant and will continue through breast-feeding.

4. Soft seedy unformed stools with each feeding are normal for this age infant and will continue through breast-feeding.

A nurse is assessing a client who is at 35 weeks gestation and has mild gestational hypertension. Which of the following findings should the nurse identify as the priority?

480 mL urine output in 24 hours

A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only)

A nurse in the labor and delivery suite is planning care for a group of 4 clients. Which of the following clients should the nurse see first?

A client who is in active labor and has late decelerations on the fetal heart monitor strip

A nurse is teaching a client during the clients first prenatal visit. Which of the following instructions should the nurse include?

A doppler device can detect your baby's heart rate at 12 weeks.

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? -A home pregnancy test can be used right after your first missed period. -These tests are most accurate after you have missed your second period. -Home pregnancy tests often give false positives and should not be trusted. -The test can provide accurate information when used right after ovulation.

A home pregnancy test can be used right after your first missed period.

A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify a requiring intervention?

A newborn whose axillary temp is 36.1 degrees Celsius (96.9 degrees F)

A 38 weeks primigravida is admitted in labor -delivery with a non - reactive result (NST). The nurse begins a contraction stress with oxytocin Pitocin infusion. Which finding is most important for the nurse to report health provider?

A pattern of fetal late decelerations

A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include?

A reduction in sexual interest could indicate postpartum depression

The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant?

A sore throat last week

8. A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond? A) "That is called caput succedaneum. It will absorb and cause no problems." B) "That is called a cephalhematoma. It will cause no problems." C) "That is called a cephalhematoma. It can cause jaundice as it is absorbed." D) "That is called caput succedaneum. It will have to be drained."

A) "That is called caput succedaneum. It will absorb and cause no problems."

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin E drug. How should the nurse respond? A) "You may be at risk for having a spontaneous miscarriage" ? B) "You may have an increased chance of having preeclampsia" C) "This medication will have no effect on your unborn child" D) "You may experience postpartum hemorrhaging after delivery

A) "You may be at risk for having a spontaneous miscarriage" ?

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: A) Counterpressure against the sacrum B) Pant-blow (breaths and puffs) breathing techniques C) Effleurage. D) Conscious relaxation or guided imagery.

A) Counterpressure against the sacrum

The home health nurse visits a client who delivered a full term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curd-like patches on the newborn's oral mucous membranes. What action should the nurse implement? A) Discuss the need for medication to treat curd-like oral patches B) Suggest switching the infant's formula C) Assess the baby's blood glucose level D) Remind mother not put the baby to bed with a propped bottles

A) Discuss the need for medication to treat curd-like oral patches

A new mother who is breastfeeding her 4-week old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. What action should the nurse implement? A) Inform her that a decreased for insulin occurs while breastfeeding B) Advice the client to breastfeed more frequently C) Counsel her to increase her caloric intake D) Schedule an appointment for the client with diabetic nurse educator

A) Inform her that a decreased for insulin occurs while breastfeeding

When planning care for a laboring woman whose membranes have ruptured, the LPN/LVN recognizes that the woman's risk for has increased. A) Intrauterine infection B) Hemorrhage C) Precipitous labor D) Supine hypotension

A) Intrauterine infection

What position would be least effective when gravity is desired to assist in fetal descent? A) Lithotomy B) Walking C) Kneeling D) Sitting

A) Lithotomy

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The LPN/LVN concludes that: A) The placenta has separated. B) A cervical tear occurred during the birth C) The woman is beginning to hemorrhage. D) Clots have formed in the upper uterine segment.

A) The placenta has separated.

The LPN/LVN providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by: A) Umbilical cord compression. B) Altered fetal cerebral blood flow C) Fetal hypoxemia. D) Uteroplacental insufficiency

A) Umbilical cord compression.

The LPN/LVN caring for the woman in labor should understand that maternal hypotension can result in: A) Uteroplacental insufficiency. B) Spontaneous rupture of membranes C) Fetal dysrhythmias. D) Early decelerations.

A) Uteroplacental insufficiency.

8. Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings."

A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A. A home pregnancy test can be used right after your first missed period. B. These tests are most accurate after you have missed your second period. C. Home pregnancy tests often give false positives and should not be trusted. D. The test can provide accurate information when used right after ovulation.

A. A home pregnancy test can be used right after your first missed period.

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) A. Admission weight of 4 pounds, 15 ounces (2244 grams). B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm). D. Skin smooth with visible veins and abundant vernix. E. Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position.

A. Admission weight of 4 pounds, 15 ounces (2244 grams). B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm).

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? A. Choking, coughing, and cyanosis. B. Projectile vomiting and cyanosis. C. Apneic spells and grunting. D. Scaphoid abdomen and anorexia.

A. Choking, coughing, and cyanosis.

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency department. C. Lie on your left side for about 1 hour and see if the bleeding stops. D. Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).

A. Come to the clinic today for an ultrasound.

Which action should the LPN/LVN implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty her bladder. B. Request the client lie on her left side. C. Perform Leopold's maneuvers first. D. Give the client some cold juice to drink.

A. Have the client empty her bladder.

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" A. Lying prone with a pillow on the abdomen. B. Using a breast pump. C. Massaging the abdomen. D. Giving oxytocic medications.

A. Lying prone with a pillow on the abdomen.

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is A. November 22. B. November 8. C. December 22. D. October 22.

A. November 22.

After feeding a newborn, how should the nurse position the infant in the crib? A. On the right side. B. Supine in a slight Trendelenburg. C. Supine with the head elevated. D. Prone with the foot of the crib elevated

A. On the right side.

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A. Pain in the lower back that radiates to abdomen B. Contractions decreased in frequency with ambulation C. Progressive cervical dilation and effacement D. Discomfort localized in the abdomen E. Regular and rhythmic painful contractions

A. Pain in the lower back that radiates to abdomen C. Progressive cervical dilation and effacement E. Regular and rhythmic painful contractions

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. Patellar reflex 4+ B. Blood pressure 158/80. C. Four-hour urine output 240 ml. D. Respiration 12/minute.

A. Patellar reflex 4+

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. Patellar reflex 4+. B. Blood pressure 158/80. C. Four-hour urine output 240 ml. D. Respiration 12/minute.

A. Patellar reflex 4+.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? A. Raise the foot of the bed. B. Assess for vaginal bleeding. C. Evaluate the fetal heart rate. D. Take the client's blood pressure.

A. Raise the foot of the bed.

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? A. Reduce activity level and notify the healthcare provider. B. Go to bed and assume a knee-chest position. C. Massage the uterus and go to the emergency room. D. Do not worry as this is a normal occurrence.

A. Reduce activity level and notify the healthcare provider.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.) A. Reposition the client. B. Call the healthcare provider. C. Increase IV fluid. D. Provide oxygen via face mask.

A. Reposition the client. C. Increase IV fluid. D. Provide oxygen via face mask. B. Call the healthcare provider.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn. B. The client's educational background. C. The order in which the information is presented. D. The extent to which the pregnancy was planned.

A. The client's readiness to learn.

client at 20 weeks gestation comes to the antepartum clinic complaining of vaginal warts (human papillomavirus). What information should the nurse provide this client? A. Treatment options, while limited due to the pregnancy, are available B. The client should be treated with Penicillin G C. This client should be treat with acyclovir (Zovirax) D. Termination of the pregnancy should be considered

A. Treatment options, while limited due to the pregnancy, are available

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation

A. Two weeks before menstruation

A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide?

Apply hot packs just before each feeding.

new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on.

A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on.

A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on.

A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Ask the mother to stop feeding, confront the infant, and then assist the mother to help the baby latch on.

The role of the LPN/LVN with regard to informed consent is to: A) Inform the client about the procedure and have her sign the consent form. B) Act as a client advocate and help clarify the procedure and the options. C) Call the physician to see the client D) Witness the signing of the consent form.

B) Act as a client advocate and help clarify the procedure and the options.

A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height in measured at 29 cm. Based on these findings, what actions the nurse implement? A) Notify the healthcare provider of the finding B) Document the finding in the medical record C) Schedule the client for a biophysical profile D) Request another nurse measure the fundus

B) Document the finding in the medical record

The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is: A) Fetal hypoxemia B) Fetal sleep cycles C) Altered cerebral blood flow. D) Umbilical cord compression.

B) Fetal sleep cycles

Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,317 grams), weighs 7 lbs (3,175 grams) today. A) Monitor the stool and urine output of the neonate for the last 24 hours B) Inform and assure the mother that this is a normal weight loss C) Encourages the mother to increase frequency of breastfeeding. D) After verifying the accuracy of the weight, notify the healthcare provider.

B) Inform and assure the mother that this is a normal weight loss

What is an expected characteristic of amniotic fluid? A) Deep yellow color B) Pale, straw color with small white particles C) Acidic result on a Nitrazine test D) Absence of ferning

B) Pale, straw color with small white particles

With regard to a pregnant woman's anxiety and pain experience, LPN/LVN should be aware that: A) Even mild anxiety must be treated. B) Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. C) Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. D) Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity

B) Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on.

Cient at 35 weeks' gestation complains of a "pan whenever the baby moves on assessment, the nurse notes the client's temperature to 101.2 F(38.4) with severe abdominal or uterine tenderness on palpation the nurse knows that these findings are indicative of which condition? A- Abruptio placenta B- Chorioamniondis C-Round ligament strain D-Viral infection

B- Chorioamniondis

A primigravida client asks the nurse about exercising during pregnancy to help her prepare for labor Which recommendation should the nurse provide? A-Limit exercise to brisk walking during pregnancy B-Stretching exercises are good preparation for labor C- Leg lifts will help to strengthen abdominal muscles D-Avoid weight-bearing exercises until the postpartum period

B-Stretching exercises are good preparation for labor

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide? A Avoid using the breast pump. B. Breastfeed the infant every 2 hours. C. Reduce fluid intake for 24 hours. D Skip feedings to let the sore breasts rest.

B. Breastfeed the infant every 2 hours.

A client who has an autosomal dominant inherited disorderis exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? A. Males inherit the disorder with a greater frequency than females. B. Each pregnancy carries a 50% chance of inheriting the disorder. C. The disorder occurs in 25% of pregnancies. D. All children will be carriers of the disorder.

B. Each pregnancy carries a 50% chance of inheriting the disorder.

The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? A. Encourage the parents to report this to the healthcare provider B. Explain the newborns normal stepping reflex C. Acknowledge the parent's observation D. Schedule the newborn for further neurological testing

B. Explain the newborns normal stepping reflex

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the LPN/LVN implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot. C. Lower the leg off the side of the bed. D. Elevate the leg above the heart.

B. Extend the leg and dorsiflex the foot.

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot. C. Lower the leg off the side of the bed. D. Elevate the leg above the heart.

B. Extend the leg and dorsiflex the foot.

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot. C. Lower the leg off the side of the bed. D. Elevate the leg above the heart.

B. Extend the leg and dorsiflex the foot.

3-hour old male infant's hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best for the nurse to implement? A. Perform a heel- stick to monitor blood glucose level B. Gradually warm the infant under a radiant heat source C. Administer oxygen by mask at 2L/minute D. Notify the pediatrician of the infant's unstable vital signs

B. Gradually warm the infant under a radiant heat source

Which maternal behavior is the LPN/LVN most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body.

B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

1. A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted? A. If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C. If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D. If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.

B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing? A. Taking-in phase B. Postpartum blues C. Attachment difficulty D. Letting-go phase

B. Postpartum blues

The LPN/LVN should explain to a 30-year-old gravida client that alpha fetoprotein testing is recommended for which purpose? A. Detect cardiovascular disorders. B. Screen for neural tube defects. C. Monitor the placental functioning. D. Assess for maternal pre-eclampsia.

B. Screen for neural tube defects.

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose? A. Detect cardiovascular disorders. B. Screen for neural tube defects. C. Monitor the placental functioning. D. Assess for maternal pre-eclampsia.

B. Screen for neural tube defects.

A new mother asks the LPN/LVN, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide? A. Weigh the baby daily, and if she is gaining weight, she is eating enough. B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry. D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.

B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide? A. Weigh the baby daily, and if she is gaining weight, she is eating enough. B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry. D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.

B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores. B. lower birth weights. C. respiratory distress. D. a higher rate of congenital anomalies.

B. lower birth weights.

The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?

Betamethasone (Celestone) 12 mg deep IM.

A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system?

Block the effects of narcotics on the CNS

The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?

Blood pressure 149/90.

The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?

Blood pressure 149/90.

The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?

Blood pressure 149/90.

The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this fiding?

Both the lower uterine segment and the fundus must be massaged.

A blind litter girld, 8 year sold was admitted to the hospital .....

Bring familiarly toys from home, such as bear, doll.

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The LPN/LVN first priority is to: A) Notify the care provider. B) Assist with amnioinfusion C) Change the woman's position D) Insert a scalp electrode

C) Change the woman's position

The nurse is performing a newborn assessment. Which symptoms, if present in newborn, would indicate respiratory distress? A) Abdominal breathing with synchronous chest movement B) Shallow and irregular respirations C) Flaring of the nares D) Respiratory rate of 50 breaths per minute

C) Flaring of the nares

A laboring woman received meperidine (Demerol) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? A) Fentanyl (Sublimaze) B) Promethazine (Phenergan) C) Naloxone (Narcan) D) Nalbuphine (Nubain)

C) Naloxone (Narcan)

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The LPN/LVN increases the woman's intravenous fluid for a pre-procedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? A) She is too far dilated B) She is anemic. C) She has thrombocytopenia D) She is septic

C) She has thrombocytopenia

A 39-week-gestational multigravida is admitted to labor and delivery with spontaneous rupture of membranes (SROM) and contractions occurring every 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6 cm, 90% effaced, and the fetus is at a +2 station. During the n last 45 minutes the fetal heart rate (FHR) has ranged between 170 and 180 beats/minute. What action should the nurse implement? A) Obtain a blood specimen for hemoglobin B) Take an oral maternal temperature ? C) Straight catheterize the client D) Send amniotic fluid for analysis

C) Straight catheterize the client

The LPN/LVN providing care for the laboring woman should understand that amnioinfusion is used to treat: A) Fetal tachycardia. B) Fetal bradycardia. C) Variable decelerations D) Late decelerations.

C) Variable decelerations

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A 3 B. 4 C. 5 D 8

C. 5 The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options A, B, and D are not accurate.

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) B. Fetal scalp electrode. C. A sterile glove. D. An amnihook. E. Sterile vaginal speculum. F. Lubricant.

C. A sterile glove. D. An amnihook. F. Lubricant.

The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) A. Litmus paper. B. Fetal scalp electrode. C. A sterile glove. D. An amniotic hook. E. Sterile vaginal speculum. F.A Doppler.

C. A sterile glove. D. An amniotic hook. F.A Doppler.

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? A. Begin as soon as your baby is born to establish a four-hour feeding schedule. B. Resting helps with milk production. Ask that your baby be fed at night in the nursery. C. Feed your baby every 2 to 3 hours or on demand, whichever comes first. D. Do not allow your baby to nurse any longer than the prescribed number of minutes.

C. Feed your baby every 2 to 3 hours or on demand, whichever comes first.

7. A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort related to nausea and abdominal distention C. Impaired bowel motility related to pain medication and immobility D. Fatigue related to cesarean delivery and physical care demands of infant

C. Impaired bowel motility related to pain medication and immobility

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next? A. Check the hematocrit results. B. Administer pain medication. C. Increase the rate of IV fluids. D. Monitor client for contractions.

C. Increase the rate of IV fluids.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing

C. Move about every hour.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? A. Provide oral hydration. B. Have a complete blood count (CBC) drawn. C. Obtain a specimen for urine analysis. D. Place the client on strict bedrest.

C. Obtain a specimen for urine analysis.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B. Wash off the yellow exudate on the glans once every day to prevent infection. C. Place petroleum ointment around the glans with each diaper change and cleansing. D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.

C. Place petroleum ointment around the glans with each diaper change and cleansing.

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? A. Back pain. B. Abdominal pain. C. Shoulder pain. D. Leg cramps.

C. Shoulder pain.

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate? A. Drowsiness and paroxysmal bradycardia B. Depressed reflexes and increased respirations C. Tachycardia and a feeling of nervousness D. A flushed warm feeling and dry mouth

C. Tachycardia and a feeling of nervousness

blood under periosteum does not cross suture lines

Cephalhematoma

A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?

Contact the healthcare provider

A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?

Contact the healthcare provider.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. the newborn is pink with acrocyanosis. Which of the following actions should the nurse take?

Continue to monitor the newborn routinely

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

Contraction pattern.

Which of the following is NOT a reassuring component of the fetal heart rate A) FHR of 114 B) Accelerations of the FHR C) Moderate Variability D) Absent FHR Variability

D) Absent FHR Variability

A client who is 3-weeks postpartum tells the nurse, "I am so tired all the time. I didn't know having a baby would be so hard." What response should the nurse provide? A) It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps. B) It is normal to feel tired for the first couple weeks. Be patient with yourself and rest more. C) You should not be doing any housework. Are any of your family members helping you? D) Adjusting to a new baby can be difficult. Tell me more about any help you are receiving.

D) Adjusting to a new baby can be difficult. Tell me more about any help you are receiving.

The LPN/LVN providing care for the laboring woman should understand that accelerations with fetal movement: A) Are caused by umbilical cord compression B) Are caused by uteroplacental insufficiency C) Warrant close observation D) Are reassuring.

D) Are reassuring.

When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include? A) Exercise for 15 minutes before starting the counting to help increase fetal movement B) Count the movements once daily, for one hour, before breakfast C) Avoid caffeinated drinks for 24 hours before conducting the kick test. D) If 10 kicks are not felt within one hour, drink orange juice and count for another hour.

D) If 10 kicks are not felt within one hour, drink orange juice and count for another hour.

Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30minutes and has a boggy uterus. What action should the nurse implement first? A) Have the client empty her bladder B) Inspect the perineum for lacerations C) Increase oxytocin IV infusion D) Perform fundal massage until firm

D) Perform fundal massage until firm

A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital is begun and 8 hours later the client's contractions are irregular and mild Based on these data, the nurse plans to monitor which sign for the average laboring client A-Maternal blood pressure B-Color of amniotic fluid C-Deep tendon reflexes D- Maternal temperature

D- Maternal temperature

A woman who is 38- weeks' gestation is receiving magnesium sulfate preeclampsia Which assessment finding warrants immediate intervention by the nurse? A- Sinus tachycardia B. Dizziness when standing C-Lower back pain D-Absent patellar reflexes

D-Absent patellar reflexes

The nurse is teaching a client who has gestational diabetes how to sell inject the prescribed Daly issuing doses Based on her religious beliefs the client explains that she must abstain from all food and drink during the daylight hours for the next several weeks because it is a holy month What intervention should the nurse implement for this client? A-Obtain a medical depensation from the client's spatula leader xplain the complications of gestational diabetes and necessity of taking insulin C-Teach the client to monitor blood glucose and to report any results that are too high D-Collaborate with the healthcare provider to design an alternative insulin schedule

D-Collaborate with the healthcare provider to design an alternative insulin schedule

A 30-year old primigravida delivers a 9-pound infant vaginally after a 30-hour labor. What is the priority nursing action for third? A-Gently massage fundus every 4 hours B-Encourage direct contact with the infant C-Assess the blood pressure for hypertension D-Observe for signs of uterine hemorrhage

D-Observe for signs of uterine hemorrhage

Vaginal prostaglandin gel is used to induce labor for a woman who is at 42-weeks' gestation Thirty minutes after insertion of the gel, the client complain vaginal warmth, and is experiencing 90 second contractions with fetal heart rate decelerations What action should the nurse implement first? A- Assess the maternal vital signs B- A Increase the IV infusion rate. C- Notify the healthcare provider D-Tum to a side-lying position

D-Tum to a side-lying position

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the LPN/LVN document in this client's record? A. 3-1-2-0-3. B. 4-1-2-0-3. C. 2-1-2-1-2. D. 3-1-1-0-3.

D. 3-1-1-0-3.

18. A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Cervical dilation of 5 cm with 90% effacement. B. White blood cell count of 12,000/mm3. C. Hemoglobin of 12 mg/dl and hematocrit of 38%. D. A platelet count of 67,000/mm3.

D. A platelet count of 67,000/mm3.

The LPN/LVN is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? A. Check the client for urinary bladder distention. B. Notify the healthcare provider of the nonreactive results. C. Have the mother stimulate the fetus to move. D. Ask the client if she has felt any fetal movement.

D. Ask the client if she has felt any fetal movement.

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation

D. At 30 weeks of gestation

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM Å~ 1. What action should the LPN/LVN take immediately? A. Give the medication as prescribed and monitor for efficacy. B. Encourage the client to breastfeed rather than bottle feed. C. Have the client empty her bladder and massage the fundus. D. Call the healthcare provider to question the prescription.

D. Call the healthcare provider to question the prescription.

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A. Reapply the external transducer. B. Insert the intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress.

D. Continue to monitor labor progress.

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take? A. Encourage her to pant between contractions and blow with contractions. B. Coach her to take a deep cleansing breath and then refocus. C. Instruct her to pant three times and then exhale through pursed lips. D. Have her cup both hands over her nose and mouth while breathing.

D. Have her cup both hands over her nose and mouth while breathing.

The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? A. August 1. B. August 10. C. September 3. D. September 8.

D. September 8.

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula? A. The new formula is a coconut milk formula used with babies with impaired fat absorption. B. Enfamil® Formula is a demineralized whey formula that is needed with diarrhea. C. The new formula is a casein protein source that is low in phenylalanine. D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? A. Elevate lower legs while resting. B. Increase caloric intake by 200 to 300 calories per day. C. Increase water intake to 8 full glasses per day. D. Take prescribed multivitamin and mineral supplements.

D. Take prescribed multivitamin and mineral supplements.

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A. Exercise regimen of both partners includes running four miles each morning. B. History of having sexual intercourse 2 to 3 times per week. C. The woman's menstrual period occurs every 35 days. D. They use lubricants with each sexual encounter to decrease friction.

D. They use lubricants with each sexual encounter to decrease friction.

Determine current cervical dilation

Determine current cervical dilation.

An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take?

Determine the infant's blood sugar level.

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement?

Document the vital signs in the record.

A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first?

Dry the newborn

The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity?

Early ambulation after surgery will be encouraged to reduce complications and promote healing.

The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity?

Early ambulation after surgery will be encouraged to reduce complications and promote healing.

The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity?

Early ambulation after surgery will be encouraged to reduce complications and promote healing.

At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client.

Elevate the head with two pillows while sleeping.

During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client.

Elevate the head with two pillows while sleeping.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect?

Exaggerated reflexes

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? -Ask the client if she takes a daily calcium tablet. -Extend the leg and dorsiflex the foot. -Lower the leg off the side of the bed. -Elevate the leg above the heart.

Extend the leg and dorsiflex the foot.

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effect?

Fetal asphyxia

A primipara at 20weeks' gestation is scheduled on ultrasound. In preparing the client for the procedure. The nurse should explain that the primary reason for conducting the diagnosis study is obtain which information?

Fetal growth and gestational age

A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider?

Frequent Headaches

A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make?

Gaining weight will promote a healthy pregnancy

A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions?

Giving the hepatitis B vaccine

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department?

Gonorrhea

A client tells the nurse that she thinks is pregnant. Which sign a symptom and signs provide is the best indication that the client is pregnant?

Hegar's sign

A nurse is reviewing the laboratory findings of a 24 hour old newborn. Which of the following findings should the nurse report to the provider?

Hemoglobin 12g/dL

A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statemnts indicates an understanding of the teaching?

I should be careful to avoid becoming pregnant within next month

A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client. Which of the following statements should the nurse make?

I'm here for you if you would like to talk

pelvic inflammatory disease (PID)

IV antibiotics

A nurse is providing education for a pregnant client about symptoms that should be reported immediately to the provider. Which of the following client responses indicates a understanding of the teaching?

If I notice that my eyes are puffy, I should call my provider

Which action should the nurse take on infant who was born yesterday weighing 7.5 lbs. Weighing 7 pounds today

Inform and assure the mother that this a normal weight loss.

Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client's medical record lists have client's religion as Jehovah's Witness. What action should the nurse take?

Inform the client of the critical need for a blood transfusion

A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?

Initiate normal saline IV at 50ml/hr.

A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?

Initiate normal saline IV at 50ml/hr.

While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Inspect the posterior oropharynx.

While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?

Inspect the posterior oropharynx.

A nurse is caring for a client who is pregnant and whose last menstrual period began on April 8th . using Naegele's rule, which of the following dates would be the clients estimated date of birth ( Estimated date of birth) ?

January 15th

A nurse on the antepartum unit is caring for a client who is at 28 weeks gestation and reports dizzieness when lying on her back. Into which of the following positions should the nurse assist the client?

Lateral

The mother of a 3 dayold male infant notices that his skin has yellowish tint. She asks the nurse about it. What is the most likely reason for jaundice in his infant?

Lowered serum bilirrubin level die to red blood cells breakdown and immature renal function

A 33 years old client gravida 7 para 5 is submitted to the hospital in emergency room at 32 weeks of gestation.She is not pain, is alert and is not acute distress FHR 120 BEATS/MINUTES with minim variability. She tells the nurse thatshe woke up to find that she was lyingin a pool a blood. Which assessment data should the nurse obtain first? Cervical dilation Maternal blood pressure Hematocrit and Hemoglobin Uterine Contraction

Maternal blood pressure

A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide?

Maternal blood pressure

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is 40 weeks pregnant?

Maternal blood pressure

A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide?

Maternal blood pressure.

A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide?

Maternal blood pressure.

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis af eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

Monitor Blood pressure, pulse, and respirations q4h.

Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl with a history of frequent urinary tract infections?

Monitor for changes in urinary odor.

Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl with a history of frequent urinary tract infections?

Monitor for changes in urinary odor.

The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority?

Monitor urinary output.

The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority?

Monitor urinary output.

Monitoring bleeding from IV sites

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) -Mood swings. -Panic attacks. -Tearfulness. -Decreased need for sleep. -Disinterest in the infant.

Mood swings. Tearfulness.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take?

Obtain blood samples for baseline lab values

A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

Offer information about ultrasonography and genotyping to determine sex assignment.

A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

Offer information about ultrasonography and genotyping to determine sex assignment.

A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?

Offer information about ultrasonography and genotyping to determine sex assignment.

Which finding for a client in labor at 41weeks gestation requires additional assessment by the nurse? -Cervix dilated 2 cm and 50% effaced. -Score of 8 on the biophysical profile. -Fetal heart rate of 116 beats per minute. -One fetal movement noted in an hour.

One fetal movement noted in an hour.

The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client's teaching plan?

Oral contraceptive use for at least one year.

The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to the body size. Which action is most important for the nurse to take next?

Palpate the anterior fontanel for tension and bulding.

A client who is 38 weeks pregnant is concerned her body get communicable disease before any immunizations are given. Which physiological mechanism should the nurse responding to the mother's concerns?

Passive immunity in the first months of life provides protection in newborns.

The nurse has completed a teaching plan for the mother of a child who is taking digitalis and a diuretic for treatment of the heart failure. Choosing which lunch would indicate that the mother understands the best diet for her child?

Peanut butter and banana sandwich with orange juice.

A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?

Place the infant on the abdomen to protect the sac.

A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?

Place the infant on the abdomen to protect the sac.

a laboring client with gestational diabetes is receiving an IV infusion with regular insulin at 5 units/hour The IV solution contains 100 units of regular insulin in 250ml of 0.9 % normal saline the nurse should program the infusion pump to deliver how many ml/hours (enter numeric only if rounding is required round to the nearest tenth)

R/12.5

The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?

Reduce cerebral edema and lower intracranial pressure.

A nurse is planning care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan?

Reposition the newborn every 3 hours

A nurse is discussing risk factors for necrotizing enterocolitis in the newborns with a newly licensed nurse. Which of the following risks factors should the nurse include?

Respiratory distress syndrome

What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes?

Restrict carbohydrate intake.

What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes?

Restrict carbohydrate intake.

Nurse is caring for a client who had a cesarean birth 36 hours ago and is experiencing pain due to gas. Which of the following strategies should the nurse recommend?

Rock in a rocking chair

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? -Elevate lower legs while resting. -Increase caloric intake by 200 to 300 calories per day. -Increase water intake to 8 full glasses per day. -Take prescribed multivitamins and mineral supplements

Take prescribed multivitamin and mineral supplements

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding?

The TSH is high because of the low production of T4 by the thyroid.

A nurse is providing care to a client who is 2 hour postpartum and is receiving an oxytocin iv. The client asks the nurse, " why is there so little bleeding"? which of the following responses should the nurse make?

The bleeding is minimal until I discontinue your iv medication

A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? -It is not necessary to keep such a close watch on weight gain. -Try to exercise more because too much weight has been gained. -Increase the calories in your diet to gain more weight per week. -The weight gain is acceptable for the number of weeks pregnant

The weight gain is acceptable for the number of weeks pregnant

"Your milk supply will noticeably increase in volume around the 3rd/4th day after delivery A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord?

They can cause delayed cord separation

Patient with Duchenne Disease. The nurse has to explain to the mother that:

This condition is inherited in an X-linked recessive chromosome pattern

A nurse is assessing a 2 day old newborn and notes an egg shaped, edematous. Bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding?

This will resolve in 3 to 6 weeks without treatment

pregnant woman had accident , supine position , no abdominal pain , but BP low

Tilt in side position

A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side?

Tonic neck

A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a button attached to the fetal monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. Which outcome indicates a reactive NST?

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded.

treat mastitis all apply

Use bras Take antibiotic regular interval Warm compresses

A nurse is assessing an 18 hour old newborn. Which of the following findings should be reported to the provider?

Yellow tinged skin

A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus . which of the following statement should the nurseinclude in the teaching?

You should continue to take zidovudine throughout the pregnancy

after circumcision

a petrolatum gauze dressing may be applied with each diaper

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching on the gravid client? a. The client's readiness to learn b. The client's educational background c. The order in which the information is presented d. The extent to which the pregnancy was planned

a. The client's readiness to learn

Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum? a. pudendal block b. epidural block c. saddle block d. paracervical block

a. pudendal block

fundal massage technique

anchor the lower uterine segment with one hand, while massaging the fundus with the other hand, to prevent uterine prolapse and uterine inversion

why not eat solid food pregnant woman after labor and delivery

avoid aspiration

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? a. Supplementary iron is more efficiently utilized during pregnancy b. It it difficult to consume 18 mg of additional iron by diet alone c. Iron absorption is decreased in the GI tract during pregnancy d. Iron is needed to prevent megaloblastic anemia in the last trimester b. It is difficult to consume 18 mg of additional iron by diet alone

b. It it difficult to consume 18 mg of additional iron by diet alone

A client who is an ovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, Menopur), and human chronic gonadotropin (hCG). Which side effect should the nurse tell the client to report immediately? a. Persistent daytime fatigue b. Episodes of headache and irritability c. Rapid increase in abdominal girth d. Nauseas and vomiting

c. Rapid increase in abdominal girth

woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy? a. complaints of feeling tired all the time b. presence of amenorrhea for 2 months c. visualization of implantation by vaginal ultrasound d. maternal blood serum tests positive for alpha-fetoprotein

c. visualization of implantation by vaginal ultrasound

pregnant in labor go to bathroom to put gown the nurse heard to baby cry

call light

A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? · Alert the neonatal team and prepare for neonatal resuscitation · Notify the healthcare provider from the client's bedside · Obtain written consent for an emergency cesarean section · Draw a blood sample for stat hemoglobin and hematocrit

· Notify the healthcare provider from the client's bedside

The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child? · Reduce cerebral edema and lower intracranial pressure · Avert hypotension and septic shock · Prevent cardiac arrhythmias and heart failure · Promote kidney perfusion and normal blood pressure.

· Reduce cerebral edema and lower intracranial pressure

Which nursing intervention is most important to include in the plan of care for for a child with acute glomerulonephritis? · Encourage fluid intake · Promote complete bed rest · Weight the child daily · Administer vitamin supplements

· Weight the child daily

"What food does your baby usually eat in a normal day?"

20 weeks' gestation a client who has gained 20 pounds during this pregnancy tells the nurse that she is feeling fetal movement. Fundal height measurement is 20cm and the client only complaint is that her breast is leaking clear fluid. Which assessment finding warrants further evaluation? - Leakage from the breast - Present of fetal movement - Fundal height measure - Gestational weight gain

- Gestational weight gain

Assessment finding of a 4 hours old newborn include, axillary temperature of 96.8 F (35.8 C) heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/min, jitteriness, hypotonic and weak cry. Based in this finding, what action should the nurse implement? - placed a pulse oximeter on the heel - Swaddle the infant in a warm blanket -Obtain a heel stick blood glucose level - document the finding in a record

- Swaddle the infant in a warm blanket

Which fetal heart rate patterns requires immediate nurse interventions?

- a decrease in a fetal heart rate that occurs after the peak of a contraction

Then nurse is planning care for a client at 30-week gestation, how is experiencing preterm labor. What maternal prescription is most important preventing the fetus for developing respiratory distress syndrome?

- betamethasone (celestone) 12 mg deep IM

A client who is 32 weeks gestation arrives at the clinic reporting nauseas and vomiting for the past 24 hours. The nurse reviews the record and observes there is a been of rapid weight gain over 6 weeks. Which action should the nurse implement first|? - inspect pedal edema - listen the fetal heart rate - obtain a blood pressure - ask for 24 hours diet recall

- obtain a blood pressure

A client of 33 weeks gestation is admitted with a moderate amount of vaginal bleeding and no contraction are noted on the external monitor. What intervention should the nurse implement?

- weight perineal pads

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? -3+ deep tendon reflexes and hyperclonus. -Periorbital edema, flashing lights, and aura. -Epigastric pain in the third trimester. -Recent decreased urinary output.

-3+ deep tendon reflexes and hyperclonus.

A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which designation is the most accurate summary of this client's obstetrical history? -3-1-1-1-3. -4-1-2-0-3. -3-0-3-0-3. -4-3-1-0-2.

-4-1-2-0-3. Rationale The client with 3 previous gravid experiences and this current pregnancy totals 4 gravid experiences, and 1 term delivery (37weeks or greater), 2 preterm deliveries (20 to 37 weeks, whether viable or not viable), no spontaneous abortions and 3 living children. (B) best designates this client's obstetrical history. (A, C, and D) are inaccurate for this client's history using the TPAL system.

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? -A gravida 6, para 5 who is 38 years of age and in early labor. -A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. -A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. -A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

-A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? -4+ reflexes. -Urinary output of 50 ml per hour. -A decrease in respiratory rate from 24 to 16. -A decreased body temperature.

-A decrease in respiratory rate from 24 to 16.

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? -Cervical dilation of 5 cm with 90% effacement. -White blood cell count of 12,000/mm3. -Hemoglobin of 12 mg/dl and hematocrit of 38%. -A platelet count of 67,000/mm3.

-A platelet count of 67,000/mm3.

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) -Litmus paper. -Fetal scalp electrode. -A sterile glove. -An amniotic hook. -Sterile vaginal speculum. -A Doppler.

-A sterile glove. -An amniotic hook. -A Doppler.

A client at 28weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? -Contraction stress test. -Internal fetal monitoring. -Abdominal ultrasound. -Lecithin-sphingomyelin ratio.

-Abdominal ultrasound.

A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client? -During second trimester beer can be consumed without harm to the fetus. -Wine can be consumed several times a week after the first trimester. -Only one drink with the evening meal is not harmful to the fetus. -Abstinence is strongly recommended throughout the pregnancy

-Abstinence is strongly recommended throughout the pregnancy

A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collossion. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor? -Suspect that the monitor is malfunctioning and recount the heart rate manually -Explain to the client that a rapid heart right is normal for a preterm fetus. -Perform a vaginal Examination to see if the accident initiated preterm labor -Administer oxygen to the client and contact the healthcare provider immediately.

-Administer oxygen to the client and contact the healthcare provider immediately.

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) -Admission weight of 4 pounds, 15 ounces (2244 grams). -Head-to-heel length of 17 inches (42.5 cm). -Frontal occipital circumference of 12.5 inches (31.25 cm). -Skin smooth with visible veins and abundant vernix. -Anterior plantar crease and smooth heel surfaces. -Full flexion of all extremities in resting supine position.

-Admission weight of 4 pounds, 15 ounces (2244 grams). -Head-to-heel length of 17 inches (42.5 cm). -Frontal occipital circumference of 12.5 inches (31.25 cm).

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? -Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. -An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. -Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. -Frequent voiding minimizes the need for catheterization which increases the chance of bladder

-An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? -Apply cold compresses to both breasts for comfort. -Instruct the client run warm water on her breasts. -Wear a loose-fitting bra to prevent nipple irritation. -Express small amounts of milk to relieve pressure.

-Apply cold compresses to both breasts for comfort.

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? -Discontinue the oxytocin (Pitocin) infusion. -Place the client in a semi-Fowler's position. -Inform the healthcare provider. -Apply firm pressure to sacral area.

-Apply firm pressure to sacral area.

The parents of a normal male newborn have signes an informed consent for circumsion. The healthcare provider has prescribed EMLA(eutectic mixture of local anesthetics) cream 1 gram to penis per occlusive dressing 60 minutes prior to procedure.What priority intervention should the nurse implement? -offer a pacifier dipped in glucose water -give a PRN dose of liquid acetaminophen -Apply petrolateum gauze dressings to the site. -position the swaddled newborn laterally

-Apply petrolateum gauze dressings to the site.

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? -Check the client for urinary bladder distention.] -Notify the healthcare provider of the nonreactive results. -Have the mother stimulate the fetus to move. -Ask the client if she has felt any fetal movement.

-Ask the client if she has felt any fetal movement.

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first? -Prepare the client for imminent birth. -Assess the fetal heart rate and pattern. -Document the characteristics of the fluid. -Notify the client's primary healthcare provider

-Assess the fetal heart rate and pattern.

The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? -Check the infant's arterial blood gases. -Notify the pediatrician of the infant's vital signs. -Assess the infant's blood glucose level. -Encourage the infant to take the breast or sugar water.

-Assess the infant's blood glucose level.

-Assist the client to the bathroom.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? -Between the time the temperature falls and rises. -Between 36 and 48 hours after the temperature rises. -When the temperature falls and remains low for 36 hours. -Within 72 hours before the temperature falls.

-Between the time the temperature falls and rises.

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? -Biophysical profile (BPP). -Ultrasound for fetal anomalies. -Maternal serum alpha-fetoprotein (AF) screening. -Percutaneous umbilical blood sampling (PUBS).

-Biophysical profile (BPP).

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately? -Give the medication as prescribed and monitor for efficacy. -Encourage the client to breastfeed rather than bottle feed. -Have the client empty her bladder and massage the fundus. -Call the healthcare provider to question the prescription.

-Call the healthcare provider to question the prescription.

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? -Molding. -Hemangioma. -Cephalohematoma. -Caput succedaneum.

-Caput succedaneum.

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? -Blood glucose level of 45 mg/dl. -Blood pressure of 82/45 mmHg. -Non-bulging anterior fontanel. -Central cyanosis when crying.

-Central cyanosis when crying.

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? -Molding. -Cephalohematoma. -Caput succedaneum. -Bulging fontanel.

-Cephalohematoma.

A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? -Slowly increasing urinary output over the last week. -Respiratory rate changes from the 40s to the 60s. -Changes in apical heart rate from the 180s to the 140s. -Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.

-Changes in apical heart rate from the 180s to the 140s.

A client at 28weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? -Vaginal bleeding. -Complaints of abdominal pain. -Changes in fetal heart rate patterns. -Alteration in maternal blood pressure.

-Changes in fetal heart rate patterns.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? -Monitor urinary output via an indwelling catheter. -Assess the abdominal dressings for drainage. -Give the Ringer's Lactated infusion at 125 ml/hr. -Check the firmness of the uterus every 15 minutes.

-Check the firmness of the uterus every 15 minutes.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? -Come to the clinic today for an ultrasound. -Go immediately to the emergency room. -Lie on your left side for about one hour and see if the bleeding stops. -Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

-Come to the clinic today for an ultrasound.

A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? -Complete a sterile vaginal exam. -Take maternal temperature every 2 hours. -Prepare for an immediate cesarean birth. -Obtain sterile suction equipment.

-Complete a sterile vaginal exam.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? -Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. -We want your baby to be healthy, and this is the only way we can make sure that will happen. -I know you're upset. Would you like to talk about some things you could do while in bed? -Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties

-Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? -Wear a cotton bra. -Increase nursing time gradually. -Correctly place the infant on the breast. -Manually express a small amount of milk before nursing.

-Correctly place the infant on the breast.

When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? -Quiet the infant before counting the heart rate. -Listen at the apex of the heart. -Count the heart rate for at least one full minute. -Palpate the umbilical cord.

-Count the heart rate for at least one full minute.

A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? -Notify the healthcare provider. -Move the newborn to an isolation nursery. -Document the finding in the infant's record. -Obtain a culture of the vesicles.

-Document the finding in the infant's record.

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? -Males inherit the disorder with a greater frequency than females. -Each pregnancy carries a 50% chance of inheriting the disorder. -The disorder occurs in 25% of pregnancies. -All children will be carriers of the disorder.

-Each pregnancy carries a 50% chance of inheriting the disorder.

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? -Edema, basilar rales, and an irregular pulse. -Increased urinary output and tachycardia. -Shortness of breath, bradycardia, and hypertension. -Regular heart rate and hypertension.

-Edema, basilar rales, and an irregular pulse.

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? -Discuss various contraceptive methods to use until pregnancy is desired. -Provide written or verbal information about prenatal care. -Ask the client about risk factors associated with complications of pregnancy. -Encourage healthy lifestyles for families desiring pregnancy

-Encourage healthy lifestyles for families desiring pregnancy

The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? -Provide phototherapy for 30 minutes q8h. -Feed the newborn sterile water hourly. -Encourage the mother to breastfeed frequently. -Assess the newborn's blood glucose level.

-Encourage the mother to breastfeed frequently.

A multiparous client who delivered her infant three hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perineal pain after her last deliver. Which response would be best fot the nurse to provide this client? -explain the use of an analgesic spray to the perineal area to reduce pain -tell the client that warm sitz baths are used after the first 24 hours. -Encourage use of an ice pack for the first 24 hours. -teach the client to sit and stand with her buttocks tightened

-Encourage use of an ice pack for the first 24 hours.

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement? -Massage the calf and foot. -Extend the leg and dorsiflex the foot. -Lower the leg off the side of the bed -Elevate the leg above the heart.

-Extend the leg and dorsiflex the foot.

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? -Begin as soon as your baby is born to establish a four-hour feeding schedule. -Resting helps with milk production. Ask that your baby be fed at night in the nursery. -Feed your baby every 2 to 3 hours or on demand, whichever comes first. -Do not allow your baby to nurse any longer than the prescribed number of minutes.

-Feed your baby every 2 to 3 hours or on demand, whichever comes first.

While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change? -Fetal well being with labor progression. -Signs of uteroplacental insufficiency. -Episodes of fetal head compression. -Occurrences of cord compression.

-Fetal well being with labor progression.

A 34 weeks' gestation multigravida come to clinic for herbimonthly appointment. Which assessment finding should the nurse report in the healthcare provider? -1+ Edema in lower extremities. -Fundal height of 30 cm. -Fetal heart rate 110 beats/minute. -weight gain of 2 pounds.

-Fundal height of 30 cm.

A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first? -Ventilate with an Ambu bag. -Perform nasal and airway suctioning. -Administer supplemental oxygen. -Gently rub the infant's feet or back.

-Gently rub the infant's feet or back.

The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? -Give 10 liters of oxygen via face mask. -Prepare for an emergency cesarean section. -Continue to monitor the fetal heart rate pattern. -Obtain an oral maternal temperature.

-Give 10 liters of oxygen via face mask.

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? -Herpes. -Staphylococcus -Gonorrhea. -Syphilis.

-Gonorrhea.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate? -Grief related to her perceptions about the loss of this child. -Relief of ambivalent feelings experienced with this pregnancy. -Shock because she may not have realized that she was pregnant. -Guilt because she had not followed her healthcare provider's instructions.

-Grief related to her perceptions about the loss of this child.

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? -Administer oxygen by face mask. -Notify the healthcare provider of the client's symptoms. -Have the client breathe into her cupped hands. -Check the client's blood pressure and fetal heart rate.

-Have the client breathe into her cupped hands.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? -Have the client empty her bladder. Correct -Request the client lie on her left side. -Perform Leopold's maneuvers first. -Give the client some cold juice to drink.

-Have the client empty her bladder. Correct

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? -She eagerly reaches for the infant, undresses the infant, and examines the infant completely. -Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. -Her arms and hands receive the infant and she then cuddles the infant to her own body. -She eagerly reaches for the infant and then holds the infant close to her own body

-Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

When reviewing the records of a gravid client, the nurse notes that her deep tendion reflexes(DTRs) are 2+ Based on this information, which evaluation of the client's condition is correct? -She is in the early stages of eclampsia -she has severe preeclampsia -Her reflexes are within normal limits -Her neurological functoning is depressed

-Her reflexes are within normal limits

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? -Dehydration. -Hyperstimulation. -Galactorrhea. -Fetal tachycardia.

-Hyperstimulation.

A client with endometritis is preparing for discharge on her third postpartum day, Which statement by he client indicates that the discharge teaching was effective? -I should limit my visitors until this infection clears -I will resume breastfeeding when the infection is gone -I should sit an upright position as much as possible -I will stop taking antibiotics when my fever disappears

-I should sit an upright position as much as possible

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Whichaction should the nurse implement next? -Check the hematocrit results. -Administer pain medication. -Increase the rate of IV fluids. -Monitor client for contractions.

-Increase the rate of IV fluids.

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? -Length of labor and method of delivery. -Infant's condition at birth and treatment received. -Feeding method chosen by the parents. -History of drugs given to the mother during labor.

-Infant's condition at birth and treatment received.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next? -Initiate positive pressure ventilation. -Intervene after the one minute Apgar is assessed. -Initiate CPR on the infant. -Assess the infant's blood glucose level.

-Initiate positive pressure ventilation.

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? -Supplementary iron is more efficiently utilized during pregnancy. -It is difficult to consume 18 mg of additional iron by diet alone. -Iron absorption is decreased in the GI tract during pregnancy. -Iron is needed to prevent megaloblastic anemia in the last trimester.

-It is difficult to consume 18 mg of additional iron by diet alone.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? -Herbs are a cornerstone of good health to include in your treatment. -Touch is also therapeutic in relieving discomfort and anxiety. -Your healthcare provider should direct treatment options for herbal therapy. -It is important that you want to take part in your care.

-It is important that you want to take part in your care.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? -Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. -Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. -Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. -Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

-Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" -Lying prone with a pillow on the abdomen. -Using a breast pump. -Massaging the abdomen. -Giving oxytocic medications.

-Lying prone with a pillow on the abdomen.

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? -Your current dose of Insulin should be maintained throughout your pregnancy. -Maintain blood sugar levels in a constant range within normal limits during pregnancy. -The course and outcome of your pregnancy is not an achievable goal with diabetes. -Expect an increase in insulin dosages by 5 units/week during the first trimester.

-Maintain blood sugar levels in a constant range within normal limits during pregnancy.

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? -Maternal blood pressure and respirations. -Maternal and fetal heart rates. -Hourly urinary output. -Deep tendon reflexes.

-Maternal and fetal heart rates.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? -Encourage the mother to provide total care for her infant. -Provide privacy so the mother can develop a relationship with the infant. -Encourage the father to provide most of the infant's care during hospitalization. -Meet the mother's physical needs and demonstrate warmth toward the infant.

-Meet the mother's physical needs and demonstrate warmth toward the infant.

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? -Insert an internal fetal monitor. -Assess for cervical changes q1h. -Monitor bleeding from IV sites. -Perform Leopold's maneuvers.

-Monitor bleeding from IV sites.

A client in labor receives an epidural block. What intervention should the nurse implement first? -Encourage oral fluids. -Assess contractions. -Monitor blood pressure. -Obtain a radial pulse.

-Monitor blood pressure.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? -Wear support stockings. -Reduce salt in her diet. -Move about every hour. -Avoid constrictive clothing.

-Move about every hour.

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? -Recheck the client's vital signs. -Notify the healthcare provider. -Insert an indwelling urinary catheter. -Massage the fundus in 30 minutes.

-Notify the healthcare provider.

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is -November 22. -November 8. -December 22. -October 22.

-November 22.

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? -Elicit a positive scarf sign on the affected side. -Observe for an asymmetrical Moro (startle) reflex. -Watch for swelling of fingers on the affected side. -Note paralysis of affected extremity and muscles.

-Observe for an asymmetrical Moro (startle) reflex.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? -Ask the mother why she won't look at the infant. -Observe the mother for other attachment behaviors. -Examine the newborn's eyes for the ability to focus. -Recognize this as a common reaction in new mothers.

-Observe the mother for other attachment behaviors.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? -Provide oral hydration. -Have a complete blood count (CBC) drawn. -Obtain a specimen for urine analysis. -Place the client on strict bedrest.

-Obtain a specimen for urine analysis.

A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? -Assess newborn reflexes for signs of neurological impairment. -Leave the infant in the room with the mother to foster attachment. -Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. -Perform a gestational age assessment to determine if the infant is large for-gestational-age

-Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia.

Which finding for a client in labor at 41-weeks gestation requires additional assessment by the nurse? -Cervix dilated 2 cm and 50% effaced. -Score of 8 on the biophysical profile. -Fetal heart rate of 116 beats per minute. -One fetal movement noted in an hour.

-One fetal movement noted in an hour.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? -Heart rate of 100 beats/minute. -Variable fetal heart rate. -Onset of uterine contractions. -Burning on urination.

-Onset of uterine contractions.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? -Cleanse the perineum. -Obtain a blood pressure. -Palpate the firmness of the fundus. -Inspect the perineum for lacerations.

-Palpate the firmness of the fundus.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? -Patellar reflex 4+. Correct -Blood pressure 158/80. -Four-hour urine output 240 ml. -Respiration 12/minute.

-Patellar reflex 4+. Correct

A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement? -Escort the client to the bathroom. -Offer the client a bed pan. -Perform a nitrazine test. -Clean the perineal area.

-Perform a nitrazine test.

A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? -Periodic abdominal pain. -Ankle edema in the afternoon. -Backache with prolonged standing. -Shortness of breath when climbing stairs.

-Periodic abdominal pain.

What action should the nurse implement when caring for a newborn receiving phototherapy? -Reposition every 6 hours. -Place an eyeshield over the eyes. -Limit the intake of formula. -Apply an oil-based lotion to the skin.

-Place an eyeshield over the eyes.

The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? -Notify the healthcare provider of fetal status. -Give oxygen at 10 L per nasal cannula. -Place the client in a side-lying position. -Increase the flow rate of intravenous fluids

-Place the client in a side-lying position.

A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first? -Administer 10 L of oxygen via face mask. -Give the healthcare provider a status report. -Place the client in the knee-chest position. -Wrap the cord with gauze soaked in saline.

-Place the client in the knee-chest position.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? -Notify the healthcare provider or anesthesiologist immediately. -Continue to assess the blood pressure q5 minutes. -Place the woman in a lateral position. -Turn off the continuous epidural.

-Place the woman in a lateral position.

The nurse has explained safety precautions and infant care to a primagravida mother and observes the mother as she gives care to her newborn during the first 2 days of rooming in. What action indicated the mother understands the instructions? -Uses a bulb syringe in the newborn nare's -Places the infant in a supine position to sleep. -wakes the infant up to breastfeed every 2 hours -bather the newborn in water using an infant sized tub

-Places the infant in a supine position to sleep.

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? -Cuddles the baby close to her. -Rocks and soothes the infant in her arms. -Places the infant prone in the bassinet. -Wraps the baby in a warm blanket after bathing

-Places the infant prone in the bassinet.

The nurse is preparing for the delivery of an infant whose primiparous mother is 35 years old and a low birth weight(LBW) infant is expected. Which intervention is most important for the nurse to implement? -send the placenta to pathology for analysis -encourage breast feeding after delivery -Preheat the radiant warmer. -obtain the infant's birth weight

-Preheat the radiant warmer.

Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)? -Woman whose blood group is AB Rhpositive. -Newborn with rising serum bilirubin level. -Newborn whose Coombs test is negative. -Primigravida mother who is Rhnegative.

-Primigravida mother who is Rhnegative.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? -Assess the husband's feelings about his wife's decision to breastfeed their baby. -Ask the client to describe why she was unsuccessful with breastfeeding her last child. -Encourage the client to develop a positive attitude about breastfeeding to help ensure success. -Provide assistance to the mother to begin breastfeeding as soon as possible after delivery

-Provide assistance to the mother to begin breastfeeding as soon as possible after delivery

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? -Use a thread to tie off the umbilical cord -Provide as much privacy as possible for the woman. -Reassure the husband and try to keep him calm. -Put the newborn to breast.

-Put the newborn to breast.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? -Raise the foot of the bed. -Assess for vaginal bleeding. -Evaluate the fetal heart rate. -Take the client's blood pressure.

-Raise the foot of the bed.

Following vaginal delivery in a birthing suite, the nurse assesses a newborn male and finds that his respiration are 58 breaths per minute and his hands and feet are cyanotic. What action should the nurse take? -Record the findings and continue to observe the infant -administer oxygen at 5l/minute -Notify the pediatrician immediately -transfer the infant into the nursery to determine his oxygen saturation rate.

-Record the findings and continue to observe the infant

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? -Reduce activity level and notify the healthcare provider. -Go to bed and assume a knee-chest position. -Massage the uterus and go to the emergency room. -Do not worry as this is a normal occurrence.

-Reduce activity level and notify the healthcare provider.

A 30-year-old multiparous woman who has a 3-year-old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? -Tell the older child that he is a big boy now and should love his new sister. -Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. -Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn. -Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

-Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? -Plan for a possible cesarean birth. -Arrange for home uterine monitoring. -Make arrangements for care at home. -Report uterine cramping or low backache.

-Report uterine cramping or low backache.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.) -Reposition the client. -Provide oxygen via face mask. -Increase IV fluid. -Call the healthcare provider.

-Reposition the client. -Provide oxygen via face mask. -Increase IV fluid. -Call the healthcare provider.

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose? -Detect cardiovascular disorders. -Screen for neural tube defects. -Monitor the placental functioning. -Assess for maternal pre-eclampsia.

-Screen for neural tube defects.

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? -Back pain. -Abdominal pain. -Shoulder pain. -Leg cramps.

-Shoulder pain.

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula? -The new formula is a coconut milk formula used with babies with impaired fat absorption. -Enfamil® Formula is a demineralized whey formula that is needed with diarrhea. -The new formula is a casein protein source that is low in phenylalanine. -Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

-Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

A multipara postpartum client complains about intenst cramping while breastfeeding. What instructions should the nurse provide to this client? -TAKE A PRESCRIBED ANALGESIC AN HOUR PRIOR TO BREASTFEEDING -change then infants position during the next feeding -drink two glasses of Water 30 minutes prior to breastfeeding -void and completely empty bladder before each feeding

-TAKE A PRESCRIBED ANALGESIC AN HOUR PRIOR TO BREASTFEEDING

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? -Drowsiness and bradycardia. -Depressed reflexes and increased respirations. -Tachycardia and a feeling of nervousness. -A flushed, warm feeling and a dry mouth

-Tachycardia and a feeling of nervousness.

A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? -Refer the client to a social worker to arrange for home care. -Recommend perinatal care from an obstetrician, not a nurse-midwife. -Teach the client why keeping prenatal care appointments is important. -Advise the client that neonatal intensive care may be needed.

-Teach the client why keeping prenatal care appointments is important.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? -This is not an unusual shaped head, especially for a first baby. -It may look funny to you, but newborn babies are often born with heads like your baby's. -That is normal; the head will return to a round shape within 7 to 10 days. -Your pelvis was too small, so the baby's head had to adjust to the birth canal.

-That is normal; the head will return to a round shape within 7 to 10 days.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? -The client's readiness to learn. -The client's educational background. -The order in which the information is presented. -The extent to which the pregnancy was planned.

-The client's readiness to learn.

The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion? -The client needs to void. -Amniotic membranes rupture. -Uterine contractions occur every 8 to 10 minutes. -The fetal heart rate is 180 bpm without variability

-The fetal heart rate is 180 bpm without variability

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? -The infant should be positioned to reduce the swelling. -The swelling is a subperiosteal collection of blood. -The pediatrician will aspirate the blood if it gets larger. -The scalp edema will subside in a few days after birth

-The scalp edema will subside in a few days after birth

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? -Some care is required when touching the large soft area on top of your baby's head until the bones fuse together. -That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot. -The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby. -There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

-There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? -Exercise regimen of both partners includes running four miles each morning. -History of having sexual intercourse 2 to 3 times per week. -The woman's menstrual period occurs every 35 days. -They use lubricants with each sexual encounter to decrease friction

-They use lubricants with each sexual encounter to decrease friction

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? -Two vessels: one artery and one vein. -Two vessels: two arteries and no veins. -Three vessels: two arteries and one vein. -Three vessels: two veins and one artery

-Three vessels: two arteries and one vein.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? -Transition labor with contractions every 2 minutes, lasting 90 seconds each. -Early labor with contractions every 5 minutes, lasting 40 seconds each. -Active labor with contractions every 31 minutes, lasting 60 seconds each. -Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each.

-Transition labor with contractions every 2 minutes, lasting 90 seconds each.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity? -Deep tendon reflexes 2+. -Blood pressure 140/90. -Respiratory rate 18/minute. -Urine output 90 ml/4 hours.

-Urine output 90 ml/4 hours.

Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)? -Using relaxation breathing techniques. -Using a breast pump. -Massaging the abdomen. -Giving oxytocic medications.

-Using relaxation breathing techniques.

At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villus sampling (CVS) procedure. What assessment finding requires immediate intervention? -Uterine cramping. -Abdominal tenderness. -Systolic blood pressure < 100 mmHg. -Intermittent nausea.

-Uterine cramping.

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? -Milia are red marks made by forceps and will disappear within 7 to 10 days. -Meconium is the first stool and is usually yellow gold in color. -Vernix is a white, cheesy substance, predominantly located in the skin folds. -Pseudostrabismus found in newborns is treated by minor surgery

-Vernix is a white, cheesy substance, predominantly located in the skin folds.

A mother who is bottle feeding her baby develops breast engorgement. What is the best recommendation for the nurse to provide this client? -Wear a tight bra and avoid breast stimulation. -Express some milk from the breast by hand -Expose the breast to air -Apply warm packs to the breast

-Wear a tight bra and avoid breast stimulation.

The nurse is performing an admission physical assessment of a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider? -heel stick glucose of 65 mg/dl -head circumference of 35 cm (14 inches) -Widened, tense, bulging fontanel -highͲpitched shrill cry

-Widened, tense, bulging fontanel

The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? -Yellowish tinge to the skin. -Babinski reflex present bilaterally. -Pink papular rash on the face -Moro reflex noted after a loud noise.

-Yellowish tinge to the skin.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide? -Weigh the baby daily, and if she is gaining weight, she is eating enough. -Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. -Offer the baby extra bottle milk after her feeding, and see if she is still hungry. -If you're concerned, you might consider bottle feeding so that you can monitor her intake.

-Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as -a cephalhematoma, caused by forceps trauma and may last up to 8 weeks -a subarachnoid hematoma, which requires immediate drainage to prevent further complications. -molding, caused by pressure during labor and will disappear within 2 to 3 days. -a subdural hematoma which can result in lifelong damage

-a cephalhematoma, caused by forceps trauma and may last up to 8 weeks

15. An RhͲnegative client sufferes a miscarraige at 12 weeks gestation. Which plan for Rho(d) immune globulin (RhoGAM) administartion should the nurse implement? -administer Rho immune globulin (RhoGAM) within 2 weeks following the miscarriage -Rho(D) immune globulin (Rhogam) is not needed since the was not a full term infant -administer Rho(D) immune globulin (RhoGAM) within 72 hrs after the misscarriage -administer Rho(d) immune globulin (RhoGAM) only if the fetus is determines to be RhͲpositive.

-administer Rho(D) immune globulin (RhoGAM) within 72 hrs after the misscarriage

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the -anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. -anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. -anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. -anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

-anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

While assessing a client at 22 weeks gestation, the nurse suspects that the placenta soufflé rate was counted, rather than fetal heart rate. To confirm that the placenta soufflé rate was obtained, what action should be nurse taken. -compare the clients radial pulse rate with the ausculcalted rate. -Apply a fetal monitor to assess for uterine contractions. -perform leopolld' maneuvers to determine the position of fetus. -collect a voided specimen to check for protein in the urine

-compare the clients radial pulse rate with the ausculcalted rate.

when assessing a client at 32 weeks gestation, the nurse determines that her deep tendon reflexes (DTRs) are 4+. What action should the nurse take first? -determines the client's blood pressure -no action is required since this is a normal finding -assess the client's for pitting edema -notify the healthcare provider

-determines the client's blood pressure

The nurse finds a client at 32 weeks gestation in cardiac arrest. What adaptation of CPR should the nurse implement? -open the airway by placing the client's head in the sniff position -displace the uterus laterally using wedge under one hip -Increase the ventilation to compression ration to 3:20 -place one had over sternum for compressions

-displace the uterus laterally using wedge under one hip

an HIV positive mother delivers a 6 pound boy. Which intervention should the nurse initiate to prevent transfer of the HIV disease to this child? -ask the mother to come the nursery to feed and care for the baby -encourage rooming in but prevent breastfeeding -clean the skin with alcohol prior to administering vitamin k injection -teach the mother to come to the nursery to feed and care for the baby

-encourage rooming in but prevent breastfeeding

13. at a routine prenatal visit, a client at 34 weeks gestation complains of nasal stuffiness and occasional nose bleeds -estrogen -progesterone -relaxin -human chorionic gonadotropion

-estrogen

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have -lower Apgar scores. -lower birth weights. -respiratory distress. -a higher rate of congenital anomalies.

-lower birth weights.

a client at 8 weeks gestation is told her hemoglobin is 9.5 mg/dl. Which nursing intervention has the highest priority? -provide the client with a list of goods high in iron -instruct the client to eat a well balance diet -explain that this is a normal finding -obtain a prescription for an iron supplement

-obtain a prescription for an iron supplement

A primigravida at 39 weeks gestation is admitted to labor and delivery with spontatneous rupture of membranes (SROM) and contractions occuring every 2 to 3 minutes. A vaginal exam indicated that the cervic is dilated 6 cm, 90% effected, and the fetus is at +2 station. During the last 30 minutes the fetal heart rate has ranged between 170 and 180 beats/min. what action should the nurse implement first? -obtain the maternal temperature -draw blood for a complete blood count -send amniotic fluid for analysis -provide 4 liters of oxygen/face mask

-obtain the maternal temperature

the nurse is assessing a postpartum client who delivered an 11 pound infant veginally 2 hours ago. The client's fundus is fingerbreadths above the umbilicus, deviated to the right side, and boogy. After the client voids 200 ml of urine using a bedpan, what action should the nurse implement? -palpate the suprapubic region for distention -assist the client to the bathroom to void -reevaluate the clinet in 15 minutes -administer a prn prescription for ocytocin

-palpate the suprapubic region for distention

after a client experiences spontaneous rupture of the membranes during labor, the nurse notes a visible prolapsed of the umbilical cord. What intervention should the nurse implement immediately. -adminsiter oxygen by face mask at 6l/min -prepare the client for a cesarean delivery -push the presenting part off the cord -turn the client to a supine position

-push the presenting part off the cord

calculated by Nagele's rul, a client is at 26 weeks gestation. She is moderately obese and carrying twins. The nurse measures her fundal height at 29 cm. Based on these findings, what conclusion is accurate? -recognizes this as a resasonable fundal height measurement for this client. -before taking further action, this finding needs to be confirmed by another nurse -this fundal height measurement many indicate intrauterine growth retardation since this is a mutiple bath. -the healthcare provider needs to be notified immideately since this fundal height measurement is greater than expected

-recognizes this as a resasonable fundal height measurement for this client.

The nurse should support and coach a client in the letent phaseof the first stage of laboe by encouraging the use of which breathing techniwue? -deep abdominal breathing -slow paced breathing -patterned paced breathing -modified paced breathing

-slow paced breathing

in caring for a newborn infant who starts gagging and becomes cyanotic, what action should the nurse implement first? -give three back blows to clear the airway -call for assistance and start CPR -suction mouth nose with bulb -provide oxygen by resuscitation bag and mask

-suction mouth nose with bulb

The registered nurse is observing a newly hired LPN give a newborn a vitamin K (aquameohyton ) injection . The LPN uses a filter needle to draw 0.25 ml of aquamephyton in to the syringe, cleanses the thigh with alcohol in a circular motion, and prepares to inject the needle to 90 degree angle in left castus lateralis. What action should the RN take? -praise the pn for using the correct injection technique -tell the Pn to change the flter needle to a ½ inch needle -instruct the pn to give the injection at 45 degrees angle -suggest injectiong the medication into the ventrogluteal muscle

-tell the Pn to change the flter needle to a ½ inch needle

The nurse should encourage the laboring client to begin pushing when -there is only an anterior or posterior lip of cervix left. -the client describes the need to have a bowel movement. -the cervix is completely dilated. -the cervix is completely effaced.

-the cervix is completely dilated.

the nurse is presenting information about fetal development to a group of parents who are attending a Lamaze birthing class. When discussing cephalocaudal fetal development, which informaton should the nurse provide? -fetal development occurs in a set order -the baby develops normally in one direction -the fetus develops from head to rump correct -brain development determines organ formation

-the fetus develops from head to rump correct

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs -two weeks before menstruation. -immediately after menstruation. -immediately before menstruation. -three weeks before menstruation.

-two weeks before menstruation.

A primigravida mother who is one day post delivery tells the nurse that she is not producing enough milk for her new baby, and she wants to begin breastfeeding at home when her milk comes in. What info should the nurse obtain before responding to the client? -when the lactation consultant is scheduled to visit the client in her home -the womans understanding of how her body produces breast milk. -if the woman is feeling pressured by her family to breast feed her infant. -why the woman thinks her infant is not receiving enough milk

-why the woman thinks her infant is not receiving enough milk

0.3

78. After instructing a primiparous client who is bottle-feeding about burping, which of the following client statements indicates that the client needs further teaching? 1. "I'll burp him after 15 minutes of feeding him formula." 2. "After he takes one-half ounce of formula, I'll burp him." 3. "I'll burp him while he is in an upright position." 4. "I'll gently pat his back to get him to burp."

1. "I'll burp him after 15 minutes of feeding him formula."

40. A primiparous client at 10 weeks' gestation questions the nurse about the need for an ultrasound. She states "I don't have health insurance and I can't afford it. I feel fine, so why should I have the test?" The nurse should incorporate which statements as the underlying reason for performing the ultrasound now? Select all that apply. 1. "We must view the gross anatomy of the fetus." 2. "We need to determine gestational age." 3. "We want to view the heart beating to determine that the fetus is viable." 4. "We must determine fetal position." 5. "We must determine that there is a sufficient nutrient supply for the fetus."

1. "We must view the gross anatomy of the fetus." 2. "We need to determine gestational age." Although ultrasounds are not considered part of routine care, the ultrasound is able to confirm the pregnancy, identify the major anatomic features of the fetus and possible abnormalities, and determine the gestational age by measuring crown-to-rump length of the embryo during the first trimester. At this time, the ultrasound cannot confirm that the fetus is viable. The ultrasound will provide information about fetal position; however, this information would be more important later in the pregnancy, not during the first trimester. The ultrasound would provide no information about nutrient supply for the fetus.

83. A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The primary health care provider has prescribed prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first? 1. Assess the frequency of uterine contractions. 2. Place the client in a side-lying position. 3. Determine whether the membranes have ruptured. 4. Prepare the client for an amniotomy.

1. Assess the frequency of uterine contractions.

9. A 17-year-old client at 33 weeks' gestation diagnosed with mild preeclampsia is treated as an outpatient. The nurse instructs the client to contact the health care provider immediately if she experiences which of the following? 1. Blurred vision. 2. Ankle edema. 3. Increased energy levels. 4. Mild backache.

1. Blurred vision. Severe headache, visual disturbances such as blurred vision, and epigastric pain are associated with the development of severe preeclampsia and possible eclampsia. These danger signs and symptoms must be reported immediately. Severe headache and visual disturbances are related to severe vasoconstriction and a severe increase in blood pressure. Epigastric pain is related to hepatic dysfunction. Ankle edema is common during the third trimester. However, facial edema is associated with increased fluid retention and the progression from mild to severe preeclampsia. Increased energy levels are not associated with a progression of the client's preeclampsia or the development of complications. In fact, some women report an "energy spurt" before the onset of labor. Mild backache is a common discomfort of pregnancy, unrelated to a progression of the client's preeclampsia.It also may be associated with bed rest when the mattress is not firm. Some multiparous women have reported a mild backache as a sign of impending labor.

13. For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia? 1. Decreased deep tendon reflexes. 2. Cool skin temperature. 3. Rapid pulse rate. 4. Tingling in the toes.

1. Decreased deep tendon reflexes. Typical signs of hypermagnesemia include decreased deep tendon reflexes, sweating or a flushing of the skin, oliguria, decreased respirations, and lethargy progressing to coma as the toxicity increases. The nurse should check the client's patellar, biceps, and radial reflexes regularly during magnesium sulfate therapy. Cool skin temperature may result from peripheral vasodilation, but the opposite—flushing and sweating—are usually seen. A rapid pulse rate commonly occurs in hypomagnesemia. Tingling in the toes may suggest hypocalcemia, not hypermagnesemia.

42. The nurse is discussing kangaroo care with the parents of a premature neonate. The nurse should tell the parents that the advantages of kangaroo care include which of the following? Select all that apply. 1. Enhanced bonding. 2. Increased IQ. 3. Improved physiologic stability. 4. Decreased length of stay in the neonatal intensive care unit. 5. Improved breast-feeding

1. Enhanced bonding. 3. Improved physiologic stability. 4. Decreased length of stay in the neonatal intensive care unit. 5. Improved breast-feeding Kangaroo care is skin-to-skin holding of a neonate by one of the parents. Research has shown increased bonding, physiologic stability, decreased length of stay, and improved breast-feeding for neonates who experience this method of holding. Research has not shown an increase in IQ as a developmental outcome. The experience is usually limited to 1 to 2 hours, 2 to 3 times/day.

96. The nurse in the labor and birth area receives a telephone call from the emergency room announcing that a multigravid client in active labor is being transferred to the labor area. The client has had no prenatal care. When the client arrives by stretcher, she says, "I think the baby's coming ... Help!" The fetal skull is crowning. The nurse should obtain which of the following information first? 1. Estimated date of birth. 2. Amniotic fluid status. 3. Gravida and parity. 4. Prenatal history.

1. Estimated date of birth.

72. The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time? 1. Firm fundus at the symphysis. 2. White, thick vaginal discharge. 3. Striae that are silver in color. 4. Soft breasts without milk.

1. Firm fundus at the symphysis.

45. A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following? 1. Humidify the air being delivered. 2. Cover the neonate's scalp with a warm cap. 3. Record the neonate's temperature every 3 to 4 minutes. 4. Assess the neonate's blood glucose level.

1. Humidify the air being delivered. Whenever oxygen is administered, it should be humidified to prevent drying of the nasal passages and mucous membranes. Because the neonate is under a radiant warmer, a stocking cap is not necessary. Temperature, continuously monitored by a skin probe attached to the radiant warmer, is recorded every 30 to 60 minutes initially. Although the oxygen concentration in the hood requires close monitoring and measurement of blood gases, checking the blood glucose level is not necessary.

6. After instructing a primigravid client at 38 weeks' gestation about how preeclampsia can affect the client and the growing fetus, the nurse realizes that the client needs additional instruction when she says that preeclampsia can lead to which of the following? 1. Hydrocephalic infant. 2. Abruptio placentae. 3. Intrauterine growth retardation. 4. Poor placental perfusion.

1. Hydrocephalic infant. Congenital anomalies such as hydrocephalus are not associated with preeclampsia. Conditions such as stillbirth, prematurity, abruptio placentae, intrauterine growth retardation, and poor placental perfusion are associated with preeclampsia. Abruptio placentae occurs because of severe vasoconstriction. Intrauterine growth retardation is possible owing to poor placental perfusion. Poor placental perfusion results from increased vasoconstriction.

35. When preparing a 20-year-old client who reports missing one menstrual period and suspects that she is pregnant for a radioimmunoassay pregnancy test, the nurse should tell the client which of the following about this test? 1. It has a high degree of accuracy within 1 week after ovulation. 2. It is identical in nature to an over-the-counter home pregnancy test. 3. A positive result is considered a presumptive sign of pregnancy. 4. A urine sample is needed to obtain quicker results.

1. It has a high degree of accuracy within 1 week after ovulation. The radioimmunoassay pregnancy test, which uses an antiserum with specificity for the b-subunit of human chorionic gonadotropin (hCG) in blood plasma, is highly accurate within 1 week after ovulation. The test is performed in a laboratory. Over-the-counter or home pregnancy tests are performed on urine and use the hemagglutination inhibition method. Radioimmunoassay tests usually use blood serum.A positive pregnancy test is considered aprobable sign of pregnancy. Certain conditions other than pregnancy, such as choriocarcinoma, can cause increased hCG levels.

44. Which of the following actions should the nurse take when performing external chest compressions on a neonate born at 28 weeks' gestation? 1. Maintain a compression to ventilation ratio of 3:1. 2. Compress the sternum with the palm of the hand. 3. Compress the chest 70 to 80 times/min. 4. Displace the chest wall half the depth of the anterior-posterior diameter of the chest.

1. Maintain a compression to ventilation ratio of 3:1. Chest compressions should be alternated with ventilation to ensure breathing and circulation. Two fingers or two thumbs encirciling hands, not the palm of the hand, are used to compress a neonate's sternum. The chest is compressed 100 to 120 times/min. The proper technique recommended by the Neonatal Resuscitation Program is to use enough pressure to depress the sternum to a depth of approximately one-third of the anterior-posterior diameter of the chest.

47. Assessment of a 2-day-old neonate born at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The priority intervention is to: 1. Obtain a prescription for a stat chest x-ray. 2. Reposition the neonate and then assess if the grunting and cyanosis resolve. 3. Begin oxygen administration at 6 to 8 L via mask. 4. Obtain a complete blood count to determine infection.

1. Obtain a prescription for a stat chest x-ray. With an absent apical pulse left of the midclavicular line accompanied by cyanosis, grunting, and diminished breath sounds, the neonate is most likely experiencing pneumothorax. Pneumothorax occurs when alveoli are overdistended and subsequently the lung collapses, compressing the heart and lung and compromising the venous return to the right side of the heart. This condition can be confirmed by x-ray or ultrasound studies. Repositioning the infant may open the airway, administering oxygen will improve oxygen saturation levels, and obtaining blood studies for infection will rule that out, but until pneumothorax is resolved, the other symptoms will continue.

21. When instructing a client about the proper use of condoms for pregnancy prevention, which of the following instructions would be included to ensure maximum effectiveness? 1. Place the condom over the erect penis before coitus. 2. Withdraw the condom after coitus when the penis is flaccid. 3. Ensure that the condom is pulled tightly over the penis before coitus. 4. Obtain a prescription for a condom with nonoxynol 9.

1. Place the condom over the erect penis before coitus. To ensure maximum effectiveness, the condom should always be placed over the erect penis before coitus. Some couples find condom use objectionable because foreplay may have to be interrupted to apply the condom. The penis, covered by the condom, should be withdrawn before the penis becomes flaccid. Otherwise sperm may escape from the condom, providing an opportunity for possible fertilization. Rather than having the condom pulled tightly over the penis before coitus, space should be left at the tip of the penis to allow the condom to hold the sperm. The client does not need a prescription for a condom with nonoxynol 9 because these are sold over the counter.

The 5 P's are:

1. Powers (contractions) 2. Passengers (fetus & placenta) 3. Passageway (birth canal) 4. Position (of the mother) 5. Psychological Response

17. Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the primary health care provider prescribes a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment findings should the nurse report immediately? 1. Respiratory rate of 12 breaths/min. 2. Patellar reflex of +2. 3. Blood pressure of 160/88 mm Hg. 4. Urinary output exceeding intake

1. Respiratory rate of 12 breaths/min. A respiratory rate of 12 breaths/min suggests potential respiratory depression, an adverse effect of magnesium sulfate therapy. The medication must be stopped and the primary health care provider should be notified immediately. A patellar reflex of +2 is normal. Absence of a patellar reflex suggests magnesium toxicity. A blood pressure reading of 160/88 mm Hg would be a common finding in a client with severe preeclampsia. Urinary output exceeding intake is not likely in a client receiving intravenous magnesium sulfate. Oliguria is more common.

26. A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. After discussing the various causes of male infertility, the nurse determines that the male partner needs further instruction when he states which of the following as a cause? 1. Seminal fluid with an alkaline pH. 2. Frequent exposure to heat sources. 3. Abnormal hormonal stimulation. 4. Immunologic factors.

1. Seminal fluid with an alkaline pH. The client needs further instruction when he says that one cause of male infertility is decreased sperm count due to seminal fluid that has an alkaline pH. A slightly alkaline pH is necessary to protect the sperm from the acidic secretions of the vagina and is a normal finding. An alkaline pH is not associated with decreased sperm count. However, seminal fluid that is abnormal in amount, consistency, or chemical composition suggests obstruction, inflammation, or infection, which can decrease sperm production. The typical number of sperm produced during ejaculation is 400 million. Frequent exposure to heat sources, such as saunas and hot tubs, can decrease sperm production, as can abnormal hormonal stimulation. Immunologic factors produced by the man against his own sperm (autoantibodies) or by the woman can cause the sperm to clump or be unable to penetrate the ovum, thus contributing to infertility.

16. The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. Which of the following are desired outcomes of this therapy? Select all that apply. 1. T 98 (36.7), P 72, R 14. 2. Urinary output less than 30 mL/h. 3. Fetal heart rate with late decelerations. 4. BP of less than 140/90. 5. DTR 2+. 6. Magnesium level = 5.6 mg/dL (2.8 mmol/L).

1. T 98 (36.7), P 72, R 14. 5. DTR 2+. 6. Magnesium level = 5.6 mg/dL (2.8 mmol/L). The use of magnesium sulfate as an anticonvulsant acts to depress the central nervous system by blocking peripheral neuromuscular transmissions and decreasing the amount of acetylcholine liberated. While being used, the temperature and pulse of the client should remain within normal limits. The respiratory rate needs to be greater than 12 respirations per minute (RPM). Rates at 12 RPM or lower are associated with respiratory depression and are seen with magnesium toxicity. Renal compromise is identified with a urinary output of less than 30 mL/hour. A fetal heart rate that is maintained within the 112 to 160 range is desired without later or variable decelerations. Deep tendon reflexes should not be diminished or exaggerated. The

19. After administering hydralazine (Apresoline) 5 mg intravenously as prescribed for a primigravid client with severe preeclampsia at 39 weeks' gestation, the nurse should assess the client for: 1. Tachycardia. 2. Bradypnea. 3. Polyuria. 4. Dysphagia.

1. Tachycardia. One of the most common adverse effects of the drug hydralazine (Apresoline) is tachycardia. Therefore, the nurse should assess the client's heart rate and pulse. Hydralazine acts to lower blood pressure by peripheral dilation without interfering with placental circulation. Bradypnea and polyuria are usually not associated with hydralazine use. Dysphagia is not a typical adverse effect of hydralazine. CN: Pharmacological and parenteral therapies; CL: Analyze 20. 4. These findings would be documented as 4+. 1+ indicates a diminished response; 2+ indicates a normal response; 3+ indicates a response that is brisker than average but not abnormal. Mild clonus is said to be present when there are two movements.

52. Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)? 1. The neonate is at risk because of multiple factors. 2. Oxygen is being administered at a level of 21%. 3. The neonate was alkalotic immediately after birth. 4. Phototherapy is likely to be prescribed by the primary health care provider.

1. The neonate is at risk because of multiple factors.

A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer?

A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only)

loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only)

10. A primigravid client at 38 weeks' gestation diagnosed with mild preeclampsia calls the clinic nurse to say she has a continuous headache for the past 2 days accompanied by nausea. The client does not want to take aspirin. The nurse should tell the client: 1. "Take two acetaminophen (Tylenol) tablets. They aren't as likely to upset your stomach." 2. "I think the doctor should see you today. Can you come to the clinic this morning?" 3. "You need to lie down and rest. Have you tried placing a cool compress over your head?" 4. "I'll ask the doctor to call in a prescription for aspirin with codeine. What's your pharmacy's number?"

2. "I think the doctor should see you today. Can you come to the clinic this morning?" A client with preeclampsia and a continuous headache for 2 days should be seen by a health care provider immediately. Continuous headache, drowsiness, and mental confusion indicate poor cerebral perfusion and are symptoms of severe preeclampsia. Immediate care is recommended because these symptoms may lead to eclampsia or seizures if left untreated. Advising the client to take two acetaminophen tablets would be inappropriate and may lead to further complications if the client is not evaluated and treated. Although the application of cool compresses may ease the pain temporarily, this would delay treatment. Aspirin with codeine may temporarily relieve the client's headache. However, this delays immediate treatment, which is crucial. Additionally, pregnant women are advised not to take aspirin at this time because it may cause clotting problems in the neonate. Codeine generally is not prescribed.

79. When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently? 1. 5 to 7 months. 2. 8 to 10 months. 3. 12 to 14 months. 4. 15 to 16 months.

2. 8 to 10 months.

82. A multigravid client in active labor has been diagnosed with class II heart disease and has had a prosthetic valve replacement. When developing the plan of care for this client, the nurse should anticipate that the primary health care provider most likely prescribe which of the following medications? 1. Anticoagulants. 2. Antibiotics. 3. Diuretics. 4. Folic acid supplements.

2. Antibiotics.

80. When preparing for discharge a 15-year-old primipara who is bottle-feeding her neonate, the nurse instructs the client not to "prop" the bottle while feeding the neonate because this can lead to which of the following? 1. Overfeeding and obesity. 2. Aspiration of the formula. 3. Tooth decay in the formative months. 4. Sudden infant death syndrome (SIDS). The Postpartal Client with a Cesarean Birth

2. Aspiration of the formula.

14. A client at 28 weeks' gestation presents to the emergency department with a "splitting headache." What actions are indicated by the nurse at this time? Select all that apply. 1. Reassure the client that headaches are a normal part of pregnancy. 2. Assess the client for vision changes or epigastric pain. 3. Obtain a nonstress test. 4. Assess the client's reflexes and presence of clonus. 5. Determine if the client has a documented ultrasound for this pregnancy

2. Assess the client for vision changes or epigastric pain. 3. Obtain a nonstress test. 4. Assess the client's reflexes and presence of clonus. Headaches could be a sign of preeclampsia/eclampsia in pregnancy. The client should be assessed for headache, vision changes, epigastric pain, hyper reflexes, and the presence of clonus. Her fetus should be assessed using a nonstress test. An ultrasound done in this pregnancy does not give information to assess the presence of preeclampsia/eclampsia.

27. A 24-year-old woman is being assessed for a malformation of the uterus. The figure below indicates which of the following uterine malformations? 1. Septate uterus. 2. Bicornuate uterus. 3. Double uterus. 4. Uterus didelphys.

2. Bicornuate uterus. A bicornuate uterus has a "Y" shape and appears to be a double uterus but in fact has only one cervix. A septate uterus contains a septum that extends from the fundus to the cervix, thus dividing the uterus into two separate compartments. A double uterus has two uteri, each of which has a cervix. A uterus didelphys occurs when both uteri of a double uterus are fully formed.

70. A new father indicates he feels left out of the new family relationship since he is not able to bond the same way as the breast-feeding mother. What is the most appropriate response by the nurse? 1. This is normal and these feelings will go away within a few days. 2. Holding, talking to, and playing with the infant will facilitate bonding between baby and Dad. 3. Bonding occurs later in the first year of life and Dad can become involved when the infant is better able to recognize him. 4. Maternal infant bonding takes priority over paternal infant bonding.

2. Holding, talking to, and playing with the infant will facilitate bonding between baby and Dad.

99. The nurse is caring for a primiparous client and her neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a priority in this neonate? 1. Anemia. 2. Hypoglycemia. 3. Delayed meconium. 4. Elevated bilirubin.

2. Hypoglycemia.

49. A viable male neonate born to a 28-year-old multiparous client by cesarean section because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? 1. Mother's development of placenta previa. 2. Neonate born preterm. 3. Mother receiving analgesia 4 hours before birth. 4. Neonate with sluggish respiratory efforts after birth.

2. Neonate born preterm.

97. A multiparous client gives birth to dizygotic twins at 37 weeks' gestation. The twin neonates require additional hospitalization after the client is discharged. In planning the family's care, an appropriate goal for the nurse to formulate is that, while the twins are hospitalized, the parents will do which of the following? 1. Discuss how they will cope with twin infants at home. 2. Participate in care of the twins as much as possible. 3. Take turns providing 24-hour observation of the twins. 4. Identify complications that may occur as the twins develop.

2. Participate in care of the twins as much as possible.

61. A 25-year-old primiparous client who gave birth 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? 1. Keeping plastic liners in the brassiere to keep the nipple drier. 2. Placing as much of the areola as possible into the baby's mouth. 3. Smoothly pulling the nipple out of the mouth after 10 minutes. 4. Removing any remaining milk left on the nipple with a soft washcloth.

2. Placing as much of the areola as possible into the baby's mouth.

69. During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do? 1. Wipe off any lanolin creams from the nipple before each feeding. 2. Position the baby with the entire areola in the baby's mouth. 3. Feed the baby less often for the next several days. 4. Use a mild soap while in the shower to prevent an infection.

2. Position the baby with the entire areola in the baby's mouth.

33. A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy? 1. Positive. 2. Probable. 3. Presumptive. 4. Diagnostic.

2. Probable. The plan of care should reflect that this woman is experiencing probable signs of pregnancy. She may be pregnant but the signs and symptoms may have another etiology. An enlarging abdomen and a positive pregnancy test may also be caused by tumors, hydatidiform mole, or other disease processes as well as pregnancy. Changes in the pigmentation of the face may also be caused by oral contraceptive use. Positive signs of pregnancy are considered diagnostic and include evident fetal heartbeat, fetal movement felt by a trained examiner, and visualization of the fetus with ultrasound confirmation. Presumptive signs are subjective and can have another etiology. These signs and symptoms include lack of menses, nausea, vomiting, fatigue, urinary frequency, and breast changes. The word "diagnostic" is not used to describe the condition of pregnancy.

56. An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply. 1. Teaches the infant to coordinate the swallow. 2. Provides oral stimulation. 3. Keeps oral mucous membranes moist while the tube is in place. 4. Reminds the infant how to suck. 5. Stimulates secretions that help gastric emptying.

2. Provides oral stimulation. 4. Reminds the infant how to suck. 5. Stimulates secretions that help gastric emptying.

95. A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely? 1. Early deceleration pattern. 2. Sinusoidal pattern. 3. Variable deceleration pattern. 4. Late deceleration pattern.

2. Sinusoidal pattern.

48. Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which of the following? 1. Somatotropin. 2. Surfactant. 3. Testosterone. 4. Progesterone.

2. Surfactant.

50. While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. The nurse should tell the mother: 1. "The humidity promotes expansion of the neonate's immature lungs." 2. "The humidity helps to prevent viral or bacterial pneumonia." 3. "Oxygen is drying to the mucous membranes unless it is humidified." 4. "Circulation to the baby's heart is improved with humidified oxygen."

3. "Oxygen is drying to the mucous membranes unless it is humidified."

24. After instructing a 40-year-old woman about osteoporosis after menopause, the nurse determines that the client needs further instruction when the client states which of the following? 1. "A standard serving of yogurt is the equivalent of one glass of milk." 2. "Women who do not eat dairy products should consider calcium supplements." 3. "Women of African descent are at the greatest risk for osteoporosis." 4. "Estrogen therapy at menopause can reduce the risk of osteoporosis."

3. "Women of African descent are at the greatest risk for osteoporosis." Small-boned, fair-skinned women of northern European descent are at the greatest risk for osteoporosis, not women of African descent. One standard serving of yogurt is the equivalent of one glass of milk. Women who do not eat dairy products, such as women who are lactose intolerant, should consider using calcium supplements. Inadequate lifetime intake of calcium is a major risk factor for osteoporosis. Estrogen therapy, or some of the newer medications that are not estrogen based, can greatly reduce the incidence of osteoporosis.

7. After instructing a multigravid client diagnosed with mild preeclampsia how to keep a record of fetal movement patterns at home, the nurse determines that the teaching has been effective when the client says that she will count the number of times the baby moves during which of the following time spans? 1. 30-minute period three times a day. 2. 45-minute period after lunch each day. 3. 1-hour period each day. 4. 12-hour period each week.

3. 1-hour period each day. Numerous methods have been proposed to record the maternal perceptions of fetal movement or "kick counts." A commonly used method is the Cardiff count-to-10 method. The client begins counting fetal movements at a specified time (eg, 8:00 AM) and notes the time when the 10th movement is felt. If the client does not feel at least 6 movements in a 1-hour period, she should notify the health care provider. The fetus typically moves an average of 1 to 2 times every 10 minutes or 10 to 12 times per hour. A 30- or 45-minute period is not enough time to evaluate fetal movement accurately. The client should monitor fetal movements more frequently than 1 time per week. One hour of monitoring each day is adequate.

4. A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. To maintain safety for this client, the priority intervention is to: 1. Maintain continuous fetal monitoring. 2. Encourage family members to remain at bedside. 3. Assess reflexes, clonus, visual disturbances, and headache. 4. Monitor maternal liver studies every 4 hours.

3. Assess reflexes, clonus, visual disturbances, and headache. The central nervous system (CNS) functioning and freedom from injury is a priority in maintaining well-being of the maternal-fetal unit. If the mother suffers CNS damage related to hypertension or stroke, oxygenation status is compromised and the well-being of both mother and infant are at risk. Continuous fetal monitoring is an assessment strategy for the infant only and would be of secondary importance to maternal CNS assessment because maternal oxygenation will dictate fetal oxygenation and well-being. In preeclampsia, frequent assessment of maternal reflexes, clonus, visual disturbances, and headache give clear evidence of the condition of the maternal CNS system. Monitoring the liver studies does give an indication of the status of the maternal system but the less invasive and highly correlated condition of the maternal CNS system in assessing reflexes, maternal headache, visual disturbances, and clonus is the highest priority. Psychosocial care is a priority and can be accomplished in ways other than having the family remain at the bedside.

12. The primary health care provider prescribes intravenous magnesium sulfate for a primigravid client at 38 weeks' gestation diagnosed with severe preeclampsia. Which of the following medications should the nurse have readily available at the client's bedside? 1. Diazepam (Valium). 2. Hydralazine (Apresoline). 3. Calcium gluconate. 4. Phenytoin (Dilantin).

3. Calcium gluconate. The client receiving magnesium sulfate intravenously is at risk for possible toxicity. The antidote for magnesium sulfate toxicity is calcium gluconate, which should be readily available at the client's bedside. Diazepam (Valium), used to treat anxiety, usually is not given to pregnant women. Hydralazine (Apresoline) would be used to treat hypertension, and phenytoin (Dilantin) would be used to treat seizures.

25. When developing a teaching plan for an 18-year old client who asks about treatments for sexually transmitted diseases, the nurse should explain that: 1. Acyclovir (Zovirax) can be used to cure herpes genitalis. 2. Chlamydia trachomatis infections are usually treated with penicillin. 3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections. 4. Metronidazole (Flagyl) is used to treat condylomata acuminata.

3. Ceftriaxone sodium (Rocephin) may be used to treat Neisseria gonorrhoeae infections. Ceftriaxone sodium (Rocephin) may be used to treat N. gonorrhoeae infections and is commonly combined with doxycycline hyclate (Vibramycin). Both the client and her partner should be treated if gonorrhea is present. Acyclovir (Zovirax) can be used to treat herpes genitalis; however, the drug does not cure the disease. C. trachomatis infections are usually treated with antibiotics such as doxycycline or azithromycin (Zithromax). Metronidazole (Flagyl) is used to treat trichomoniasis vaginitis, not condylomata acuminata (genital warts).

74. A 24-year-old primipara who has given birth to a healthy neonate plans to bottle-feed her neonate. What information regarding normal weight gain should the nurse include in the teaching plan? 1. A baby normally loses 15% of weight before beginning to gain weight. 2. Adding rice cereal to the bottle is a good way to increase calories if weight gain is slow. 3. Gaining 30 g/day is a normal weight gain pattern. 4. Babies typically double birth weight by 3 months.

3. Gaining 30 g/day is a normal weight gain pattern.

89. The primary health care provider determines that outlet forceps are needed to assist in the birth of a primigravid client in active labor with a large-for gestational-size fetus. The nurse reinforces the primary health care provider's explanation for using forceps based on the understanding about which of the following concerning the location of the fetal skull? 1. It is engaged past the inlet. 2. It is at +1 station. 3. It is visible at the perineal floor. 4. It has reached the level of the ischial spines.

3. It is visible at the perineal floor.

46. Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the primary health care provider? 1. Alkalosis. 2. Increased muscle tone. 3. Temperature instability. 4. Positive Babinski's reflex.

3. Temperature instability. The neonate is at high risk for sepsis due to exposure to the mother's infection. Temperature instability in a neonate at 38 weeks' gestation is an early sign of sepsis. Other signs include tachycardia, decreased muscle tone, acidosis, apnea, respiratory distress, hypotension, poor feeding behaviors, vomiting, and diarrhea. Late signs of infection include jaundice, seizures, enlarged liver and spleen, respiratory failure, and shock. Alkalosis is not typically seen in neonates who develop sepsis. Acidosis and respiratory distress may develop unless treatment such as antibiotics is started. A positive Babinski reflex is a normal finding and does not need to be reported.

92. A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, "The baby's coming!" To help the client remain calm and cooperative during the imminent birth, which of the following responses by the nurse is most appropriate? 1. "You're right; the baby is coming, so just relax." 2. "Please don't push because you'll tear your cervix." 3. "Your doctor will be here as soon as possible." 4. "I'll explain what's happening to guide you as we go along."

4. "I'll explain what's happening to guide you as we go along."

34. An antenatal client receives education concerning medications that are safe to use during pregnancy. The nurse evaluates the client's understanding of the instructions and determines that she needs further information when she states which of the following? 1. "If I am constipated, magnesium hydroxide (Milk of Magnesia) is okay but mineral oil is not." 2. "If I have heartburn, it is safe to use chewable calcium carbonate (Tums)." 3. "I can take acetaminophen (Tylenol) if I have a headache." 4. "If I need to have a bowel movement, sennosides (Ex-Lax) are preferred."

4. "If I need to have a bowel movement, sennosides (Ex-Lax) are preferred." Ex-Lax is considered too abrasive to use during pregnancy. In most instances, a Fleet enema will be given before Ex-Lax. Medications for constipation that are considered safe during pregnancy include compounds that produce bulk, such as etamucil and Citrucel. Colace, Dulcolax, and Milk of Magnesia can also be used. Mineral oil prevents the absorption of vitamins and minerals within the GI tract. The strategies for heartburn are considered safe and Tylenol may be used as an over thecounter analgesic.

62. Which of the following client statements indicates effective teaching about burping a breast-fed neonate? 1. "Breast-fed babies who are burped frequently will take more on each breast." 2. "If I supplement the baby with formula, I will rarely have to burp him." 3. "I'll breast-feed my baby every 3 hours so I won't have to burp him." 4. "When I switch to the other breast, I'll burp the baby."

4. "When I switch to the other breast, I'll burp the baby."

15. Which of the following would the nurse identify as the priority to achieve when developing the plan of care for a primigravid client at 38 weeks' gestation who is hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate? 1. Decreased generalized edema within 8 hours. 2. Decreased urinary output during the first 24 hours. 3. Sedation and decreased reflex excitability within 48 hours. 4. Absence of any seizure activity during the first 48 hours.

4. Absence of any seizure activity during the first 48 hours. The highest priority for a client with severe preeclampsia is to prevent seizures, thereby minimizing the possibility of adverse effects on the mother and fetus, and then to facilitate safe childbirth. Efforts to decrease edema, reduce blood pressure, increase urine output, limit kidney damage, and maintain sedation are desirable but are not as important as preventing seizures. It would take several days or weeks for the edema to be decreased. Sedation and decreased reflex excitability can occur with the administration of intravenous magnesium sulfate, which peaks in 30 minutes, much sooner than 48 hours.

39. The nurse assesses a woman at 24 weeks' gestation and is unable to find the fetal heart beat. The fetal heart beat was heard at the client's last visit 4 weeks ago. According to priority, the nurse should do the following tasks in which order? 1. Call the health care provider. 2. Explain that the fetal heart beat could not be found at this time. 3. Obtain different equipment and recheck. 4. Ask the client if the baby is or has been moving.

4. Ask the client if the baby is or has been moving. 3. Obtain different equipment and recheck. 2. Explain that the fetal heart beat could not be found at this time. 1. Call the health care provider. While initially continuing to attempt to find the fetal heart beat, the nurse can ask the client if the baby has been moving. This will give a quick idea of status. The next step would be to obtain different equipment and attempt to find the fetal heart beat again. A simple statement of fact that the nurse cannot find the heartbeat and is taking steps to rule out equipment error is appropriate. Calling the health care provider would be the last step after it is determined that the baby does not have a heartbeat.

29. During a visit to the prenatal clinic, a pregnant client at 32 weeks' gestation has heartburn. The client needs further instruction when she says she must do what? 1. Avoid highly seasoned foods. 2. Avoid lying down right after eating. 3. Eat small, frequent meals. 4. Consume liquids only between meals.

4. Consume liquids only between meals. Consuming most liquids between meals rather than at the same time as eating is an excellent strategy to deter nausea and vomiting in pregnancy but does not relieve heartburn. During the third trimester, progesterone causes relaxation of the sphincter and the pressure of the fetus against the stomach increases the potential of heartburn. Avoiding highly seasoned foods, remaining in an upright position after eating, and eating small, frequent meals are strategies to prevent heartburn.

31. Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with the nurse. The nurse should include which of the following information about changes the client can anticipate in the first trimester? 1. Differentiating the self from the fetus. 2. Enjoying the role of nurturer. 3. Preparing for the reality of parenthood. 4. Experiencing ambivalence about pregnancy.

4. Experiencing ambivalence about pregnancy. Many women in their first trimester feel ambivalent about being pregnant because of the significant life changes that occur for most women who have a child. Ambivalence can be expressed as a list of positive and negative consequences of having a child, consideration of financial and social implications, and possible career changes. During the second trimester, the infant becomes a separate individual to the mother. The mother will begin to enjoy the role of nurturer postpartum. During the third trimester, the mother begins to prepare for parenthood and all of the tasks that parenthood includes.

37. Using Nägele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of childbirth would be which of the following? 1. January 13. 2. January 17. 3. February 13. 4. February 17.

4. February 17. When using Nägele's rule to determine the estimated date of childbirth, the nurse would count back 3 calendar months from the first day of the last menstrual period and add 7 days. This means the client's estimated date is February 17.

51. A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate? 1. Breast-feeding is not recommended because the neonate needs increased fat in the diet. 2. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. 3. Breast-feeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. 4. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

4. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

32. An antenatal primigravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which of the following? 1. Preterm labor. 2. Twin-to-twin transfusion. 3. Anemia. 4. Group B Streptococcus.

4. Group B Streptococcus. Group B Streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins. The multiple gestation client is at risk for preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation. The normal uterus is only able to distend to a certain point and when that point is reached, labor may be initiated. Twin-to-twin transfusion drains blood from one twin to the second and is a problem that may occur with multiple gestation. The donor twin may become growth restricted and can have oligohydramnios while the recipient twin may become polycythemic with polyhydramnios and develop heart failure. Anemia is a common problem with multiple gestation clients. The mother is commonly unable to consume enough protein, calcium, and iron to supply her needs and those of the fetuses. A maternal hemoglobin level below 11 mg/dL (110 g/L) is considered anemic.

36. After instructing a female client about the radioimmunoassay pregnancy test, the nurse determines that the client understands the instructions when the client states that which of the following hormones is evaluated by this test? 1. Prolactin. 2. Follicle-stimulating hormone. 3. Luteinizing hormone. 4. Human chorionic gonadotropin (hCG).

4. Human chorionic gonadotropin (hCG). The hormone analyzed in most pregnancy tests is hCG. In the pregnant woman, trace amounts of hCG appear in the serum as early as 24 to 48 hours after implantation owing to the trophoblast production of this hormone. Prolactin, follicle-stimulatinghormone, and luteinizing hormone are not used to detect pregnancy. Prolactin is the hormone secreted by the pituitary gland to prepare the breasts for lactation. Folliclestimulatinghormone is involved in follicle maturation during the menstrual cycle.Luteinizing hormone is responsible for stimulating ovulation.

41. While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? 1. Phimosis. 2. Hydrocele. 3. Epispadias. 4. Hypospadias.

4. Hypospadias. The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

86. A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously withmeconium-stained amniotic fluid. Which of the following actions should the nurse do first? 1. Increase the rate of the oxytocin infusion. 2. Turn the client to a knee-to-chest position. 3. Assess cervical dilation and effacement. 4. Monitor the fetal heart rate continuously.

4. Monitor the fetal heart rate continuously.

11. When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain? 1. Oxytocin infusion solution. 2. Disposable tongue blades. 3. Portable ultrasound machine. 4. Padding for the side rails.

4. Padding for the side rails. The client with severe preeclampsia may develop eclampsia, which is characterized by seizures. The client needs a darkened, quiet room and side rails with thick padding. This helps decrease the potential for injury should a seizure occur. Airways, a suction machine, and oxygen also should be available. If the client is to undergo induction of labor, oxytocin infusion solution can be obtained at a later time. Tongue blades are not necessary. However, the emergency cart should be placed nearby in case the client experiences a seizure. The ultrasound machine may be used at a later point to provide information about the fetus. In many hospitals, the client with severe preeclampsia is admitted to the labor area, where she and the fetus can be closely monitored. The safety of the client and her fetus is the priority.

85. A primigravida is experiencing a prolonged second stage of labor with a fetus suspected of weighing over 4 kg. Which of the following interventions is most important? 1. Preparing for a vacuum-assisted birth. 2. Administering an IV fluid bolus. 3. Preparing for an emergency cesarean birth. 4. Performing the McRoberts maneuver.

4. Performing the McRoberts maneuver.

98. A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which of the following problems should the nurse identify as the priority for the client? 1. Activity intolerance. 2. Sleep deprivation. 3. Situational low self-esteem. 4. Risk for infection.

4. Risk for infection.

23. Which of the following instructions should the nurse include in the teaching plan for a 30-year-old multiparous client who will be using an intrauterinedevice (IUD) forfamily planning? 1. Amenorrhea is a common adverse effect of IUDs. 2. The client needs to use additional protection for conception. 3. IUDs are more costly than other forms of contraception. 4. Severe cramping may occur when the IUD is inserted.

4. Severe cramping may occur when the IUD is inserted. 4. Severe cramping and pain may occur as the device is passed through theinternal cervical os. The insertion of the device is generally done when the client ishaving her menses, because it is unlikely that she is pregnant at that time. Common adverse effects of IUDs are heavy menstrual bleeding and subsequent anemia, notamenorrhea. Uterine infection or ectopic pregnancy may occur. The IUD has an effectiveness rate of 98%. Therefore, additional protection is not necessary to prevent pregnancy. IUDs generally are lesscostly than other forms of contraception because they do not require additional expense. Only one insertion is necessary, in comparison to daily doses of oral contraceptives or the need for spermicides in conjunction with diaphragm use.

38. After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which of the following hormones is produced by the placenta? 1. Estrogen. 2. Progesterone. 3. Human chorionic gonadotropin (hCG). 4. Testosterone.

4. Testosterone. The placenta does not produce testosterone. Human placental lactogen, hCG, estrogen, and progesterone are hormones produced by the placenta during pregnancy. The hormone hCG stimulates the synthesis of estrogen and progesterone early in the pregnancy until the placenta can assume this role. Estrogen results in uterine and breast enlargement. Progesterone aids in maintaining the endometrium, inhibiting uterine contractility, and developing the breasts for lactation. The placenta also produces some nutrients for the embryo and exchanges oxygen, nutrients, and waste products through the chorionic villi.

68. Two weeks after a breast-feeding primiparous client is discharged, she calls the birthing center and says that she is afraid she is "losing my breast milk. The baby had been nursing every 4 hours, but nowshe's crying to be fed every 2 hours." The nurse interprets the neonate's behavior as most likely caused by which of the following? 1. Lack of adequate intake to meet maternal nutritional needs. 2. The mother's fears about the baby's weight gain. 3. Preventing the neonate from sucking long enough with each feeding. 4. The neonate's temporary growth spurt, which requires more feedings.

4. The neonate's temporary growth spurt, which requires more feedings.

1. A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/h IV piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour?

50ml

The healthcare provider prescribes 500 mg.hour of magnesium sulfate for a client with pregnancyͲ induced hypertension (PIH). The pharmacy delivers a 500 ml IV that contains 4 grams of the drug. The nurse should set the IV infusion pump to deliver how many ml per hour.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A Cephalhematoma, which is caused by forceps trauma B. Subarachnoid hematoma, which requires immediate drainage C. Molding, which is caused by pressure during labor D Subdural hematoma, which can result in lifelong damage

A Cephalhematoma, which is caused by forceps trauma

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D Increased amounts of discharge E. Increased right-side flank pain

A Cramping with bright red spotting C. Lack of tenderness of the breast Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent.

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.) A Increased heartburn that is not relieved with doses of antacids B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C. Shoes and rings that are too tight because of peripheral edema in extremities D Decrease in ability for the client to sleep for more than 2 hours at a time E. Chronic headache that has been lingering for a week behind the client's eyes

A Increased heartburn that is not relieved with doses of antacids E. Chronic headache that has been lingering for a week behind the client's eyes Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Herpregnancy test is positive. What is this client's expected date of birth (EDB)? A November 22 B. November 8 C. December 22 D October 22

A November 22 Rationale: Option A correctly applies the Nägele rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22). Options B, C, and D are not calculated correctly.

10. Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client? A The client's investment in what is being taught B. The couple's highest levels of education C. The order in which the information is presented D The extent to which the pregnancy was planned

A The client's investment in what is being taught

When managing the care of a woman in the second stage of labor, the LPN/LVN uses various measures to enhance the progress of fetal descent. These measures include: A) Encouraging the woman to try various upright positions, including squatting and standing. Giving positive feedback about her efforts. B) Telling the woman to start pushing as soon as her cervix is fully dilated. C) Stopping the epidural anesthetic so the woman can feel the urge to push and thereby push more effectively D) Coaching the woman to use sustained, 10- to 15-second, closedglottis bearing-down efforts with each contraction.

A) Encouraging the woman to try various upright positions, including squatting and standing. Giving positive feedback about her efforts.

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? A) Massaging the woman's back B) Changing the woman's position C) Giving the prescribed medication D) Encouraging the woman to rest between contractions

A) Massaging the woman's back

A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? A) Meperidine (Demerol) B) Promethazine (Phenergan) C) Butorphanol tartrate (Stadol) D) Nalbuphine (Nubain)

A) Meperidine (Demerol)

A primiparous woman is in the triage room being evaluated for labor. She has been having contractions for 2 days, has slept little and is feeling exhausted. On cervical exam she is 1.5 cm dilated, 50% effaced, -1 station - which is not changed from a day ago. Contractions are irregular, 30-40 secs long. Which of the following is the best option for her? A) Offer morphine IM, and a sedative to help her sleep. B) Admit her and give her an epidural. C) Tell her to go home, relax D) Give her a couple of seconal to help her sleep.

A) Offer morphine IM, and a sedative to help her sleep.

The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first? A) Position a radiant warmer over the crib B) Assess the infant's blood glucose level C) Nipple feed 1 ounce 5% glucose in water D) Place the infant in a side-lying position

A) Position a radiant warmer over the crib

What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken. A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask. B) Perform a vaginal examination, reposition the mother, and provide oxygen via face mask. C) Administer oxygen to the mother, increase IV fluid, and notify the care provider. D) Call the provider, reposition the mother, and perform a vaginal examination

A) Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask.

With regard to a woman's intake and output during labor, LPN/LVN should be aware that: A) The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia and studies are not showing harm from drinking fluids in labor. B) Intravenous (IV) fluids usually are necessary to ensure that the laboring woman stays hydrated. C) Routine use of an enema empties the rectum and is very helpful for producing a clean, clear delivery. D) When a nulliparous woman experiences the urge to defecate, it often means birth will follow quickly

A) The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia and studies are not showing harm from drinking fluids in labor.

A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the muse perform first? A- Massage the fundus and give an oxytocic agent B-Collect specimen for hemoglobin and hematocrit C-Place the infant to breast for bonding D- Inspect the perineum for lacerations

A- Massage the fundus and give an oxytocic agent

The nurse is teaching a client who has gestational diabetes how to self-inject the prescribed daily insulin doses Based on her religious belief the client explains that she must abstain from all food and drink during the daylight hours for the next several weeks because it is a holy month What intervention should the nurse implement for this client? A-Collaborate with the healthcare provider to design an alternative insulin schedule- B-Teach the client to monitor blood glucose and to report any results that are too high C-Obtain a medical dispensation from the client's spatula leader D-Explain the complications of gestational diabetes and necessity of taking insulin

A-Collaborate with the healthcare provider to design an alternative insulin schedule

A. A home pregnancy test can be used right after your first missed period.

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take? A. Apply cold compresses to both breasts for comfort. B. Instruct the client run warm water on her breasts. C. Wear a loose-fitting bra to prevent nipple irritation. D. Express small amounts of milk to relieve pressure.

A. Apply cold compresses to both breasts for comfort.

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? A. Apply cold compresses to both breasts for comfort. B. Instruct the client run warm water on her breasts. C. Wear a loose-fitting bra to prevent nipple irritation. D. Express small amounts of milk to relieve pressure.

A. Apply cold compresses to both breasts for comfort.

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A. Avoid alcohol because it is excreted in breast milk. B. Eat a high-roughage diet to help prevent constipation. C. Increase caloric intake by approximately 500 cal/day. D. Increase fluid intake to at least 3 quarts each day.

A. Avoid alcohol because it is excreted in breast milk.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance.

A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts.

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? A. Bathe the infant with an antimicrobial soap. B. Measure the head and chest circumference. C. Obtain the infant's footprints. D. Administer vitamin K (AquaMEPHYTON).

A. Bathe the infant with an antimicrobial soap.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. Between the time the temperature falls and rises. B. Between 36 and 48 hours after the temperature rises. C. When the temperature falls and remains low for 36 hours. D. Within 72 hours before the temperature falls.

A. Between the time the temperature falls and rises.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the LPN/LVN provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency room. C. Lie on your left side for about one hour and see if the bleeding stops. D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

A. Come to the clinic today for an ultrasound.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency room. C. Lie on your left side for about one hour and see if the bleeding stops. D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

A. Come to the clinic today for an ultrasound.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the LPN/LVN to provide this client? A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. B. We want your baby to be healthy, and this is the only way we can make sure that will happen. C. I know you're upset. Would you like to talk about some things you could do while in bed? D. Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.

A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.

complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. B. We want your baby to be healthy, and this is the only way we can make sure that will happen. C. I know you're upset. Would you like to talk about some things you could do while in bed? D. Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.

A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? A. Edema, basilar rales, and an irregular pulse. B. Increased urinary output and tachycardia. C. Shortness of breath, bradycardia, and hypertension. D. Regular heart rate and hypertension.

A. Edema, basilar rales, and an irregular pulse.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the LPN/LVN to assess the client for which condition? A. Gestational diabetes. B. Elevated blood pressure. C. Urinary tract infection. D. Swelling in lower extremities.

A. Gestational diabetes.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A. Gestational diabetes. B. Elevated blood pressure. C. Urinary tract infection. D. Swelling in lower extremities.

A. Gestational diabetes.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8- weeks gestation. What type of emotional response should the nurse anticipate? A. Grief related to her perceptions about the loss of this child. B. Relief of ambivalent feelings experienced with this pregnancy. C. Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions.

A. Grief related to her perceptions about the loss of this child.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty her bladder. B. Request the client lie on her left side. C. Perform Leopold's maneuvers first. D. Give the client some cold juice to drink.

A. Have the client empty her bladder.

A. Lying prone with a pillow on the abdomen.

When performing the daily head to toe assessment of a 1-day old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen, what action should the nurse take? A. Measure bilirubin levels using transcutaneous bilirubinometers. b. Review maternal medical records for blood type and Rh factor. c. Evaluate cord blood Comb's test results d. Prepare the newborn for phototherapy

A. Measure bilirubin levels using transcutaneous bilirubinometers.

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) A. Mood swings. B. Panic attacks. C. Tearfulness. D. Decreased need for sleep. E. Disinterest in the infant.

A. Mood swings. C. Tearfulness.

A. November 22.

6. A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan? A. Observe the parents applying a Pavlik harness. B. Provide a referral for an orthopedic surgeon. C. Schedule a physical therapy follow-up home visit. D. Teach the parents to check for hip joint mobility.

A. Observe the parents applying a Pavlik harness.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications. C. molding, caused by pressure during labor and will disappear within 2 to 3 days. D. a subdural hematoma which can result in lifelong damage.

A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications. C. molding, caused by pressure during labor and will disappear within 2 to 3 days. D. a subdural hematoma which can result in lifelong damage.

A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks.

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs A. two weeks before menstruation. B. immediately after menstruation. C. immediately before menstruation. D. three weeks before menstruation

A. two weeks before menstruation.

A nurse in a providers office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester?

Accepting the pregnancy

A nurse is caring for a client who is 12 hour postpartum. Which of the following interventions should the nurse implement?

Administer ferrous sulfate orally

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take?

Administer vitamin k in the newborn's thigh

52. A pregnant woman with hypermesis gravidarium, what is the best nurse intervention.

Administered prescribed IV solution.

A child with leukemia is admitted for Chemotherapy and the nursing diagnosis " altered nutrion, less those body requirements related to anorexia, nausea and vomiting" is identified. Which intervention the nurse included in this child plan of care?

Allow the child to eat any food desired and tolerated.

A child with leukemia is admitted for Chemotherapy and the nursing diagnosis " alterednutrion, less those body requirements related to anorexia, nausea and vomiting" is identified. Which intervention the nurse included in this child plan of care?

Allow the child to eat any food desired and tolerated.

A nurse is assessing a newborn and notes an axillary temperature of 96.9 degrees F (36 degree C). which of the following actions should the nurse perform?

Assess the newborn's blood glucose level

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? -At 16-weeks gestation. -At 20-weeks gestation -At 24-weeks gestation. -At 30-weeks gestation.

At 30-weeks gestation.

The parents of a child with phenylketonuria ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU?

Autosomal recessive

A client is admitted to the labor and delivery unit with contractions that are 3-5 minutes apart, lasting 60-70 seconds. She reports that she is leaking fluid. A vaginal exam reveals that her cervix is 80 percent effaced and 4 cm dilated and a -1 station. The LPN/LVN knows that the client is in which phase and stage of labor? A) Latent phase, First Stage B) Active Phase of First Stage C) Latent phase of Second Stage D) Transition

B) Active Phase of First Stage

LPN can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate? A) Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours B) Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours C) Lull: No contractions; dilation stable; duration of 20 to 60 minutes D) Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 3-4 hours

B) Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours

Concerning the third stage of labor, LPN/LVN should be aware that: A) The placenta eventually detaches itself from a flaccid uterus B) An active approach to managing this stage of labor reduces the risk of excessive bleeding C) It is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. D) The major risk for women during the third stage is a rapid heart rat

B) An active approach to managing this stage of labor reduces the risk of excessive bleeding

A women who delivered a 9 pound baby boy by cesarean section under spinal anesthesia is recovering in the postanesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina in observed by the nurse. Which action should the nurse implement? A) Massage the fundus vigorously B) Assess her blood pressure C) Apply ice pack to perineum D) Let the infant breast feed

B) Assess her blood pressure

An obviously pregnant woman walks into the hospital's emergency department entrance, shouting, "Help me! Help me! My baby is coming! I'm so afraid!" The nurse determines if delivery is indeed imminent. What action is most important for the nurse to take? A) Determines the gestational age of the fetus B) Assess the amount and color of the amniotic fluid C) Obtain peripheral IV access and begin administration of IV fluids D) Provide clear, concise instructions in a calm, deliberate manner

B) Assess the amount and color of the amniotic fluid

During labor, the patient at 4 cm suddenly becomes dyspneic, cyanotic, and hypotensive. The nurse must prepare immediately for: (Select all that apply.) A) Immediate vaginal delivery B) Cesarean delivery C) CPR D) McRobert's maneuver

B) Cesarean delivery C) CPR

Perinatal LPN/LVN are legally responsible for: A) Applying the external fetal monitor and notifying the care provider. B) Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes. C) Greeting the client on arrival, assessing her, and starting an intravenous line. D) Making sure that the woman is comfortable

B) Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes.

While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate in a slow curve at the onset of several contractions and returns to baseline before each contraction ends. The LPN/LVN should: A) Insert an internal monitor B) Document the finding in the client's record. C) Discontinue the oxytocin infusion D) Change the woman's position

B) Document the finding in the client's record.

With regard to systemic analgesics administered during labor, LPN/LVN should be aware that: A) Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B) Effects on the fetus and newborn can include decreased alertness and delayed sucking. C) Intramuscular administration (IM) is preferred over intravenous (IV) administration. D) IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

B) Effects on the fetus and newborn can include decreased alertness and delayed sucking.

Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The LPN/LVN would report this as: A) First stage, latent phase B) First stage, active phase C) First stage, transition phase D) Second stage, latent phase

B) First stage, active phase

The nurse is planning a class for pregnant women in the first trimester of pregnancy. Which information is most important for the nurse to include in the class? A) Plan rest periods and increase sleep time to 8 hours per day when fatigued B) If any vaginal bleeding occurs, notify the healthcare provider immediately C) Since eating often relieves nausea, carry low fat snacks to eat whenever nausea occurs D) If morning dizziness occurs, rise slowly and sit on the side of the bed for one minute

B) If any vaginal bleeding occurs, notify the healthcare provider immediately

For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention would be key for the LPN/LVN to use while providing care? A) Telling the client to relax and that it won't hurt much B) Limiting the number of procedures that invade her body C) Reassuring the client that as the nurse you know what is best D) Allowing unlimited care providers to be with the client

B) Limiting the number of procedures that invade her body

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure? Choose all that apply. A) Place the woman in a supine position. B) Place the woman in a lateral position. C) Increase intravenous (IV) fluids. D) Continuous Fetal Monitor E) Administer ephedrine per MD order

B) Place the woman in a lateral position. C) Increase intravenous (IV) fluids. E) Administer ephedrine per MD order

The LPN/LVN expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: A) Relieve pain. B) Stimulate uterine contraction C) Prevent infection D) Facilitate rest and relaxation.

B) Stimulate uterine contraction

When using intermittent auscultation (IA) to assess uterine activity, LPN/LVN should be aware that: A) The resting tone between contractions is described as either placid or turbulent B) The examiner's hand should be placed over the fundus before, during, and after contractions. C) The frequency and duration of contractions is measured in seconds for consistency D) Contraction intensity is given a judgment number of 1 to 7 by the nurse and client together.

B) The examiner's hand should be placed over the fundus before, during, and after contractions.

With regard to spinal and epidural (block) anesthesia, LPN/LVN should know that: A) This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births B) The incidence of after-birth headache is higher with spinal blocks than epidurals. C) Epidural blocks allow the woman to move freely D) Spinal and epidural blocks are never used together.

B) The incidence of after-birth headache is higher with spinal blocks than epidurals.

Vaginal examinations should be performed by the LPN/LVN under all of these circumstances EXCEPT: A) An admission to the hospital at the start of labor. B) When accelerations of the fetal heart rate (FHR) are noted. C) On maternal perception of perineal pressure or the urge to bear down. D) When membranes rupture.

B) When accelerations of the fetal heart rate (FHR) are noted.

The current vital signs for a primipara who delivered vaginally during the previous shift are temperature 100 4 F (38 C) heart rate 58 beats minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg What action should the nurse implement? A- Report heart rate to healthcare provider B- Document the vital signs in the record C- Assess perineum for excessive lochia D- Administer a PRN dine of acetaminophen

B- Document the vital signs in the record

A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats minute. What action should the nurse implement first? A- Alert the neonatal team and prepare for neonatal resuscitation B- Notify the healthcare provider from the client's bedside C-Obtain written consent for an emergency cesarean section D-Draw a blood sample for stat hemoglobin and hematocrit

B- Notify the healthcare provider from the client's bedside

the father of a 3-day old infant who is breast feeding calls the postpartum help to report that his wife is acting strangely She is irritable , can the baby and frequently cries for no apparent reason What information is most important for the nurse to provide this father? A- A fluctuation in hormones in the early postpartum period can cause mood changes B-Contact the clinic if the behaviors continue for more than two weeks or become worse C-Tell the father to count the newborn's number of soiled diapers over the next few days D- Recommend giving supplemental bottle Seedings to the baby between breast feeding

B-Contact the clinic if the behaviors continue for more than two weeks or become worse

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate? A "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." B. "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C. "Offer the baby extra bottled milk after her feeding and see if she still seems hungry." D "If you're concerned, you might consider bottle feeding so that you can monitor intake."

B. "Your milk is sufficient if the baby is voiding pale, strawcolored urine six to ten times a day."

The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.

B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.

B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body.

B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? A. Dehydration. B. Hyperstimulation. C. Galactorrhea. D. Fetal tachycardia.

B. Hyperstimulation.

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the LPN/LVN to receive when planning immediate care for the newborn? A. Length of labor and method of delivery. B. Infant's condition at birth and treatment received. C. Feeding method chosen by the parents. D. History of drugs given to the mother during labor.

B. Infant's condition at birth and treatment received.

and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? A. Length of labor and method of delivery. B. Infant's condition at birth and treatment received. C. Feeding method chosen by the parents. D. History of drugs given to the mother during labor.

B. Infant's condition at birth and treatment received.

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester.

B. It is difficult to consume 18 mg of additional iron by diet alone.

During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother? A. Lower Apgar score recorded at delivery B. Lower initial weight documented at birth C. Higher oxygen use to stimulate breathing D. Higher prevalence of congenital anomalies

B. Lower initial weight documented at birth

Following the vaginal delivery of a 9 pound infantm the nurse assess a new mother's vaginal bleeding and finds that she has saturated three pads in the past hous, and has a boogy uterus. What action should the nurse take first. a. determine the client's blood pressure B. Massage the fundus c. have the client empty her bladder d. assess the client's pulse

B. Massage the fundus

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV of ritodrine hydrochloride (Yutopar). What are the highest priority readings that the nurse should monitor frequently during the administration of this drug? A. Maternal blood pressure and respirations. B. Maternal and fetal heart rates. C. Hourly urinary output. D. Deep tendon reflexes.

B. Maternal and fetal heart rates.

A pregnant client tells the LPN/LVN that the first day of her last menstrual period was August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery? A. April 25, 2007. B. May 9, 2007. C. May 29, 2007. D. June 2, 2007.

B. May 9, 2007.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery? A. April 25, 2007. B. May 9, 2007. C. May 29, 2007. D. June 2, 2007.

B. May 9, 2007.

The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? A. Elicit a positive scarf sign on the affected side. B. Observe for an asymmetrical Moro (startle) reflex. C. Watch for swelling of fingers on the affected side. D. Note paralysis of affected extremity and muscles.

B. Observe for an asymmetrical Moro (startle) reflex.

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? A. Elicit a positive scarf sign on the affected side. B. Observe for an asymmetrical Moro (startle) reflex. C. Watch for swelling of fingers on the affected side. D. Note paralysis of affected extremity and muscles.

B. Observe for an asymmetrical Moro (startle) reflex.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? A. Ask the mother why she won't look at the infant. B. Observe the mother for other attachment behaviors. C. Examine the newborn's eyes for the ability to focus. D. Recognize this as a common reaction in new mothers.

B. Observe the mother for other attachment behaviors.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Tiny white papules on the nose or chin D Red patches on the cheeks and trunk

B. Skin color that is slightly jaundiced

Betamethasone (Celestone) 12 mg deep IM.

Both the lower uterine segment and the fundus must be massaged.

A nurse in a prenatal clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiological adaptation to pregnancy?

Breast tenderness

A blind litter girld, 8 year sold was admitted to the hospital ....

Bring familiarly toys from home, such as bear,doll.

After delivery of a normal infant, the mother tells the nurses that she would like to use oral contraceptives. Which finding in the client's health history is a contraindication of the use of contraceptives? A) Previously used an intrauterine device (IUD) B) Reported history of stroke within the family C) Diagnosed with diabetes mellitus 2 years ago D) Smoked cigarettes prior to becoming pregnant

C) Diagnosed with diabetes mellitus 2 years ago

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the LPN should: A) Notify the woman's primary health care provider immediately B) Prepare to administer an oxytocic to stimulate uterine activity C) Document the findings because they reflect the expected contraction pattern for the active phase of labor. D) Prepare the woman for the onset of the second stage of labor.

C) Document the findings because they reflect the expected contraction pattern for the active phase of labor.

A number of methods to assist in the assessment of fetal well-being have been developed for use in conjunction with electronic fetal monitoring. These various technologies assist in supporting interventions for a nonreassuring fetal heart rate pattern when necessary. The labor and delivery nurse should be aware that one of these modalities, fetal oxygen saturation monitoring, includes the use of: A) Fetal blood sampling B) Umbilical cord acid-base determination C) Fetal pulse oximetry. D) A fetal acoustic stimulator.

C) Fetal pulse oximetry.

As a perinatal LPN/LVN you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations with loss of variability is nonreassuring and is associated with A) Cord compression B) Hypotension C) Hypoxemia/acidemia D) Maternal drug use.

C) Hypoxemia/acidemia

A diabetic client delivers a full-term large-for-gestation-age (LGA) infant who is jittery. What action should the nurse take first? A) Administer oxygen B) Feed the infant glucose water (10%) C) Obtain a blood glucose level D) Decrease environmental stimuli

C) Obtain a blood glucose level

The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first? A) Check the pH of the vaginal fluid B) Review the fetal heart rate pattern C) Palpate the client's bladder D) Determine cervical dilation

C) Palpate the client's bladder (NOT SURE OF ANSWER)

What assessment is least likely to be associated with a breech presentation? A) Fetal heart tones heard at or above the maternal umbilicus B) Meconium-stained amniotic fluid C) Postterm gestation D) Preterm labor and birth

C) Postterm gestation

7. When performing the daily head-to-toeassessment of a 1-day-old newborn, the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take? A) Measure bilirubin levels using transcutaneous bilirubinometry B) Review maternal medical records for blood type and Rh factor C) Prepare the newborn for phototherapy D) Evaluate cord blood Coomb's test results

C) Prepare the newborn for phototherapy

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage? A) Palpate suprapubic area for fetal head position B) Insert straight urinary catheter to drain bladder C) Test the fluid with a nitrazine strip D) Scan the bladder for urinary retention

C) Test the fluid with a nitrazine strip

What is an advantage of external electronic fetal monitoring? A) Once correctly applied by the nurse, the transducer need not be repositioned even when the woman changes positions. B) The tocotransducer can measure and record the frequency, regularity, intensity, and approximate duration of uterine contractions (UCs). C) The external EFM does not require rupture of membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring. D) The external EFM can accurately record FHR all the time.

C) The external EFM does not require rupture of membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring.

Twelve hours after the birth of a healthy infant the mother complains of feeling constant vaginal pressure the nurse determine the fundus is firm and at midline, with moderate, rubra lochia Which action should the nurse take? A- Inspect client's perineal and rectal areas B- Apply a fresh pad and check in an hour C- Check the suprapubic area for distention D- Instruct the client to take a warm sitz bath

C- Check the suprapubic area for distention

Twelve hours after the birth of a healthy infant the mother complains of feeling constant vaginal pressure the nurse determines the fundus is farm and at midline with moderate rubra lochia Which action should the nurse take? A- Inspect clients perineal and rectal area B-Apply a fresh pat and check in one hour C-Check the suprapubic area for distention D- instruct the client to take a warm sitz bath

C-Check the suprapubic area for distention

a client at 32 weeks gestation presents with extreme abdominal tenderness and a small amount of bright red vaginal bleeding Her blood pressure is respiratory rate is 24 breath / minute and her heart rate is 116 breast/ minutes he is dizzy with cold clammy skin priority? A-Type and cross match for 4 units of whole blood B-Lactated Ringer's at 200 mi/hr. using an 18-gauge needle C-Monitor oxygen saturation rate per pulse oximeter D-insert a Foley catheter

C-Monitor oxygen saturation rate per pulse oximeter

A mother spontaneously delivers har newborn infant in the taxi cab wile on the way to the hospital the emergency room reports that the mother has active herpes (HSV ) lesions on the vulva Which intervention should the nurse implement first when admitting the neonate to the nursery? A- Document the temperature and the flow sheet B-Obtain blood specimen for serum glucose level C-Place the newborn in the isolation area of the nursery D-Administer the Vitamin K injection.

C-Place the newborn in the isolation area of the nursery

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? A "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7 to 10 days." D "Your pelvis was too small, so the head had to adjust to the birth canal."

C. "That is normal. The head will return to a round shape within 7 to 10 days."

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D Apply baby lotion after the baby's daily bath.

C. Allow the cord to air-dry as much as possible.

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response? A. Telling the client and her partner that the labor process is often unpredictable B. Informing the client that this means she will give birth sooner than expected C. Asking the client and her partner if they would like the nurse to stay in the room D. Affirming that the fetal heart rate is remaining within normal limits

C. Asking the client and her partner if they would like the nurse to stay in the room

The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which assessment finding warrants immediate intervention by the nurse? A. Sweating during feedings B. Weak peripheral pulse C. Bluish tinge to the tongue D. Increased respiratory rate

C. Bluish tinge to the tongue

A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the LPN/LVN that the drug is effective? A. Slowly increasing urinary output over the last week. B. Respiratory rate changes from the 40s to the 60s. C. Changes in apical heart rate from the 180s to the 140s. D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl

C. Changes in apical heart rate from the 180s to the 140s.

A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? A. Slowly increasing urinary output over the last week. B. Respiratory rate changes from the 40s to the 60s. C. Changes in apical heart rate from the 180s to the 140s. D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.

C. Changes in apical heart rate from the 180s to the 140s.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? A. Notify the pediatrician immediately. B. Suction the infant's nares, then the oral cavity. C. Check the infant's oxygen saturation rate. D. Position the infant on the right side.

C. Check the infant's oxygen saturation rate.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first? A. Notify the pediatrician immediately. B. Suction the infant's nares, then the oral cavity. C. Check the infant's oxygen saturation rate. D. Position the infant on the right side.

C. Check the infant's oxygen saturation rate.

The father of a 3- day- old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cried for no apparent reason. What information is most important for the nurse to provide to this father? A. A fluctuation in hormones in the early postpartum period can cause mood changes B. Recommend giving supplemental bottle feedings to the baby between breast feeding C. Contact the clinic if the behaviors continue for more than two weeks or become worse D. Tell the father to count the newborns number of soiled diapers over the next few days

C. Contact the clinic if the behaviors continue for more than two weeks or become worse

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? A. Wear a cotton bra. B. Increase nursing time gradually. C. Correctly place the infant on the breast. D. Manually express a small amount of milk before nursing.

C. Correctly place the infant on the breast.

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? A. Gravidity and parity. B. Time and amount of last oral intake. C. Date of last normal menstrual period. D. Frequency and intensity of contractions.

C. Date of last normal menstrual period.

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain? A. Gravidity and parity. B. Time and amount of last oral intake. C. Date of last normal menstrual period. D. Frequency and intensity of contractions.

C. Date of last normal menstrual period.

A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? A. Notify the healthcare provider. B. Move the newborn to an isolation nursery. C. Document the finding in the infant's record. D. Obtain a culture of the vesicles.

C. Document the finding in the infant's record.

prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? A. Herpes. B. Staphylococcus. C. Gonorrhea. D. Syphilis.

C. Gonorrhea.

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record? A Gravida 1, para 0 B. Gravida 1, para 1 C. Gravida 2, para 0 D Gravida 2, para 1

C. Gravida 2, para 0

The LPN/LVN instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? A. Administer oxygen by face mask. B. Notify the healthcare provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate.

C. Have the client breathe into her cupped hands.

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A Administer oxygen by facemask. B. Notify the health care provider of the client's symptoms. C. Have the client breathe into her cupped hands. D Check the client's blood pressure and fetal heart rate.

C. Have the client breathe into her cupped hands.

The nurse instructs a laboring client to use acceleratedblow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? A. Administer oxygen by face mask. B. Notify the healthcare provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate.

C. Have the client breathe into her cupped hands.

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next? A. Check the hematocrit results. B. Administer pain medication. C. Increase the rate of IV fluids. D. Monitor client for contractions.

C. Increase the rate of IV fluids.

The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A January 14 to 15 B. January 22 to 23 C. January 29 to 30 D February 6 to 7

C. January 29 to 30 This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.

at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing.

C. Move about every hour.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately? A Notify the health care provider or anesthesiologist. B. Continue to assess the blood pressure every 5 minutes. C. Place the client in a lateral position. D Turn off the continuous epidural.

C. Place the client in a lateral position.

4. Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A Turn the client to her side. B. Begin oxygen by nasal cannula at 2 L/min. C. Place the client in a slight Trendelenburg position. D Assess for cervical dilation.

C. Place the client in a slight Trendelenburg position.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the LPN/LVN take? A. Notify the healthcare provider or anesthesiologist immediately. B. Continue to assess the blood pressure q5 minutes. C. Place the woman in a lateral position. D. Turn off the continuous epidural.

C. Place the woman in a lateral position.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? A. Notify the healthcare provider or anesthesiologist immediately. B. Continue to assess the blood pressure q5 minutes. C. Place the woman in a lateral position. D. Turn off the continuous epidural.

C. Place the woman in a lateral position.

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? A. Cuddles the baby close to her. B. Rocks and soothes the infant in her arms. C. Places the infant prone in the bassinet. D. Wraps the baby in a warm blanket after bathing.

C. Places the infant prone in the bassinet.

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth.

C. Tachycardia and a feeling of nervousness.

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth.

C. Tachycardia and a feeling of nervousness.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure andgave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now, and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent.

C. Take your blood pressure now, and if it is seriously elevated, go to the hospital.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the LPN/LVN is best? A. This is not an unusual shaped head, especially for a first baby. B. It may look funny to you, but newborn babies are often born with heads like your baby's. C. That is normal; the head will return to a round shape within 7 to 10 days. D. Your pelvis was too small, so the baby's head had to adjust to the birth canal.

C. That is normal; the head will return to a round shape within 7 to 10 days.

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? A. Two vessels: one artery and one vein. B. Two vessels: two arteries and no veins. C. Three vessels: two arteries and one vein. D. Three vessels: two veins and one artery.

C. Three vessels: two arteries and one vein.

9. When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappearwithin 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.

C. Vernix is a white cheesy substance, predominantly located in the skin folds.

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white, cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.

C. Vernix is a white, cheesy substance, predominantly located in the skin folds.

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is: A. shortness of breath. B. joint pain. C. a persistent cold. D. organomegaly.

C. a persistent cold.

The LPN/LVN should encourage the laboring client to begin pushing when A. there is only an anterior or posterior lip of cervix left. B. the client describes the need to have a bowel movement. C. the cervix is completely dilated. D. the cervix is completely effaced.

C. the cervix is completely dilated.

The nurse should encourage the laboring client to begin pushing when A. there is only an anterior or posterior lip of cervix left. B. the client describes the need to have a bowel movement. C. the cervix is completely dilated. D. the cervix is completely effaced.

C. the cervix is completely dilated.

A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse to review before reporting to the healthcare provider?

Calcium.

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

Check the differential, since the WBC is normal for this client.

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

Check the differential, since the WBC is normal for this client.

Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest?

Checkers

Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest?

Checkers

A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet?

Chicken.

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

Contraction pattern.

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?

Contraction pattern.

Contractions decrease with walking.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide? A Most infants of HIV-positive women will continue to test positive for HIV antibodies. B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C. Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-negative. D HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.

D HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A Remove all ice from the client's room. B. Ask the client what foods she might consider eating. C. Remind the client that what she eats affects her baby. D Notify the health care provider.

D Notify the health care provider.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

D The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client? A) Administration of Pitocin B) Artificial rupture of the membranes C) Amnioinfusion for the baby D) Administration of antibiotics

D) Administration of antibiotics

To assess uterine contractions the LPN/LVN would A) Asses duration from the beginning of the contraction to the peak of the same contraction, frequency by measuring the time between the beginning of one contraction to the beginning of the next contraction. B) Assess frequency as the time between the end of one contraction and the beginning of the next contraction, duration as the length of time from the beginning to the end of contractions, and palpate the uterus for strength C) Assess duration from beginning to end of each contraction. Assess the strength of the contraction by the external fetal monitor reading. Measure frequency by measuring the beginning of one contraction to another. D) Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength

D) Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse initial response would be to: A) Prepare the woman for imminent birth B) Notify the woman's primary health care provider. C) Document the characteristics of the fluid. D) Assess the fetal heart rate and pattern.

D) Assess the fetal heart rate and pattern.

Maternity nurse often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, LPN/LVN should be aware that: A) Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. B) Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. C) Effleurage is permissible, but counterpressure is almost always counterproductive. D) Electrodes attached to either side of the spine to provide mild intensity electrical impulses facilitate the release of endorphins

D) Electrodes attached to either side of the spine to provide mild intensity electrical impulses facilitate the release of endorphins

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement? A) Schedule weekly prenatal appointments B) Contact social services for a temporary shelter C) Obtain a hemoglobin and hematocrit level D) Have the client transported to the hospital

D) Have the client transported to the hospital

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The LPN/LVN should: A) Notify the woman's physician. B) Tell the woman to "calm down" and slow the pace of her breathing. C) Administer oxygen via a mask or nasal cannula. D) Help her breathe into a paper bag

D) Help her breathe into a paper bag

A term multigravida, who is receiving oxytocin (Pitocin) for labor augmentation, is requesting pain medication. Review of the client's record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client's cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement? A) Discontinue the Pitocin infusion B) Medicate the client with an additional 1 mg of Stadol IV push C) Notify the healthcare provider D) Instruct the client to use deep breathing during a contraction

D) Instruct the client to use deep breathing during a contraction

Which of the following is true about placenta previa? A) The bleeding from placenta previa usually occurs late in pregnancy at term. B) In evaluating the bleeding, a vaginal exam would be done to determine the cause of the bleeding. C) Symptoms of placenta previa are painful frequent contractions and bright red vaginal bleeding D) Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta previa will resolve in the third trimester.

D) Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta previa will resolve in the third trimester.

The factors that affect the process of labor and birth, known commonly as the five Ps, include all EXCEPT: A) Passageway. B) Powers. C) Passenger. D) Pressure.

D) Pressure.

During labor a fetus with an average heart rate of 175 beats/min over a 15-minute period would be considered to have: A) A normal baseline heart rate. B) Bradycardia. C) Hypoxia. D) Tachycardia.

D) Tachycardia.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one fullterm baby, and has had no abortions. Which GTPAL should the nurse document in this client's record? A. 3-1-2-0-3. B. 4-1-2-0-3. C. 2-1-2-1-2. D. 3-1-1-0-3.

D. 3-1-1-0-3.

The LPN/LVN is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? A. A gravida 6, para 5 who is 38 years of age and in early labor. B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. C. A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. D. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

D. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? A. A gravida 6, para 5 who is 38 years of age and in early labor. B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. C. A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. D. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

D. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? A. Check the client for urinary bladder distention. B. Notify the healthcare provider of the nonreactive results. C. Have the mother stimulate the fetus to move. D. Ask the client if she has felt any fetal movement.

D. Ask the client if she has felt any fetal movement.

When assessing a client who is at 12-weeks gestation, the LPN/LVN recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16-weeks gestation. B. At 20-weeks gestation. C. At 24-weeks gestation. D. At 30-weeks gestation

D. At 30-weeks gestation

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16-weeks gestation. B. At 20-weeks gestation. C. At 24-weeks gestation. D. At 30-weeks gestation.

D. At 30-weeks gestation.

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately? A. Give the medication as prescribed and monitor for efficacy. B. Encourage the client to breastfeed rather than bottle feed. C. Have the client empty her bladder and massage the fundus. D. Call the healthcare provider to question the prescription

D. Call the healthcare provider to question the prescription

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client? A. Which symptom did you experience first? B. Are you eating large amounts of salty foods? C. Have you visited a foreign country recently? D. Do you have a history of rheumatic fever?

D. Do you have a history of rheumatic fever?

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? A. Which symptom did you experience first? B. Are you eating large amounts of salty foods? C. Have you visited a foreign country recently? D. Do you have a history of rheumatic fever?

D. Do you have a history of rheumatic fever?

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? A. Discuss various contraceptive methods to use until pregnancy is desired. B. Provide written or verbal information about prenatal care. C. Ask the client about risk factors associated with complications of pregnancy. D. Encourage healthy lifestyles for families desiring pregnancy.

D. Encourage healthy lifestyles for families desiring pregnancy.

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A. Place a wedge under the client's left side. B. Determine cervical dilation and effacement. C. Administer 10 L of oxygen via facemask. D. Increase the rate of the oxytocin (Pitocin) infusion.

D. Increase the rate of the oxytocin (Pitocin) infusion.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? A. Herbs are a cornerstone of good health to include in your treatment. B. Touch is also therapeutic in relieving discomfort and anxiety. C. Your healthcare provider should direct treatment options for herbal therapy. D. It is important that you want to take part in your care.

D. It is important that you want to take part in your care.

An expectant father tells the LPN/LVN he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. Encourage the mother to provide total care for her infant. B. Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D. Meet the mother's physical needs and demonstrate warmth toward the infant.

D. Meet the mother's physical needs and demonstrate warmth toward the infant.

The nurse is assessing a 35-week primigravida with a breech presentation who is experiencing moderate uterine contraction every 3-5 minutes. During the examination the client tells the nurse, "I think my water just broke". Inspection of the perineal area reveals the umbilical cord protruding from the vagina. After activating the call bell system for assistance, what intervention should the nurse implement? A. Administer oxygen at 10 liters via face mask B. Don gloves and push the cord back into the vagina C. Wrap the umbilical cord with sterile gauze D. Position the client into a knee-chest position

D. Position the client into a knee-chest position

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the LPN/LVN to implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the client to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the client to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the woman to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the woman to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

An off-duty LPN/LVN finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use a thread to tie off the umbilical cord. B. Provide as much privacy as possible for the woman. C. Reassure the husband and try to keep him calm. D. Put the newborn to breast.

D. Put the newborn to breast.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use a thread to tie off the umbilical cord. B. Provide as much privacy as possible for the woman. C. Reassure the husband and try to keep him calm. D. Put the newborn to breast.

D. Put the newborn to breast.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use thread to tie off the umbilical cord. B. Provide privacy for the woman. C. Reassure the husband and keep him calm. D. Put the newborn to the breast immediately.

D. Put the newborn to the breast immediately.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father? A. Suggest that his wife seek professional counseling to deal with her symptoms. B. Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D. Reassure him that normal maternal-fetal bonding is occurring.

D. Reassure him that normal maternal-fetal bonding is occurring.

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? A. The infant should be positioned to reduce the swelling. B. The swelling is a subperiosteal collection of blood. C. The pediatrician will aspirate the blood if it gets larger. D. The scalp edema will subside in a few days after birth.

D. The scalp edema will subside in a few days after birth.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? A. Some care is required when touching the large soft area on top of your baby's head until the bones fuse together. B. That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot. C. The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby. D. There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

D. There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

D. They use lubricants with each sexual encounter to decrease friction.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity? A. Deep tendon reflexes 2+. B. Blood pressure 140/90. C. Respiratory rate 18/minute. D. Urine output 90 ml/4 hours.

D. Urine output 90 ml/4 hours.

At 34- weeks' gestation, a primigravida is assessed at her bimonthly clinic visits, which assessment finding is important for the nurse to report to the hcp? A. Increased appetite B. Fetal heart rate of 110 beats/minute C. Fundus below the xiphoid D. Weight gain of 7 pounds

D. Weight gain of 7 pounds

During a prenatal visit, the LPN/LVN discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores. B. lower birth weights. C. respiratory distress. D. a higher rate of congenital anomalies.

D. a higher rate of congenital anomalies.

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

Document the vital signs in the record.

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching?

Encourage nonnutritive sucking for pain relief

husband of postpartum woman concerned because his wife is irritable after delivery/ postpartume blues

Encourage use of support persons to help with housework for first 2 postpartum week without Improve look to help with specialist

Exercise in a swimming pool

Exercise in a swimming pool.

A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress?

Expiratory grunting

Maternal blood pressure.

A nurse is preforming a physical assessment of a newborn. Which of the following actions should the nurse take?

Measure the circumference of the newborn's head with a tape measure just above the eyebrows

A nurse is assessing a client who is 3 days post-partum. When examining the client's uterus, which of the following techniques should the nurse use?

Measure the height of the fundus in fingerbreadths in relation to the umbilicus

A woman who delivered a normal newborn 24 hours ago complains, "I seem to be urinating every hour or so. Is that ok?". Which action should the nurse implement?

Measure the next voiding, then palpate the client's bladder

A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit?

Metabolic Alkalosis.

A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration?

Metabolic acidosis

A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration?

Metabolic acidosis

During the admission of a newborn, the nurse identifies alocalized swelling that does not cross the suture line on the posterior area of the parietal bone. What intervention the nurse implement?

Notification pediatrician of the cephalohematoma

A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client to report to the provider during the first trimester?

Persistent vomiting

A nurse is assessing a 4 hour old newborn prior to breastfeeding and notes hands and feet that are cold and slightly blue. Which of the following actions should the nurse take?

Place the naked newborn on the mother's bare chest and cover both with a blanket

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?

Place the unwrapped newborn on the mothers bare chest

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider?

Platelet count 135,000

Position the client into a knee-chest position

A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take?

Provide examples of how eating well will help maintain a healthy weight during pregnancy.

nurse is preparing to perform leopoldmanuevaers on a client who is in labor. Which of the following actions should the nurse plan to take?

Stand at the clients right side if the nurse is right handed

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

Stimulate the infant to cry.

A primigravida client ask the nurse about educating during pregnancy to help her to prepare for labor. Which recommendation should the nurse provide?

Stretching exercises are good preparation for labor

A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?

Sweat-chloride test.

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea ( sudden aimless movements of the arms and legs). Which information should the nurse tell to the parents?

The chorea or movements are temporary and will eventually disappear.

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea ( sudden aimless movements of the arms and legs). Which information should the nurse tell to the parents?

The chorea or movements are temporary and will eventually disappear.

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded.

A nurse at a family planning clinic preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching?

Use spermicidal jelly whenever you use your diaphragm

A nurse is caring for a client at 37 weeks gestation who is undergoing a nonstress test. The fetal heart rate is 130/min without acceleration for the past 10 min. which of the following actions should the nurse take?

Use vibroacoustic stimulation on the clients abdomen for 3 sec

A nurse is assessing a client at 37 weeks gestation who has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect?

Uterine contractions

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio-placenta?

Uterine tone

A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin (Nix) shampoo and calls his parents. What instruction should the nurse provide to the parents about treatment for head lice?

Wash the child's bed linens and clothing in hot soapy water

A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse provide?

We need to observe your baby more closely

A nurse is teaching a prenatal class for a group of antepartum clients. Which of the following pieces of information should the nurse include about the hepatitis B immunization?

We will need your consent prior to administering the vaccine

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1?

Weak cry

The nurse is teaching a new mother about breast feeding. The client tell the nurse that her sister become very uncomfortable when she tries to breast feeding because she had too much milk What suggestion should the nurse provide to help this client complains with the discomfort associated with engorged breast ?

Wear a supportive bra at all time

A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention?

Weight loss 12% of birth weight

The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which answer should the nurse to provide?

Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider"

When planning care for a laboring client, the nurse identifies the needs to withhold solid foods while the client is in labor. What is the most important reason for this nursing intervention? a. An increased risk of aspiration can occur if general anesthesia is needed b. Nausea occurs analgesics used during labor c. Autonomic nervous system stimulation during labor decrease peristalsis d. Gastric emptying time decrease during labor

a. An increased risk of aspiration can occur if general anesthesia is needed

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefor, the best time for intercourse to ensure conception? a. Between the time the temperature falls and rises b. Between 36 and 48 hours after the temperature rises c. When the temperature falls and remains low for 36 hours d. Within 72 hours before the temperature falls a. Between the time the temperature falls and rises

a. Between the time the temperature falls and rises

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefor, the best time for intercourse to ensure conception? a. Between the time the temperature falls and rises b. Between 36 and 48 hours after the temperature rises c. When the temperature falls and remains low for 36 hours d. Within 72 hours before the temperature falls

a. Between the time the temperature falls and rises In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.

the nurse is preparing a 5 day old infant with a serum bilirubin level of 19mg/dl for discharge from the hospital. When teaching the parents about a prescription for home phototherapy, what instructions should the nurse include in the discharge teaching plan? a. Change the position every two hours b. perform diaper changes under the light c. feed the infant every 4 hours d. dress with a white cotton shirt

a. Change the position every two hours

a. Complete a sterile vaginal exam

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? a. Complete bedrest decreases oxygen needs and demands on the heart muscle b. We want your baby to be healthy, and this is the only way we can make sure that will happen again c. I know you're upset. Would you like to talk about somethings you could so while in bed? d. Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties a. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue

a. Complete bedrest decreases oxygen needs and demands on the heart muscle

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? a. Complete bedrest decreases oxygen needs and demands on the heart muscle b. We want your baby to be healthy, and this is the only way we can make sure that will happen again c. I know you're upset. Would you like to talk about somethings you could so while in bed? d. Labor is difficult, and you need to use this time to rest before you have to assume all child-caring duties

a. Complete bedrest decreases oxygen needs and demands on the heart muscle

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply) a. Dark, red vaginal bleeding b. Lower back pain c. Premature rupture of membranes d. Increased uterine irritability e. Bilateral pitting edema f. A rigid abdomen

a. Dark, red vaginal bleeding d. Increased uterine irritability f. A rigid abdomen

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply) a. Dark, red vaginal bleeding b. Lower back pain c. Premature rupture of membranes d. Increased uterine irritability e. Bilateral pitting edema f. A rigid abdomen a. Dark, red vaginal bleeding d. Increased uterine irritability f. A rigid abdomen

a. Dark, red vaginal bleeding d. Increased uterine irritability f. A rigid abdomen

An obviously pregnant woman walks into the hospital's emergency department entrance, shouting, "Help me! Help me! My baby is coming! I'm so afraid!" The nurse determines that delivery is indeed imminent. What action is most important for the nurse to take? a. Determine the gestational age of the fetus b. Assess the amount of color of the amniotic fluid c. Obtain peripheral IV access

a. Determine the gestational age of the fetus

At 6-weeks' gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? a. Early postpartum, within 72 hours of delivery b. After the client reach 20 weeks' gestation c. After the client stops breastfeeding d. Before the client stool and urine

a. Early postpartum, within 72 hours of delivery

Following the vaginal delivery of a large for gestation age (LGA) infant, a woman is admitted to the ICU due to post-partum hemorrhaging. The client's medical record describes Jehovah's Witness notes as her religion. What action should the nurse take next? a. Inform the client of the critical need for a blood transfusion b. Obtain consent from the family to infuse packed red blood cells c. Clarify the clients wishes about receiving blood products d. Prepare to infuse multiple units of fresh frozen plasma

a. Inform the client of the critical need for a blood transfusion

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" a. Lying prone with a pillow on the abdomen b. Using a breast pump c. Massaging the abdomen d. Giving oxytocic medications a. Lying prone with a pillow on the abdomen

a. Lying prone with a pillow on the abdomen

a. Lying prone with a pillow on the abdomen Lying prone (A) keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone.

3. When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) a. Mood swings b. Panic attacks c. Tearfulness d. Decreased need for sleep e. Disinterest in the infant

a. Mood swings c. Tearfulness

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) a. Mood swings b. Panic attacks c. Tearfulness d. Decreased need for sleep e. Disinterest in the infant

a. Mood swings c. Tearfulness "Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings (A), tearfulness (C), feeling low, emotional, and fatigued.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? a. Raise the foot of the bed b. Assess for vaginal bleeding c. Evaluate the fetal heart rate d. Take the client's blood pressure

a. Raise the foot of the bed

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? a. Reduce activity level and notify the healthcare provider b. Go to bed and assume a knee-chest position c. Massage the uterus and go to the emergency room d. Do not worry as this is a normal occurrence

a. Reduce activity level and notify the healthcare provider

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? a. Reduce activity level and notify the healthcare provider b. Go to bed and assume a knee-chest position c. Massage the uterus and go to the emergency room d. Do not worry as this is a normal occurrence

a. Reduce activity level and notify the healthcare provider

18. A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? a. Transition labor with contractions every 2 minutes, lasting 90 seconds each a. Early labor with contractions every 5 minutes, lasting 40 seconds each c. Active labor with contractions every 31 minutes, lasting 60 seconds each d. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each

a. Transition labor with contractions every 2 minutes, lasting 90 seconds each

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions? a. Transition labor with contractions every 2 minutes, lasting 90 seconds each a. Early labor with contractions every 5 minutes, lasting 40 seconds each c. Active labor with contractions every 31 minutes, lasting 60 seconds each d. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds e

a. Transition labor with contractions every 2 minutes, lasting 90 seconds each

A client at 20 weeks' gestation comes to the antepartum clinic complaining of vaginal warts (human papillomavirus). What information should the nurse provide this client? a. Treatment options, while limited due to the pregnancy, are available b. The client should be treated with Penicillin G c. This client should be treat with acyclovir (Zovirax) d. Termination of the pregnancy should be considered

a. Treatment options, while limited due to the pregnancy, are available

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first? a. check the differential, since the WBC is normal for this client b. notify the HCP, since this finding is indicative of infection c. assess the client's temperature, pulse and respirations q4h d. assess the client's perineal area for signs of perineal hematoma

a. check the differential, since the WBC is normal for this client

The nurse performs a vaginal examinationa nd determines that a laboring client is 6 cm dilated, 85% effaced, and at stattion Ͳ1. When the membranes rupture, the nurse notices the amniotic fluid is clear but contains bits of vernix, and the fetal heart rate remains withing normal limits. Which action should the nurse implement. a. document the color and characteristics of the amniotic fluid b. collect a sample of the amniotic fluid for analysis c. place the client in lithomy position and adjust the stirrups. D. position the delivery table at foot of the bed

a. document the color and characteristics of the amniotic fluid

a. edema, basilar rales, and an irregular pulse

A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse's assessment reveals approximately 30 ml of bright red vaginal bleeding, FHR of 130 to 140 beats/min, no contraction, and no complaints of pain. What is the most likely case of this client's bleeding? a. placenta previa b. a ruptured blood vessel in the vaginal vault c. normal bloody show indicating initiation of labor d. abruptio placenta

a. placenta previa

puerperal with SIDA received AZT during the pregnancy the newborn is received for the nurse prior

administered AZT before the 6 hours to newborn

38cm fundal height, 30 weeks gestation

after 20 weeks, the fundal height in cm should approximate # of weeks gestation

when do screen for phenylketonuria

after 24 hours of breast milk of formula ingestion

diaphragm size

after each birth the diaphragm should be evaluated for correct sizing and use an alternative form of contraception until verified

A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, Manipur) and HCG. Which side effect should the nurse tell the client to report immediately? a. persistent daytime fatigue b- rapid increase in abdominal girth c- nausea and vomiting d. episodes of headache and irritability

b- rapid increase in abdominal girth

In determining the one-minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has a loud cry with stimulation, good muscle tone and his color is acrocyanotic. What Apgar score should the nurse assign? a. 7 b. 9 c. 10 d. 8

b. 9

The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? a. terbutaline (Brethine) 0.25 mg SubQ Q15 mins x 3 b. Betamethasone (Celestone) 12 mg deep IM c. Butorphanol 1 mg IV push q2h PRN pain d. Ampicillin 1-gram IV push q8h

b. Betamethasone (Celestone) 12 mg deep IM

A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? a. Carrots b. Chicken C. Yogurt d. Cheese

b. Chicken

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? a. Ask the client if she takes a daily calcium tablet b. Extend the leg and dorsiflex the foot c. Lower the leg off the side of the bed d. Elevate the leg above the heart b. Extend the leg and dorsiflex the foot

b. Extend the leg and dorsiflex the foot

b. Extend the leg and dorsiflex the foot Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B) and putting the heel of the foot on the floor is the best means of relieving leg cramps.

A 3-hour old male infant's hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best for the nurse to implement? a. Perform a heel- stick to monitor blood glucose level b. Gradually warm the infant under a radiant heat source c. Administer oxygen by mask at 2L/minute d. Notify the pediatrician of the infant's unstable vital signs

b. Gradually warm the infant under a radiant heat source

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? a. She eagerly reaches for the infant, undresses the infants, and examines the infant completely b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips c. Her arms and hands receive the infant and she then cuddles the infant to her own body d. She eagerly reaches for the infant and then holds the infant close to her own body

b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? a. Supplementary iron is more efficiently utilized during pregnancy b. It difficult to consume 18 mg of additional iron by diet alone c. Iron absorption is decreased in the GI tract during pregnancy d. Iron is needed to prevent megaloblastic anemia in the last trimester

b. It difficult to consume 18 mg of additional iron by diet alone

A woman who delivered a normal newborn 24 hours ago complains, "I seem to be urinating every hour or so. Is that ok?". Which action should the nurse implement? a. Catheterize the client for residual urine volume b. Measure the next voiding, then palpate the clients' bladder c. Evaluate for normal involution, then massage the fundus d. Obtain a specimen for urine culture and sensitivity

b. Measure the next voiding, then palpate the clients' bladder

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? a. Elicit positive scarf sign on the affected side b. Observe for an asymmetrical Moro (startle) reflex c. Watch for swelling of fingers on the affected side d. Note paralysis of affected extremity and muscles

b. Observe for an asymmetrical Moro (startle) reflex

Postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client? a. RhoGAM is not necessary unless all her pregnancies are Rh-positive b. RhoGAM prevents maternal antibody formation for future Rh-positive babies c. the mother should receive RhoGAM when the baby is Rh-negative d. the R-positive factor from the fetus threatens her blood cells

b. RhoGAM prevents maternal antibody formation for future Rh-positive babies

a client asks the nurse about the harmful effects of taking prescribed drugs during pregnancy. When do drugs taken by a mother have the most significant effect on a fetus? a. 24 hours before delivery b. the first trimester c. first stage of labor d. six weeks prior to becoming pregnant

b. the first trimester

When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the HCP? a. +1 pedal edema b. 130/70 blood pressure c. 101.2 F oral temp d. +1 proteinuria

c. 101.2 F oral temp

a 28 year old gravida 2, para 1 client at 30 weeks gestation presents with contractions occuring 3 minutes apart with moderate intensity. A vaginal examination reveals that her cervix is dilated to 3 cm and is 100% effaced. Which nursing intervention has the highest priority for this client? a. assess blood pressure q15 minutrs b. send urine to the lab for urinalysis c. Administer betamethasne (Celestone) per prescription. d. obtain the client's fingerprints for the birth record.

c. Administer betamethasne (Celestone) per prescription.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? a. Wear a cotton bra b. Increase nursing time gradually c. Correctly place the infant on the breast d. Manually express a small amount of milk before nursing

c. Correctly place the infant on the breast

c. Correctly place the infant on the breast The most common cause of nipple soreness is incorrect positioning (C) of the infant on the breast, e.g., grasping too little of the areola or grasping on the nipple.

The total bilirubin level of a 36-hour, breastfeeding newborns is 14 mg/dl. Based on this finding, which intervention should the nurse implement? a. Provide phototherapy for 30 minutes q8h b. Feed the newborn sterile water hourly c. Encourage the mother to breastfeed frequently d. Assess the newborn's blood glucose level

c. Encourage the mother to breastfeed frequently

c. Gonorrhea

c. January 30-31 This woman can expect her next period to begin 36 days from the first day of her last menstrual period - the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31 (C).

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? a. Insert an internal fetal monitor b. Assess for cervical changes q1h c. Monitor bleeding from IV sites d. Perform Leopold's maneuvers

c. Monitor bleeding from IV sites

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between, contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? a. Insert an internal fetal monitor b. Assess for cervical changes q1h c. Monitor bleeding from IV sites d. Perform Leopold's maneuvers c. Monitor bleeding from IV sites

c. Monitor bleeding from IV sites

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? a. Provide oral hydration b. Have a complete blood count (CBC) drawn c. Obtain a specimen for urine analysis d. Place the client on strict bedrest c. Obtain a specimen for urine analysis

c. Obtain a specimen for urine analysis

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? a. Provide oral hydration b. Have a complete blood count (CBC) drawn c. Obtain a specimen for urine analysis d. Place the client on strict bedrest

c. Obtain a specimen for urine analysis Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.

One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next? a. Document number of pad changes in the last hour b. Increase the rate of the oxytocin infusion c. Palpate the suprapubic area for bladder distention d. Provide bedpan to void if unable to ambulate

c. Palpate the suprapubic area for bladder distention

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is: a. shortness of breath b. joint pain c. a persistent cold d. organomegaly

c. a persistent cold

The nurse is preparing a client with Type 1 diabetes who is at 35 weeks gestation for amniocentesis. After obtaining maternal vital signs and a baseline fetal heart rate, which nursing interventin has the highest priority? a. obtain a baseline CBC b. provide family support c. ask the woman to void D. inititate a heparin lock

c. ask the woman to void

assessment findings of a 4 hour old newborn include: axillary temp 97.9 F, heart rate 150 beat/s min with a soft murmur, and irregular resp rate at 46 breaths//min. based on these finding what action should the nurse take? a. obtain a heel stick blood glucose level b. swaddle the infant in a warm blanket c. document the findings in the record d. place a pulse oximeter on the heel

c. document the findings in the record

the nurse observes a newborn with swelling of the scalp and suspects that is the result of birth trauma. Which intervention should the nurse implement to differentiate between caput succedaneum and cephalhematoma? a. transilluminate the skull b. palpate the anterior fontanel c. examine the suture lines d. measure the head circumference

c. examine the suture lines

A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some "heart damage." The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing diagnosis has the highest priority? a. sleep deprivation b. risk for infection c. fluid volume excess d. nausea and vomiting

c. fluid volume excess

a woman who recently delivered a normal newborn calls the clinic crying and describes feeling overwhelmed and discouraged. Which information is most important for the nure to obtain? a. does she describe herself as described b. has she seen a mental health provider c. how long has she been feeling this way d. is there anyone with her at this time?

c. how long has she been feeling this way

The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision? a. give a PRN dose of liquid acetaminophen b. wrap the infant in warm receiving blankets c. place petrolatum gauze dressings on the site d. offer a pacifier dipped in glucose water

c. place petrolatum gauze dressings on the site

The nurse should encourage the laboring client to begin pushing when a. there is only an anterior or posterior lip of cervix left b. the client describes the need to have a bowel movement c. the cervix is completely dilated d. the cervix is completely effaced c. the cervix is completely dilated

c. the cervix is completely dilated

c. the cervix is completely dilated Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated (A, B, and D), the cervix can become edematous and may never completely dilate, necessitating an operative delivery. Many primigravida's begin active labor 100% effaced and then proceed to dilate.

the last vaginal examination for a primigravida in active labor revealed a cervical dilation at 8 cm and fetal position at a 0 station. The client has been contracting regularly every 2 to 3 minutes with moderate identation, and now begins to have increased bloody show, and become nauseated. The nurse should plan this client's care based on which phase of labor? a. early active b. prodromal c. transition d. latent active

c. transition

Positive Homan sign

call the physician

what do the nurse do if the pregnant woman has variable deceleration :

change maternal position

Dilantin, newly diagnosed tonic - clonic epilepsy, seizure management

child should have routine serum levels monitored, as well as liver function

pregnancy of 32 weeks has urinary freq elevated during day and night , what nurse must implement

collect urine specimen x culture

The nurse is conducting post-partum teaching with a mother who is breastfeeding her infant. When discussing birth control, which method should the nurse recommend to this client as best for her to used in preventing an unwanted pregnancy?

condoms and contraceptive foam or gel

pregnancy with contraction irregular the nurse what to rule out false labor

contraction decrease with ambulation

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicated that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record? a. 3-1-2-0-3 b. 4-1-2-0-3 c. 2-1-2-1-2 d. 3-1-1-0-3

d. 3-1-1-0-3

d. 3-1-1-0-3 (D) describes the correct GTPAL. The client has been pregnant 3 times including the current pregnancy (G-3). She had one full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). There were no abortions (A-0), so this client has a total of 3 living children

A client at 38 weeks' gestation complains of severe abdominal pain. Upon palpation, the nurse notes that the abdomen is rigid. How should the nurse document the findings? a. Placenta previa b. Chorioamnionitis c. Oligohidramnios d. Abrupción placenta

d. Abrupción placenta

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM x 1. What action should the nurse take immediately? a. Give the medication as prescribed and monitor for efficacy b. Encourage the client to breastfeed rather than bottle feed c. Have the client empty her bladder and massage the fundus d. Call the healthcare provider to question the prescription

d. Call the healthcare provider to question the prescription

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM x 1. What action should the nurse take immediately? a. Give the medication as prescribed and monitor for efficacy b. Encourage the client to breastfeed rather than bottle feed c. Have the client empty her bladder and massage the fundus d. Call the healthcare provider to question the prescription

d. Call the healthcare provider to question the prescription

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? a. Blood glucose level of 45 mg/dl b. Blood pressure of 82/45 mmHg c. Non-bulging anterior fontanel d. Central cyanosis when crying

d. Central cyanosis when crying

A pregnant woman who is at 10-weeks' gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? a. an amniocentesis conducted at 24 weeks' gestation confirms or denies Down Syndrome in the fetus b. maternal serum Human Chorionic Gonadotropic (HCG) can identify Down Syndrome at 6 weeks of gestation c. Weekly fundal height measurements are a noninvasive method used to check for Down Syndrome d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome

d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome

Pregnant woman who is at 10-weeks' gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? a. an amniocentesis conducted at 24 weeks' gestation confirms or denies Down Syndrome in the fetus b. maternal serum Human Chorionic Gonadotropic (HCG) can identify Down Syndrome at 6 weeks of gestation c. Weekly fundal height measurements are a noninvasive method used to check for Down Syndrome d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome

d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome

The father of a 3-day-old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no apparent reason. What information is most important for the nurse to provide this father? a. Tell the father to count the newborn's number of soiled diapers over the next few days. b. Recommend giving supplemental bottle feeding to the baby between breast feeding. c. A fluctuation in hormones in the early postpartum period can cause mood changes d. Contact the clinic if the behavior continues for more than two weeks or becomes worst

d. Contact the clinic if the behavior continues for more than two weeks or becomes worst (salio)

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? a. Which symptom did you experience first? b. Are you eating large amounts of salty foods? c. Have you visited a foreign country recently? d. Do you have a history of rheumatic fever?

d. Do you have a history of rheumatic fever?

The nurse is caring for a new born who is 18" long weight 4 lbs., 14 ounces, has a head circumference 13 inches, and a chest circumference of 10 inches. Base on the physical findings, assessment for which condition has the highest priority? a. Hyperbilirubinemia b. Polycythemia c. Hyperthermia d. Hypoglycemia

d. Hypoglycemia

Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs. and weight 7 lbs. today. a. Monitor the stool and urine output of the last 24 hours b. After verifying the accuracy of the weight, notify the health care provider c. Encourage the mother to increase frequency of breastfeeding d. Informed and assure the mother that this is a normal weight loss

d. Informed and assure the mother that this is a normal weight loss

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? a. Herbs are a corner stone of good health to include in your treatment b. Touch is also therapeutic in relieving discomfort and anxiety c. Your healthcare provider should direct treatment options for herbal therapy d. It is important that you want to take part in your care d. It is important that you want to take part in your care

d. It is important that you want to take part in your care

d. It is important that you want to take part in your care The emphasis of alternative and complementary therapies, such as herbal therapy, is that the client is viewed as a whole being, capable of decision-making and an integral part of the health care team, so (D) recognizes the client's request.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? a. Encourage the mother to provide total care for her infant b. Provide privacy so the mother can develop a relationship with the infant c. Encourage the father to provide most of the infant's care during hospitalization d. Meet the mother's physical needs and demonstrate warmth toward the infant

d. Meet the mother's physical needs and demonstrate warmth toward the infant

A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? a. Encourage the mother to provide total care for her infant b. Provide privacy, so the mother can develop a relationship with the infant c. Encourage the father to provide most of the infant's care during hospitalization d. Meet the mother's physical needs and demonstrate warmth toward the infant

d. Meet the mother's physical needs and demonstrate warmth toward the infant

A newborn infant is receiving immunization prior to discharge. Which action should the nurse implement? a. Give the first dose of the vaccine for Rotavirus if any siblings have diarrhea now b. Ask the mother if she wants the infant immunized for Hemophilus influenza c. Prepare the first dose for Diphtheria, tetanus toxoid and acellular pertussis (DTap) d. Obtain signed consent from the mother for administration of hepatitis B vaccine

d. Obtain signed consent from the mother for administration of hepatitis B vaccine

The nurse is calculating the estimated date of confinement (EDC) using Nagele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? a. August 1 b. August 10 c. September 3 d. September 8

d. September 8

d. September 8 Calculation of a client's EDC provides baseline data to monitor fetal gestation. Nagele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8 (D

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important is most important for the nurse to provide this client? a. Elevate lower legs while resting b. Increase caloric intake by 200 to 300 calories per day c. Increase water intake to 8 full glasses per day d. Take prescribed multivitamin and mineral supplements

d. Take prescribed multivitamin and mineral supplements

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity? a. Deep tendon reflexes 2+ b. Blood pressure 140/90 c. Respiratory rate 18/minute d. Urine output 90 ml/4 hours

d. Urine output 90 ml/4 hours

a client at 29 weeks gestation is receiving magnesium sulfate 3 grams pre term labor. After administering the loading dose, what asssessment finding should the nurse report to the healthcare provider immediately? a. a decrease in respirations from 20 to 17 breaths/min b. an increase in temperature from 98.9 to 99.9 can increase in blod pressure from 110/65 to 120/85 d. a decrease in deep tendon reflexes from 3+ to 1+

d. a decrease in deep tendon reflexes from 3+ to 1+

A client at 38 weeks gestation presents to the labor and delivery unit in active labor. Based on which assessment finding should the nurse notify the surgery team to prepare for a primary cesarean section a. treated ten days ago for Chlamydia b. Group Beta Strep positive c. Positive western blot for HIV d. active herpes lesions on the perineum

d. active herpes lesions on the perineum

A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client? a. postpartum psychosis b. hard, painful uterine afterpains c. placenta accreta d. disseminated intravascular coagulation

d. disseminated intravascular coagulation

When performing the daily head to toe assessment of a one-day old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take? a. review maternal medical records for blood type and Rh factor b. prepare the newborn for phototherapy c. evaluate cord blood coombs test result d. measure bilirubin levels using transcutaneous bilirubinometer

d. measure bilirubin levels using transcutaneous bilirubinometer

Four clients at full term present to the labor and delivery unit at the same time. which client should the nurse assess first? a. primipara with vaginal show and leaking membranes b. primipara with burning on urination and urinary frequency c. multipara scheduled for a non-stress test and biophysical profile d. multipara with contractions occurring every 3 minutes

d. multipara with contractions occurring every 3 minutes

Assessment findings of a 3-hour old newborn include: axillary temperature of 97.7 F, heart rate of 140 beats/min with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement? a. record findings in electronic medical record b. obtain venous blood sample for glucose level c. attach a pulse oximeter on the heel d. place the infant under the radiant warmer

d. place the infant under the radiant warmer

a 38 week primipara is admitted with spontaneous rupture of membranes (SROM) and irregular contractions occuring ever 10 min. the fetal heart rate is 178 beats/ min, and maternal vital signs include the temp 100.6 F, pulse 88 beats/ min, respirations 22 breaths/min, and blood pressure 120/79. What information is mot important for the nurse to obtain? A. color and amount of amniotic fluid b. last oral intake c. anesthesia choice d. time membranes ruptures

d. time membranes ruptures

The nurse is caring for a client following an emergency cesarean delivery under a general anesthesia. Which assessment finding, occurring in the first 8 hours after delivery, is more critical and requires immediate intervention? a. mild nausea and anorexia d. uterine atony c. a positive Homan's sign d. Respiratory rate 12

d. uterine atony

delivery woman in the street , pregnant has herpes

isolate the newborn in nursing room

after precipitous labor continuous tricking of bright red blood from vaginal is noted

laceration of cervix

the nurse should the physician for

late deceleration

Find anormal in postpartum client the more 24 hours

look temp elevated 102

on pregnancy with gestational diabetes , what is the goal in the treatment:

maintain euglycemic

postpartum client said void every 1 hr :

measure next voiding, palpate client bladder

18 weeks gestation, high AFP level

need for follow up evaluation with a sonogram to provide visual evidence of fetal age and presence of neural tube defects

newborn has white plaques in mouth

need treatment medical

teach to pregnancy adolescents focus in

nutritonal requirements

using the ballar gestational age assessment tool, the nurse determine than a 15 hours infant has a gestational age is 42 weeks , based on this finding which intervension is important for the nurse to implement

obtain a capillary blood glucose

primipara of 36 weeks with abdominal trauma is RH neg

obtener fetal hemoglobin fetal

1 month old vomiting forcefully after each meal, is afebrile, dehydrated, and pyloric stenosis

olive shaped mass in the abdominal area that is evident at diaper change

newborn in warmer

on abdomen

what to use when changing newborn's diaper

plain water

pregnancy lithotomy position has dizziness

put wedge below hip

postpartum woman need to ant conceptive method

recommended condoms and gel

pregnancy with abdominal pain and fever :

remember temp above 100.4 is fever chorioamnionitis

folic acid

roasted peanut in the shell

the nurse is caring for a postpartum client with spinal headache 24 following delivery , prior to anesthesiology arrival what does the nurse should do ?

set the anesthesia prepared in bedside

6 month old introducing solid foods

should be introduced one at a time, every 4 to 7 days to determine food allergies

vaginal exam a one pregnancy what the nurse should use

sterile glove and lubricant

patient with hypertonic contraction use Oxytocin

stop infusion

pregnancy with Magnesium Sulfate has blurred speech and decrease reflexes :

stop infusion of magnesium

Ion intake

take at bedtime stool dark

pregnancy arrive with ruptured premature membrane with dilation , + 2 stage of fetal head , FHR is 170-180 , 45 min ago , whar should the nurse do

take temp of the mother

A post-partum client who is RH negative refuse to receive globulin (RHOGAM) after a delivery of an infant who is RH positive, which intervention should the nurse provide the client?

the R-positive factor from the fetus threatens her blood cells

the mother RH negative do not want to put RH o immune globulin

the nurse explains possible conflict in the future baby are RH positive

One day after vaginal delivery of a full-term baby, a post-partum client's white blood cells count is 15.000. what action should the nurse take first?

the nurse should look at the entire differential (lymphocytes, monocity, eosinophils) to analyze if there I an infection process present

primipara see her newborn for first time

the trip is fingertips

purpera no breastfeeding , has breast engorgement

use bras and no estimulate of nipples

30 minutes postpartum continue bleeding, boggy uterus

uterine massage

newborn with apnea and the FC 100 x min treatment stimulation no respond

ventilation

Encourage breastfeeding

which decreases insulin requirrements

A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history which finding should the nurse expect to obtain? · High blood cholesterol level on routine screening · Increased thirst and urination · A recent strep throat infection · A recent DPT immunization

· A recent strep throat infection

The nurse assessing a 9-year old boy who has been admitted to the hospital with possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? · Back pain for a few days · A history of hypertension · A sore throats last week · Diuresis during the nights

· A sore throats last week

A two year old child with a heart failure(HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement? · Determine the pulse deficit · Administer the schedule dose · Calculate the safe dose range · Review the serum digoxin level

· Administer the schedule dose

A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? · Turn the client to her left side · Contact the healthcare provider · Assess the fetal heart rate · Check the cervical dilation

· Assess the fetal heart rate

The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. · Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 · Ampicillin 1 gram IV push q8h. · Betamethasone (Celestone) 12 mg deep IM · Butorphanol (Stadol) 1 mg IV push q2h PRN pain

· Betamethasone (Celestone) 12 mg deep IM

The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? · Respiratory rate of 22 breaths/min · A large amount of lochia rubra · Blood pressure 149/90 · Positive Homan's sign

· Blood pressure 149/90

A child who received multiple blood transfusions after correction of a congenital heart defects is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider? · CO combining power · Calcium · Sodium · Chloride

· Calcium

· Check the differential, since the WBC is normal for this client

A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? · Carrots · Chicken · Yogurt · Cheese

· Chicken

During a well-child visit for their child, one of the parent who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder". How should the nurse respond? · Explain that the risk of inhering the disorder decrease by 50% with each child the couple has · Acknowledge that the next that the next child will inherit the disorder since the first child did not · Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked · Confirm that there is a 50% chance of their future children inheriting the disorder

· Confirm that there is a 50% chance of their future children inheriting the disorder

A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? · Pain level · Blood pressure · Infusion site · Contraction pattern

· Contraction pattern

A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? · Discuss the need for cortisol and aldosterone replacement therapy after discharge · Support the parents in their decision to assign sex of their child according to their preference · Offer information about ultrasonography and genotyping to determine sex assignment · Explain that corrective surgical procedures consistent with sex assignment can be delayed

· Discuss the need for cortisol and aldosterone replacement therapy after discharge

The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? · Begin a training program lifting weights and running · Splint affected joints during activity · Exercise in a swimming pool · Perform passive range of motion exercises twice daily

· Exercise in a swimming pool

A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? · Bilateral bronchial breath sounds · Diaphragmatic respiration · A resting respiratory rate of 35 breathe per minute · Flaring of the nares

· Flaring of the nares

A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? · Decrease the oxytocin infusion rate · Determine current cervical dilation · Request placement of the epidural · Give a bolus of intravenous fluids

· Give a bolus of intravenous fluids

A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? · Decrease the oxytocin infusion rate · Determine current cervical dilation · Request placement of the epidural · Give a bolus of intravenous fluids

· Give a bolus of intravenous fluids

A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? A. Obtain a culture of any sputum or wound drainage. · Obtain a culture of any sputum or wound drainage · Initiate normal saline IV at 50 ml/hr · Administer a loading dose of penicillin IM · Administer the initial dose of folic acid PO

· Initiate normal saline IV at 50 ml/hr

A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? · Obtain a culture of any sputum or wound drainage · Initiate normal saline IV at 50 ml/hr · Administer a loading dose of penicillin IM · Administer the initial dose of folic acid PO

· Initiate normal saline IV at 50 ml/hr

16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? · Keep airway equipment at the bedside. · Allow liberal family visitation · Monitor blood pressure, pulse, and respirations q4h · Assess temperature q1h

· Keep airway equipment at the bedside.

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? · Keep airway equipment at the bedside. · Allow liberal family visitation · Monitor blood pressure, pulse, and respirations q4h · Assess temperature q1h

· Keep airway equipment at the bedside.

A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? · Respiratory alkalosis · Respiratory acidosis · Metabolic acidosis · Metabolic alkalosis

· Metabolic acidosis

A child has been vomiting for 3 days is admitted for correction of fluid and electrolyte ,imbalances. What acid base imbalance is this child likely to exhibit? · Respiratory alkalosis · Respiratory acidosis · Metabolic alkalosis · Metabolic acidosis

· Metabolic alkalosis

A child has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? · Respiratory alkalosis · Respiratory acidosis · Metabolic alkalosis · Metabolic acidosis

· Metabolic alkalosis

The nurse is caring for a one-year-old child following surgical correction of hypospadias. The nursing action has the highest priority? · Monitor urinary output · Auscultate bowel sounds · Observe appearance of stool · Record percent of diet eaten

· Monitor urinary output

· Notify the healthcare provider from the client's bedside

The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next? · Measure the infant's head to heel length · Observe the infant for sunset eyes · Palpate the anterior fontanel for tension and bulging · Plot the measurement on the infant's growth chart

· Palpate the anterior fontanel for tension and bulging

An infant with letralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? · Administer morphine sulphate · Start IV fluids · Place the infant in a knee-chest position · Provide 100% oxygen by face mask

· Place the infant in a knee-chest position

The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12 year old sibling at the child's bedside. Which instruction best supports family? · While waiting for the healthcare provider, only one visitor may stay with the child · All of you should leave while the healthcare provider sutures the child's forehead · It is best if the sibling goes to the waiting room until the suturing is completed · Please decide who will stay when the healthcare provider begins suturing

· Please decide who will stay when the healthcare provider begins suturing

A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic (sudden aimless movements of the arms and legs). Which information should the nurse to the parents? · Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged · The chorea or movements are temporary and will eventually disappear · Permanent life-style changes need to be made to promote safety in the home · Consistent discipline is needed to help the child control the movements

· The chorea or movements are temporary and will eventually disappear

The parents of a 3 year-old boy who has Duchenne muscular dystrophy (DMD) ask "how can our son have this disease? We are wondering if we should have any more children" What information should the nurse provide these parents? · This is an inherited X-linked recessive disorder, which primarly affects male children in the family · The male infant had a viral infection that went unnoticed and iuntreated, so muscle damage was incurred · The XXXX muscle groups of males can be impacted by a lack of the protein dystrophyn in the mother · Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles

· This is an inherited X-linked recessive disorder, which primarly affects male children in the family

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