OB "HESI" Practice Questions
C
A multigravida client at 35 weeks gestation is diagnosed with pregnancy induced hypertension. Which symptom should the nurse instruct the client to report immediately? A. backache B. constipation C. Blurred vision D. Increased urine output
B
During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? A. Discontinue all forms of contraception. B. Make sure to include adequate folic acid in the diet. C. Continue to take any medications that are taken regularly. D. Lose weight so more weight is gained during pregnancy.
C
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC)for a client at 32-weeks gestation who has severe preeclampsia with edema. As the PAC enters the right ventricle, what is the priority nursing assessment? A. Observe for maternal blood pressure changes. B. Assess fetal response to the procedure. C. Monitor for premature ventricular contractions. D. Note to any complaint of sudden chest pain.
D
The nurse is calculating the estimated date of confinement (EDC) using Ngele'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
CDF
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) A. Litmus paper B. Fetal scalp electrode C. A sterile glove D. An amnihook E. Sterile vaginal speculum F. Lubricant
D
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A. Double prenatal milk intake to improve vitamin D transfer to the infant. B. Increase caloric intake by approximately 500 calories/day. C. Avoid spicy foods to prevent infant colic. D. Avoid alcohol because it is excreted in breast milk.
B
What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? A. Maternal bradycardia B. Hard, board like abdomen C. Decrease in fundal height D. Decrease in abdominal pain
C
Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? A. Decrease in blood pressure. B. Increase in red blood cell production C. Decrease in pulse rate. D. Increase in heart sounds (S1, S2).
D
Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? A. Silver Nitrate B. Erythromycin C. Ceftriazone (Rocephin) D. Vitamin K (AquaMEPHYTON)
D
Which procedure evaluates the effect of fetal movement on fetal heart activity? A. Sonography B. Contraction test C. Biophysical profile D. Non-stress test (NST)
D
While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that DOES cross the suture lines. How should the nurse document this finding? A. Molding B. Hemangioma C. Cephalohematoma D. Caput succedaneum
BCF
he nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (select all that apply) A. Shallow with an irregular rhythm B. Chest breathing with nasal flaring C. Diaphragmatic with chest retraction D. Abdominal with synchronous chest movements E. Heart rate of 158 BPM F. Grunting heard with stethoscope
ACE
A primigravida at 12-weeks gestation who just move to United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? (Select all that apply.) A. Tetanus. B. Rubella. C. Hepatitis B. D. Chickenpox. E. Diphtheria.
C
The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occuring with the peak of each contraction. What action should the nurse implement? A. notify the HCP of fetal status B. Give oxygen at 10 L per nasal cannula C. Place the client in a side-lying position D. increase the flow rate of IV fluids
C
The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement? A. Institute contact precautions B. Obtain a rectal temperature C. Assess for abdominal distention D. Decrease the amount of the feeding
B
The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1200 mg during pregnancy. The client responds, "I don't like milk." What dietary adjustments should the nurse recommend? A. increase organ meats in the diet B. Eat more green, leafy vegetables C. add molasses and whole-grain breads to the diet D. choose more fresh citrus and other fruits daily
B
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? A. Molding B. Cephalohematoma C. Caput Succedaneum D. Bulging fontanel
D
A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first? A. Ventilate with an Ambu bag B. Perform nasal and airway suctioning C. Administer supplemental oxygen D. Gently rub the infant's feet or back
A
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? A. Fetal well being with labor progression B. signs of uteroplacental insufficiency C. Episodes of fetal head compression D. Occurrences of cord compression
D
A 36 week gestation client with pregnancy induced hypertension is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? A. BP of 100/60 mm Hg B. FHR of 120-125 BPM C. Contractions occurring every 30 mins D. Respiratory rate of 11 breaths/minute
D
A client at 28 weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? A. it is not necessary to keep such a close watch on weight B. try to exercise more because too much weight has been gained C. increase the calories in your diet to gain more weight per week D. The weight gain is acceptable for the number of weeks pregnant.
A
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? A. Periodic abdominal pain B. ankle edema in the afternoon C. backache with prolonged standing D.. shortness of breath when climbing stairs
A
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 the clients obstetrical history? A. 4-1-2-0-3. B. 3-1-1-1-3. C. 4-3-1-0-2. D. 3-0-3-0-3.
B
A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide? A. Advise to stop breastfeeding until the infection clears B. Inform the client to continue breastfeeding C. Begin all feedings with the infected breast D. Tell the client to pump then discard the milk from the affected breast
C
A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to give? A. "Don't be sad. You'll need to be strong to care for your healthy baby." B. "Do you want to go to the nursery and see your baby?" C. "I am sorry for your loss. Do you want to talk about it?" D. "It is always sad to lose a baby. Would you like me to call your minister?"
D
A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate slows at the onset of several contractions with subsequent return to baseline. What action should the nurse implement? A. Insert an internal monitor device B. Change the woman's position C. Discontinue the oxytocin infusion D. Document the finding in the client record
C
A client who is at 24 weeks gestation presents to the emergency department holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation? A. The woman and her partner are having a loud and hostile argument B. The woman avoids eye contact and hesitates when answering questions. C. Other parts of her body have injuries that are in different stages of healing D. Examination reveals a fracture to the right humerus and multiple bruises
C
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? A. Document the color of the lochia B. Observe maternal vital signs C. Assist the Client to the bathroom D. Notify the HCP
B
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 funud is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the fundus, the fundus remains difficult to locate and the rubra lochia remains heavy. What action should the nurse implement next? A. Recheck the client's vital signs B. Notify the healthcare provider C. insert an indwelling urinary catheter D. massage the fundus in 30 mins
B
A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement? A. Obtain a precipitous delivery tray B. Visualize the perineum for bulging C. Call the HCP for a STAT delivery D. Instruct the client's partner to stay for the delivery
B
A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? A. Inform the healthcare provider of the bleeding. B. Determine the firmness of the fundus. C. Give oxytocin (Pitocin) intravenously. D. Assess the vital signs for indicators of shock.
D
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? A. Bruising B. Oral intake C. Hemoglobin D. Bilirubin
D
A newborn infant who is 24 hours old is on a 4 hour feeding schedule of formula. To meet daily caloric need, how many ounces are recommended at each feeding? A. 2 oz B. 4 oz C. 1.5 oz D. 3.5 oz
A
A women 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
1. Wrap the infant's foot with a heel warmer for 5 minutes 2. Collect a spring-loaded automatic puncture device 3. Restrain the newborn's foot with your free hand 4. Cleanse puncture site on the lateral aspect of the heel
An infant born at 37 weeks gestation, weighing 4.1 kg is 2 hours old and appears large for gestational age, flushed, and tremulous. What procedure should the nurse follow to implement? (4 steps)
C
An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide to parents about this finding? A. Further assessment is indicated. B. An increased blood volume causes broken blood vessels. C. The pinpoint spots are benign and disappear within 48 hours. D. Petechiae occurs with forceps delivery.
B
An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement? A. Maintain NPO status. B. Monitor temperature. C. Apply skin lotion as prescribed. D. Change T-shirt every 3 hours.
A
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? A. Evaluate the newborn's color and respirations. B. Assess the functionality of the monitoring device. C. Provide tactile stimulation. D. Administer flow by 100% oxygen.
C
The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? A. The thick layer of subcutaneous fat is inadequate for insulation. B. Warmth promotes sleep so that the infant will grow quickly. C. A large body surface area favors heat loss to the environment. D. The kidneys and renal function are not fully developed.
A
The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? A. Give 10 liters of oxygen via face mask B. Prepare for an emergency C section C. Continue to monitor the FHR pattern D. Obtain an oral maternal temperature
B
What action should the nurse implement to prevent conductive heat loss in a newborn? A. Place the infant under a radiant warming system. B. Put a blanket on the scale when weighing the infant C. Dry the newborn with a warmed blanket D. Position the crib away from the windows
D
What information should the nurse include about perineal self-care for a client who is 24 hours post delivery? A. Use cool water to decrease swelling of the perineum B. Perineal care should be done at least twice a day C. Reapply ice packs to perineum after each voiding D. Spray with warm water from front to back using a squeeze bottle
C
Which action is most important for the nurse to implement for a client at 36 weeks gestation with vaginal bleeding? A. Monitor uterine contractions B. Apply disposable pads under the client C. Determine fetal heart rate and maternal vital signs D. Obtain blood samples for hemoglobin and hematocrit levels
D
Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)? A. Women whose blood group is AB Rh-Positive B. Newborn with rising serum bilirubin level C. Newborn whose Coombs test is negative D. Primigravida mother who is Rh-negative
A
Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routinestanding order for methylergonovine maleate (Methergine)? A. Pregnancy induced hypertension B. Placenta previa C. Gestational Diabetes D. Postpartum Hemorrhage
B
Which nursing intervention is the priority during the fourth stage of labor? A. Promote bonding B. Assess for hemorrhage C. Provide comfort measures D. Monitor uterine contractions
D
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? A. Clean the perineal area. B. Offer the client a bed pan. C. Escort the client to the bathroom. D. Perform a nitrazine test.
A
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
D
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? 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."
B
A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and has not been sleeping well. The clients physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results? A. Being under too much stress at work. B. Using an anticonvulsant for epilepsy. C. Having an irregular menstrual cycle. D. Taking the pregnancy test too early.
A
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 B. 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 3 to 3 minutes, lasting 70 to 80 seconds each
B
A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? A. Report the fetus's behavior to the healthcare provider. B. The fetus can respond to sound by 24-weeks gestation. C. This is a demonstration of the fetus's acoustical reflex. D. It is a coincidence the fetus responded at the same time.
C
A client at 28-weeks 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? A. Contraction stress test. B. Lecithin-sphingomyelin ratio. C. Abdominal ultrasound. D. Internal fetal monitoring.
A
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? A. Changes in fetal heart rate patterns. B. Alteration and maternal blood pressure. C. Complains of abdominal pain. D. Vaginal bleeding.
D
A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? A. Maternal serum alpha-fetoprotein. B. Amniocentesis. C. Chorionic villus sampling. D. Ultrasonography.
C
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
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? A. The interaction between the mother's voice and the fetus's response ensures bonding. B. The healthcare provider should address her concerns about her baby's hearing function. C. The fetus in utero is capable of hearing and does respond to the mother's voice. D. Many women imagine what their baby is like by interpreting fetal movements.
B
A client at 8-weeks gestation ask the nurse about the risk for congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? A. They usually occur in the first trimester pregnancy. B. The heart develops in the third to fifth weeks after conception. C. It depends on what the causative factors are for a CHD. D. We don't really know what or when CHDs occur.
A
A client delivers her first infant and asks the nurse if her skin changes from pregnancy are permanent. Which change should the nurse tell the client that will remain after pregnancy? A. Striae gravidarum. B. Chloasma. C. Vascular spiders. D. Pruritus.
C
A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mmHg at the peak of the contraction and the resting tone is 6 to 10 mmHg. Based on this information, what action should the nurse implement? A. Bring the delivery table to the room. B. Prepare to administer an oxytocic. C. Document the findings in the client record. D. Notify the client's healthcare provider.
D
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? A. Only one drink with the evening meal is not harmful to the fetus. B. Wine can be consumed several times a week after the first trimester. C. During second trimester beer can be consumed without harm to the fetus. D. Abstinence is strongly recommended throughout the pregnancy.
D
A client in labor receives an epidural block. What intervention should the nurse implement first? A. Assess contractions. B. Encourage oral fluids. C. Obtain a radial pulse. D. Monitor blood pressure.
C
A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement? A. Notify the healthcare provider. B. Administer oxygen via nasal cannula. C. Help her breathe into a paper bag. D. Tell the client to slow her breathing.
D
A client is experiencing "back" labor and complains of intense pain in the lower lumbar-sacral area. What action should the nurse implement? A. Assist the client in guided imagery. B. Encourage pant-blow breathing techniques. C. Perform effleurage on the abdomen. D. Apply counter pressure against the sacrum.
D
A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? A. The client may have a bladder or kidney infection. B. Bladder capacity increases during pregnancy. C. During pregnancy a woman is especially sensitive to body functions. D. The growing uterus is putting pressure on the bladder.
B
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
A
A client who is breastfeeding engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement? A. Continue breastfeeding every 2 hours. B. Skip a feeding to rest the breasts. C. Avoid pumping her breasts. D. Decreased fluid intake for at least 24 hours.
D
A client who is stable has family members present when the nurse enters the birthing suite to access the mother and newborn. What action should the nurse implement at this time? A. Do a brief assessment for only the infant while the family members are present. B. Reschedule the visit so that the mother and infant can be assessed privately. C. Ask to meet with the client and infant without family members present. D. Observe interactions of family members with the newborn and each other.
C
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
A
A client with asthma who is 8-hours post-delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer? A. Oxytocin (Pitocin). B. Ibuprofen (Motrin). C. Fentanyl (Sublimaze). D. Hemabate (Carboprost).
D
A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide? A. Natural childbirth without analgesia is used to manage pain during labor. B. And obstetrician should also follow the client during pregnancy. C. Birth in the home setting is the preference for using a midwife for delivery. D. The pregnancy should progress normally and be considered low risk.
B
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 wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? A. "Your current dose of insulin should be maintained throughout your pregnancy." B. "Maintain blood sugar levels in a constant range within normal limits during pregnancy." C. "The course and outcome of your pregnancy is not an achievable goal with diabetes." D. "Expect an increase in insulin dosages by 5 units/week during the first trimester."
A
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to exhibit? A. Choking, coughing, and cyanosis B. Projectile vomiting and cyanosis C. Apneic spells and grunting D. Scaphoid abdomen and anorexia
BCDE
A gravid client develops maternal hypotension following regional anesthesia. What intervention(s) should the nurse implement? (Select all that apply.) A. Perform a vaginal examination. B. Increase IV fluids. C. Administer oxygen. D. Monitor fetal status. E. Place the client in a lateral position. F. Assist client to a sitting position.
C
A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 lbs., 6 oz.), what is the priority nursing action? A. Assess newborn reflexes for signs of neurological impairment. B. Leave the infant in the room with the mother to foster attachment. C. Obtain serum glucose levels frequently while observing for signs of hypoglycemia. D. Perform a gestational age assessment to determine if the infant is large-for-gestational-age.
D
A multigravida client at 40+ weeks gestation is induced by using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action? A. Oxytocin is infusing at a rate of 30 mU/min. B. Labor has progressed at 1 cm/hr dilation. C. Contractions are lasting 60 to 80 seconds. D. Intensity of contractions is 130 mmHg.
A
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 the fetus? A. Biophysical profile (BPP) B. Ultrasound for fetal anomalies C. Maternal serum alpha-fetoprotein (AF) screening D. Percutaneous umbilical blood sampling (PUBS)
D
A multiparous client has been in labor for 8 hours when her membranes ruptured. What action should the nurse implement first? A. Prepare the client for imminent birth. B. Document the characteristics of the fluid. C. Notify the client's primary healthcare provider. D. Assess the fetal heart rate and pattern.
C
A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tachycardia, and a cutaneous rash. What nursing intervention should be implemented first? A. Inform the healthcare provider. B. Monitor vital signs electronically. C. Stop the infusion. D. Administer calcium gluconate.
C
A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement? A. Suggest the client to come to the hospital for labor evaluation. B. Tell the woman to stay home until her membranes rupture. C. Ask the client to describe why she thinks she is in labor. D. Emphasize that food and fluid intake should stop.
A
A nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting the clients pregnancy outcome? A. Degree of glycemic control during pregnancy. B. Mother's age. C. Amount of insulin required prenatally. D. Number of years since diabetes was diagnosed.
A
A pregnany 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 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
A primigravida at 12-weeks gestation tells the nurse that she does not like dairy products. Which food should the nurse recommend to increase the clients calcium intake? A. Canned sardines. B. Spaghetti with meat sauce. C. Canned clams. D. Fresh apricots.
D
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 that the umbilical cord protruding from the vagina. What action should the nurse implement first? A. Give the healthcare provider a status report. B. Administer 10 L of oxygen via face mask. C. Wrap the cord with gauze soaked in saline. D. Place the client in the knee-chest position.
D
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
A
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
B
A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give? A. Wear a loose-fitting bra. B. Apply ice to the breasts. C. Run warm water on the breasts during a shower. D. Express small amounts of milk from the breasts.
A
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 appropriate? A. "A home pregnancy test can be used right after your 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."
C
A woman, whose pregnancy is confirm, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? A. Produces nutrients for fetal nutrition. B. Forms a protective, impenetrable barrier. C. Secretes both estrogen and progesterone. D. Excretes prolactin and insulin.
B
An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. What is the priority nursing intervention? A. Evaluate the blood pH. B. Begin humidified oxygen via hood. C. Place the infant under a radiant warmer. D. Stimulate infant crying.
D
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
A
At 10 weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villavilla sampling (CVS) procedure. What assessment finding requires immediate intervention? A. Uterine cramping. B. Intermittent nausea. C. Systolic blood pressure < 100 mmHg. D. Abdominal tenderness.
B
During an assessment of a multiparous client who delivered an 8-lb 7-oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next? A. Encourage the client to avoid. B. Perform fundal massage. C. Notify the healthcare provider. D. Assess blood pressure.
A
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
D
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
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
A
The father of a newborn tells the nurse, "My son just died." How should the nurse respond A. "I am sorry for your loss." B. "I understand how you feel." C. "There is an angel in heaven." D. "You can have other children."
A
The nurse administers meperidine (Demerol) 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. What medication should the nurse anticipate administering to the infant? A. Naloxone (Narcan). B. Nalbuphine (Nubain). C. Promethazine (Phenergan). D. Fentanyl (Sublimaze).
D
The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What action should be implemented? A. Elevate feet 15°. B. Place socks on infant. C. Wrap feet loosely in prewarmed blanket. D. Report findings to the healthcare provider.
C
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 of 48 breaths/minute. Based on these findings, which action should the nurse take first? A. Notify the pediatrician of the infant's vital signs. B. Encourage the infant to take the breast or sugar water. C. Assess the infant's blood glucose level. D. Check the infant's arterial blood gases.
A
The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption during pregnancy. Which findings should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)? A. Flat nasal bridge. B. An extra digit on the left hand. C. Asymmetrical bulging fontanels. D. Corneal clouding.
ABE
The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) A. Grunting heard with a stethoscope. B. Diaphragmatic with chest retraction. C. Abdominal with synchronous chest movements. D. Shallow with an irregular rhythm. E. Chest breathing with nasal flaring. F. Rate of 58 breaths per minute.
C
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
Which nonpharmacological interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? A. Commercial warm packs. B. Tactile stimulation. C. Oral sucrose and nonnutritive sucking. D. Skin-to-skin contact with parent.
A
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? A. The fetal heart rate is 180 bpm without variability. B. Amniotic membranes rupture. C. The client needs to void. D. Uterine contractions occur every 8 to 10 minutes.
B
The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provide examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? A. Walking. B. Squatting. C. Kneeling. D. Lithotomy.
C
The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? A. Molar reoccurrences are higher if conception occurs within 1 year after initial mutation. B. Pregnancy within 1 year decreases the chances of a future successful pregnancy. C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. D. Oral contraceptives prevent a reoccurrence of a molar pregnancy.
ABC
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
D
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 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
A
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 occurance
C
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? A. Arrange for home uterine monitoring. B. Plan for a possible cesarean birth. C. Report uterine cramping or low backache. D. Make arrangements for care at home.
C
The nurse is teaching a primigravida at 10 weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care A. the risk for neonatal cerebral palsy increases with folic acid deficiencies during pregnancy B. folic acid can significantly reduce the incidence of mental retardation C. adequate folic acid during embryogenesis reduces the incidence of neural tube defects D. the incidence of congenital heart defects is related to folic acid intake deficiencies
A
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
D
The nurse notes an irregular bluish hue on the sacral area of a 1-day old Hispanic infant. How should the nurse document this finding? A. Harlequin sign. B. Acrocyanosis. C. Erythema toxicum. D. Mongolian spots
A
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? A. Observe the mother for other attachment behaviors. B. Ask the mother why she won't look at the infant. C. Examine the newborn's eyes for the ability to focus. D. Recognize this as a common reaction in new mothers.
A
The nurse on the postpartum unit receives a report for 4 clients during change of shift. Which client should the nurse assessed for risk of postpartum hemorrhage (PPH) A. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. B. A primiparous client who had an emergency cesarean birth due to fetal distress. C. A multigravida who delivered an 8 pound 2 ounce infant after an 8-hour labor. D. A primigravida who had a spontaneous birth of preterm twins.
B
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make? A. Inform the mother that the injection was prescribed by the healthcare provider. B. Explore the mother's concern about the infant receiving an injection of vitamin K. C. Remind the mother that all babies receive the shot and it is relatively painless. D. Explain that vitamin K is required by state law and compliance is mandatory.
D
Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? A. Brighten the lighting so the mother can view the infant. B. Provide positive reinforcement for maternal care of infant. C. Complete a newborn assessment as quickly as possible. D. Encourage early initiation of breast or formula feeding.
D
What action should the nurse implement when caring for a newborn receiving phototherapy? A. Reposition every 6 hours. B. Apply an oil-based lotion to the skin. C. Limit the intake of formula. D. Place an eyeshield over the eyes.
B
What action should the nurse implement with the family when an infant is born with anencephaly? A. Ensure that measures to facilitate the attachment process are offered. B. Prepare the family to explore ways to cope with the imminent death of the infant. C. Provide emotional support to facilitate the consideration of fetal organ donation. D. Inform the family about multiple corrective surgical procedures that will be needed.
D
What nursing action should be implemented when intermittently gavage-feeding a preterm infant? A. Insert feeding tube through nares. B. Apply steady pressure to syringe. C. Avoid letting infant suck on tube. D. Allow formula to flow by gravity.
C
What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal? A. Play soft music and talk to soothe the infant. B. Feed every 4 to 6 hours to allow extra rest. C. Swaddle the infant snuggly and hold tightly. D. Administer chloral hydrate for sedation.
A
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? A. Count the heart rate for at least one full minute. B. Quiet the infant before counting the heart rate. C. Palpate the umbilical cord. D. Listen at the apex of the heart.
C
When assessing the integument of a 24 hour old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next? A. Notify the HCP B. move the newborn to an isolation nursery C. document the finding as erythema toxicum D. obtain a culture form one of the vessels
A
When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth? A. Medical back up should be available quickly in case of complications. B. The women's extended family should be allowed to attend the home birth. C. Only the woman and her midwife should be present during the delivery. D. The woman should live no more than 15 minutes from the hospital.
D
Which action should the nurse implement when caring for a newborn immediately after birth? A. Administer eye prophylaxis and vitamin K. B. Foster parent-newborn attachment. C. Dry the newborn and wrapping in a blanket. D. Keep the newborn's airway clear.
D
Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? A. Request help with ambulation and perineal care. B. Be very excited and talkative about the birth experience. C. Sleep most of the time when the baby is not present. D. Exhibit interest in learning more about infant care.
C
Which client finding should the nurse document as a positive sign of pregnancy? A. A urine sample with a positive pregnancy test. B. Presence of Braxton Hicks contractions. C. Fetal heart tones (FHT) heard with a doppler. D. Last menstrual cycle occurred 2 months ago.
B
Which finding for a client in labor at 41-weeks gestation requires additional assessment by the nurse? A. Score of eight on the biophysical profile. B. One fetal movement noted in an hour .C. Cervix dilated 2 cm and 50% effaced. D. Fetal heart rate of 116 bpm.
C
Which finding indicates to the nurse that a 4-day-old infant is receiving adequate breast milk? A. Gains 1 to 2 ounces per week. B. Defecates at least once per 24 hours. C. Saturates 6 to 8 diapers per day. D. Rests for 6 hours between feedings.
D
Which gastrointestinal findings should the nurse be concerned about any client at 28-weeks gestation? A. Decrease peristalsis. B. Ptyalism. C. Pyrosis. D. Pica.
B
Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy? A. "Gestational diabetes is prevented by eating protein." B. "Protein helps the fetus grow while I am pregnant." C. "My baby will develop strong teeth after he is born." D. "Anemia is averted by consuming enough protein."