OB Final Study Set

The nurse is caring for a 32 week G 1 P 0 with moderate Pregnancy Induced Hypertension. Her BP is 169/98, pulse 90, resps. 18, DTRs 3+, 1 beat of clonus. The nurse is to start an IV infusion of Magnesium Sulfate at 1.5 grams/hour. The medication is available 40 grams of Magnesium Sulfate in 500 mL of Lactated Ringers. How many mL/hr will the nurse set the IV pump? (Round to the nearest tenth)

18.8 mL/hr

The nurse is caring for a patient whose labor is being augmented with oxytocin. The nurse has an order to increase the medication to 5 mu/min. The medication is available Pitocin 30 units in 500 mL of Lactated Ringers. How many mL/hr will the nurse set the pump?

5 mL/hr

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

8

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification? a. "I should increase my calcium intake to 1,500 milligrams per day" b. "I should drink about 2 liters of fluid each day." c. "I can have a moderate amount of caffeine daily." d. "I should not drink alcoholic beverages during my pregnancy."

a. "I should increase my calcium intake to 1,500 milligrams per day"

A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations? a. "It promotes fetal lung maturity." b. "It halts cervical dilation." c. "It increases the fetal heart rate." d. "It is used to stop preterm labor contractions."

a. "It promotes fetal lung maturity."

A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include? a. "Position the newborn at a 45-degree angle in the car seat." b. "Place the shoulder harness straps below the level of the newborn's armpits." c. "Place the retainer clip across the newborn's abdomen." d. "Keep the car seat rear-facing until the newborn can sit unsupported."

a. "Position the newborn at a 45-degree angle in the car seat."

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? a. "The rate and rhythm of breath are irregular in newborns." b. "Newborns do not expand their lungs fully with each respiration." c. "Activity will increase the respiratory rate." d. "Newborns are abdominal breathers."

a. "The rate and rhythm of breath are irregular in newborns."

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching? a. "This medication promotes softening of the cervix." b. "This medication is used to treat preeclampsia." c. "It is used to treat genital herpes simplex virus." d. "It causes relaxation of the uterine muscles."

a. "This medication promotes softening of the cervix."

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? a. A client who is experiencing preterm labor at 26 weeks of gestation b. A client who has a post-term pregnancy at 42 weeks of gestation c. A client who is experiencing fetal death at 32 weeks of gestation d. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation

a. A client who is experiencing preterm labor at 26 weeks of gestation

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Blot the perineal area dry after cleansing. b. Perform hand hygiene before and after voiding. c. Clean the perineal area from front to back. d. Apply ice packs to the perineal area several times daily. e. Wash the perineal area using a squeeze bottle of warm water after each voiding.

a. Blot the perineal area dry after cleansing. b. Perform hand hygiene before and after voiding. c. Clean the perineal area from front to back. e. Wash the perineal area using a squeeze bottle of warm water after each voiding.

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? a. Changes in the cervix b. Pattern of contractions c. Rupture of the membranes d. Station of the presenting part

a. Changes in the cervix

A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? a. Consume foods fortified with folic acid. b. Avoid foods containing aspartame. c. Limit alcohol consumption. d. Increase intake of iron-rich foods.

a. Consume foods fortified with folic acid.

A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times? a. Every morning before arising b. Before going to bed every night c. On days 13 to 17 of her menstrual cycle d. 1 hour following intercourse

a. Every morning before arising

A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? a. Fundus firm to palpation b. Report of absent breast pain c. Increase in blood pressure d. Increase in lochia

a. Fundus firm to palpation

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? a. Heart rate 110/min b. Orthostatic hypotension c. Fundus palpable at the umbilicus d. Urine output of 3,000 mL in 12 hr

a. Heart rate 110/min

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? a. Hypertension b. Cocaine use c. Blunt force trauma d. Cigarette smoking

a. Hypertension

A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? a. Hypoglycemia b. Hyperbilirubinemia c. Hypomagnesemia d. Hypocalcemia

a. Hypoglycemia

A nurse is admitting a client who has a diagnosis of preterm labor. The nurse anticipates a prescription by the provider for which of the following medications? (Select all that apply.) a. Indomethacin b. Magnesium sulfate c. Methylergonovine d. Oxytocin e. Prostaglandin E2

a. Indomethacin b. Magnesium sulfate

A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings? a. Missed miscarriage b. Incomplete miscarriage c. Inevitable miscarriage d. Complete miscarriage

a. Missed miscarriage

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) a. Provide a dark, quiet environment. b. Ensure that calcium gluconate is readily available. c. Evaluate neurologic status every 8 hr. d. Administer magnesium sulfate IV. e. Assess respiratory status every 4 hr.

a. Provide a dark, quiet environment. b. Ensure that calcium gluconate is readily available. d. Administer magnesium sulfate IV.

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? a. Report of headache b. Absence of clonus c. Tachycardia d. Polyuria

a. Report of headache

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? a. Respiratory distress b. Hypothermia c. Acrocyanosis. d. Accidental lacerations

a. Respiratory distress

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene? a. The mother plans to use a cotton-tipped swab to clean the nares. b. The mother leaves the yellow exudate on the circumcision site. c. The mother cleans the umbilical cord with tap water. d. The mother cleans the newborn's eyes from the inner canthus outwards.

a. The mother plans to use a cotton-tipped swab to clean the nares.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? a. There is no evidence of uteroplacental insufficiency. b. There are less than 3 uterine contractions in a 10-min period. c. There is evidence of cervical incompetence. d. There is no evidence of two or more accelerations in fetal heart rate in 20 min.

a. There is no evidence of uteroplacental insufficiency.

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching? a. "I will reduce my stress level." b. "I will use only nonprescription medications while pregnant." c. "I will monitor my weight gain during the remaining months." d. "I will tell my doctor before using home remedies for nausea."

b. "I will use only nonprescription medications while pregnant."

A nurse is caring for a client who is 16 -hr postpartum and states "My baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse provide? a. "Most new mothers feel somewhat anxious about things like this." b. "Let's sit here together and observe your baby while you feed him." c. "Why do you think there is something wrong with that?" d. "There's nothing for you to worry about. Newborns often breathe this way."

b. "Let's sit here together and observe your baby while you feed him."

A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? a. "This is a concern, but strabismus is easily treated with patching." b. "This occurs because newborns lack muscle control to regulate eye movement." c. "I will take your baby to the nursery for further examination." d. "I will call your primary care provider to report your concerns."

b. "This occurs because newborns lack muscle control to regulate eye movement."

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? a. "All you need to do is relax." b. "What part of the exam makes you most nervous?" c. "Don't worry, I will be with you during the exam." d. "A pelvic exam is required if you want birth control pills."

b. "What part of the exam makes you most nervous?"

A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives? a. A 26-year-old client who has migraine headaches at the start of each menstrual cycle b. A 38-year-old client who reports smoking one pack of cigarettes every day c. A 32-year-old client who has benign breast disease d. A 28-year-old client who has a history of pelvic inflammatory disease

b. A 38-year-old client who reports smoking one pack of cigarettes every day

A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take? a. Infuse a bolus of IV fluid. b. Administer betamethasone 12 mg IM. c. Administer hydralazine 25 mg IV. d. Prepare the client for immediate delivery.

b. Administer betamethasone 12 mg IM.

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients? a. A client who has been exposed to AIDS b. All of the clients c. A client who has a history of preterm labor d. A client who has mitral valve prolapse

b. All of the clients

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification? a. Assess deep tendon reflexes every hour. b. Obtain a daily weight. c. Ambulate twice daily. d. Continuous fetal monitoring

b. Ambulate twice daily.

A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? a. Evaluate client for the presence of chills and increased uterine tenderness using palpation. b. Assess the client's temperature. c. Assess the fetal heart rate pattern. d. Observe color and consistency of fluid.

b. Assess the client's temperature.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? a. Monitor the client's temperature. b. Assess the fetal heart rate. c. Assess the odor of the amniotic fluid. d. Provide clean, dry under pads.

b. Assess the fetal heart rate.

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? a. Apply a fetal scalp electrode. b. Change the client's position. c. Increase the rate of the IV infusion. d. Administer oxygen at 10 L/min via a nonrebreather mask.

b. Change the client's position.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next? a. Administer oxytocin by continuous IV infusion b. Massage the client's fundus to promote contractions. c. Tilt the client onto her right side with her legs elevated to at least 30°. d. Insert an indwelling urinary catheter.

b. Massage the client's fundus to promote contractions.

A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? (Select all that apply.) a. Cephalopelvic disproportion b. Neural tube defects c. Rh incompatibility d. Anomalies in fetal chromosomes e. Fetal gender

b. Neural tube defects c. Rh incompatibility d. Anomalies in fetal chromosomes e. Fetal gender

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? a. Diminished deep-tendon reflexes b. Respiratory rate of 16/min c. Heart rate of 56/min d. Urine output of 50 mL in 4hr

b. Respiratory rate of 16/min

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? a. Dorsogluteal b. Vastus lateralis c. Ventrogluteal d. Deltoid

b. Vastus lateralis

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching? a. "I should crush cabbage leaves and place them on my breasts." b. "I will breastfeed every 2 hours." c. "I should apply hot packs to my breasts during feeding." d. "I will apply ice packs to my breasts after feeding."

c. "I should apply hot packs to my breasts during feeding."

A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? a. "This test checks for a genetic disorder that can be managed by diet." b. "Sometimes the test is repeated in the doctor's office at the baby's 2-week check-up." c. "My baby will be placed under special lights if the test result is positive." d. "My baby needs to be on formula or breast milk before the test can be done."

c. "My baby will be placed under special lights if the test result is positive."

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? a. "Preterm newborns have a smaller body surface area than normal newborns." b. "The heat in the incubator rapidly dries the sweat of preterm newborns." c. "Preterm newborns lack adequate temperature control mechanisms." d. "The added brown fat layer in a preterm newborn reduces his ability to generate heat."

c. "Preterm newborns lack adequate temperature control mechanisms."

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide? a. "It's too soon for you to be worrying about this now." b. "There are so many variables that you'll have to ask your obstetrician." c. "The primary consideration is what type of incision was performed this time." d. "A repeat cesarean birth is safer for both you and your baby."

c. "The primary consideration is what type of incision was performed this time."

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? a. Administer glucocorticoids intramuscularly. b. Recheck the client's temperature in 4 hr c. Assess the odor of the amniotic fluid. d. Prepare the client for emergency cesarean section.

c. Assess the odor of the amniotic fluid.

A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin. The nurse should verify which of the following prior to administration? a. Client is Rh positive and the newborn is Rh negative. b. Client is Rh positive and the newborn is Rh positive. c. Client is Rh negative and the newborn is Rh positive. d. Client is Rh negative and the newborn is Rh negative.

c. Client is Rh negative and the newborn is Rh positive.

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? a. Rapid decline in human chorionic gonadotropin (hCG) levels b. Profuse, clear vaginal discharge c. Excessive uterine enlargement d. Irregular fetal heart rate

c. Excessive uterine enlargement

A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? a. Nausea and vomiting b. Urinary frequency c. Facial edema d. Leukorrhea

c. Facial edema

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make? a. In about 10 days b. In 6 to 8 days c. In 3 to 5 days d. Within 2 day

c. In 3 to 5 days

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first? a. Obtain a type and crossmatch. b. Administer oxytocin infusion. c. Initiate oxygen therapy by nonrebreather mask. d. Evaluate the firmness of the uterus

c. Initiate oxygen therapy by nonrebreather mask.

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? a. Place the client in knee-chest position. b. Cover the cord with a sterile, moist saline dressing. c. Insert a gloved hand into the vagina to relieve pressure on the cord. d. Prepare the client for an immediate birth.

c. Insert a gloved hand into the vagina to relieve pressure on the cord.

A nurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature? a. Biophysical profile score of 8 b. Nonstress test is reactive c. Lecithin/sphingomyelin (L/S) ratio of 2:1 d. Phosphatidylglycerol (PG) absent

c. Lecithin/sphingomyelin (L/S) ratio of 2:1

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? a. Viability of the fetus b. The biparietal diameter c. Location of the placenta d. Fetal lung maturity

c. Location of the placenta

A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? a. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. b. Immediately report the situation to the client's provider and prepare the client for induction of labor. c. Offer the client a snack of orange juice and crackers. d. Turn the client onto her left side.

c. Offer the client a snack of orange juice and crackers.

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications? a. Puerperal infection b. Thrombophlebitis c. Uterine atony d. Retained placental fragments

c. Uterine atony

A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make? a. "This might be related to your baby having 3 stools a day." b. "It is due to the newborn's loss of the influence of the maternal hormones." c. "You might want to offer water supplements between feedings." d. "The cause might be too short or infrequent feedings."

d. "The cause might be too short or infrequent feedings."

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? a. "You have to avoid sexual relations for 3 days." b. "If your sexual partner has no symptoms, no medication is needed." c." You need to return in 6 months for retesting." d. "This infection is treated with one dose of azithromycin."

d. "This infection is treated with one dose of azithromycin."

A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make? a. "This is a possible sign of pregnancy." b. "This is a probable sign of pregnancy." c. "This is a positive sign of pregnancy." d. "This is a presumptive sign of pregnancy."

d. "This is a presumptive sign of pregnancy."

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? a. "All medications are found in breast milk to some extent." b. "You have the option of not taking pain medication if you are concerned." c. You need to take pain medications so you are more comfortable." d. "We can time your pain medication so that you have an hour or two before the next feeding."

d. "We can time your pain medication so that you have an hour or two before the next feeding."

A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? a. A negative test b. A reactive test c. A positive test d. A nonreactive test

d. A nonreactive test

A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? a. An oral contraceptive b. A male condom c. A diaphragm with spermicide. d. An intrauterine device (IUD)

d. An intrauterine device (IUD)

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate? a. Radial artery b. Brachial artery c. Carotid artery d. Apex of the heart

d. Apex of the heart

A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? a. Caput succedaneum b. Pilonidal dimple c. Molding d. Cephalhematoma

d. Cephalhematoma

A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? a. Saturated perineal pad in 60 min b. Fundus at level of umbilicus c. Approximated edges of episiotomy d. Deep tendon reflexes 4+

d. Deep tendon reflexes 4+

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? a. 1+ pitting sacral edema b. Blood pressure 148/98 mm Hg c. 3+ protein in the urine d. Deep tendon reflexes of +1

d. Deep tendon reflexes of +1

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? a. Increase the frequency of fundal massage. b. Increase infusion rate of oxytocin. c. Notify the client's provider. d. Document the findings and continue to monitor the client.

d. Document the findings and continue to monitor the client.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? a. Witness the signature for informed consent for surgery. b. Prepare the abdominal and perineal areas c. Insert an indwelling urinary catheter. d. Initiate IV access.

d. Initiate IV access.

A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringer's with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification? a. Insert an indwelling urinary catheter. b. Obtain laboratory study of prothrombin and partial thromboplastin time. c. Administer oxygen by nonrebreather mask at 5 L/min. d. Methylergonovine 0.2 mg IM now.

d. Methylergonovine 0.2 mg IM now.

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? a. Place the newborn in a radiant warmer b. Initiate phototherapy. c. Monitor the newborn's blood pressure. d. Obtain blood glucose by heel stick.

d. Obtain blood glucose by heel stick.

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? a. Postpartum infection b. Hypertension c. Thromboembolic events d. Postpartum hemorrhage

d. Postpartum hemorrhage

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? a. Lightening b. Ballottement c. Chloasma d. Quickening

d. Quickening

A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? a. Bowel sounds b. Fetal heart rate (FHR) c. Temperature d. Respiratory rate

d. Respiratory rate

A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? a. Right lower b. Left lower c. Left upper d. Right upper

d. Right upper

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? a. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells. b. The client's blood contains the Rh factor and the newborn's does not, and antibodies that destroy red blood cells are formed in the fetus. c. The client has a history of receiving a transfusion with Rh-negative blood. d. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.

d. The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse? a. A pink rash appears on the newborn's trunk. b. The newborn's stools increase in number. c. The newborn's eyes are covered with a mask. d. The mother applies lotion to the newborn's skin.

d. The mother applies lotion to the newborn's skin.

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect? a. Enhanced production of fetal lung surfactant b. Fetal heart rate 100/min c. Maternal blood glucose 63 mg/dL d. Weakened uterine contractions

d. Weakened uterine contractions