OB Maternal Practice question

The nurse counsels clients in the prenatal clinic. The nurse is most concerned of a client makes which statement?

"I clean the cat's litter box daily."

The nurse observes 4 newborns. What are the most common characteristics in a preterm infant?

Red, wrinkled skin, languo and hypnotic muscles.

During auscultation of the fetal heart rate (FHR) during labor, the nurse assesses a rate of 50 beats/minute. Which actions does the nurse take first?

Turns the client on the left side, administers oxygen by nasal cannula, and verifies IV access.

a new parent asks the nurse if it is safe to drink wine while breastfeeding. which is the best response by the nurse?

alcohol has a depressant effect on the baby

the nurse instructs a group of expectant parents about the advantages of breastfeeding. the nurse intervenes if an expectant parent makes which statement?

my baby will grow faster and sleep more with breastmilk

The nurse cares for a patient after a breast biopsy. After the procedure, it is MOST important for the nurse to take which of the following actions? 1. apply ice to area 2. preposition the patient for comfort 3. carefully transport the specimen to the lab 4. observe for bleeding

observe for bleeding

A woman has a simple vulvectomy. Postop, the nurse instructs her to take a sitz bath and keep the area clean and dry. The nurse understands the reason for these measures is 1. to debride the area and prevent wound infection 2. to increase circulation to the area and promote wound healing 3. to prevent selling of the surround lymph nodes 4. to cleans the area and diminish the possibility of postop bleeding.

to increase circulation to the area and promote wound healing

The nurse instructs a client in the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client selects which of the following food from a menu? 1. two eggs and 8oz milk 2. 2oz steak and 10oz beer 3. lettuce and tomato salad and 12oz OJ 4. bag of chips and 16oz soda

two eggs and 8oz milk

the nurse provides care for a client 24hr after delivery, and the client states "I have been urinating so much" which response by the nurse is best?

your body is getting rid of the increased fluid

The nurse teaches a class about gonorrhea. Which client statement indicates the teaching is successful?

"I've heard that having gonorrhea can make you unable to have children."

The nurse instructs a group of expectant clients on how to recognize the onset of labor. The nurse knows further teaching is necessary is a client makes which statement?

"My baby will move more when I go into labor."

The nurse provides care for a primigravida client who is 34 weeks pregnant. Which client is of most concern to the nurse?

"This is not a good time for me to have a baby."

A infant shows a tendency to bleed two days after birth. The nurse knows this is most likely caused by what?

Absence of intestinal bacteria and Vit. K.

A nurse teaches the client about birth control methods. How long should the nurse advise the client to leave a diaphragm in place after intercourse? 1. 6hrs 2. 8hrs 3. 10hrs 4. 12hrs

6hrs

The nurse monitors a client at 30 weeks gestation, and the client reports having periodic heartburn. It is most important for the nurse to make which recommendation?

Eat frequent small meals.

The nurse explains to a client that which period of pregnancy is the most critical time for fetal development?

The first three months.

The home health care nurse makes a visit to the pregnant clinic diagnosed with type 1 diabetes mellitus. The client states, "I have been nauseated for 24 hours." It is most important for the nurse to ask which question?

"Have you taken your insulin today?"

The nurse instructs a client in the 2nd trimester at the prenatal clinic about nutrition during pregnancy. The nurse determines the teaching effective if the client makes which statement?

"I will add one nutrient dense 300 calorie snack per day."

The nurse instructs a client in the second trimester at the prenatal clinic about nutrition during pregnancy. The nurse determines teaching is successful if the client makes which statement?

"I will add one nutrient dense 300 calorie snack per day."

The nurse provides instruction to a new parent on how to care for the newborn's umbilical cord. The nurse determines teaching is effective is the parent makes which statement?

"I will clean the cord and the skin around it with water." "I will allow the cord to fall off on its own."

A client comes to the prenatal clinic for her first visit. The nursing history reveals that the client's last menstrual period was five months ago, and the client is sure she is pregnant because she has been feeling the baby move. Whcih of the following responses by the nurse is BEST? 1. "Since you have felt the fetal movement, I am sure that you are pregnant." 2. "Lie down so that I can listen for fetal heart tones with the Doppler." 3. "We'll collect a urine specimen for testing to confirm that you are pregnant." 4. "Have you noticed feeling more fatigued lately?"

"Lie down so that I can listen for fetal heart tones with the Doppler."

The nurse assesses a client in the family planning clinic. Which client statement suggests the client has been exposed to gonorrhea?

"My partner has the drip."

The nurse provides postnatal care for a client diagnosed with gestational diabetes who delivered by cesarean delivery at 37 weeks gestation about 3 hours ago. The infant's Apgar scores were 6 and 8 and birth weight 10lbs (4535.9g). The client tells the nurse, "I can't believe how big my baby is, and I even delivered early." Which response by the nurse is best?

"The baby's large size is due to the amount of glucose received in utero."

The nurse in the emergency department provides care for a client at 29 weeks gestation reporting vaginal bleeding. The nurse identifies which client statement as indicative of a placenta previa?

"The bleeding scares me, other than that I feel fine."

A client admitted to the hospital and is scheduled to have a modified radical mastectomy. The client asks the nurse about the surgical procedure. Which explanation does the nurse give?

"The breast, axillary nodes, and superior apical nodes are removed, but the muscles are preserved."

The nurse instructs a client about dietary adjustments that may be necessary during breastfeeding. Which client statement indicates to the nurse that the client understands the instructions?

"There are no specific restrictions on food or drinks."

The nurse prepares a client for an abdominal hysterectomy. The client asks why she needs a foley cath. What statement by the nurse is most appropriate?

"This will allow you to heal by keeping you bladder decompressed"

The nurse prepares the client for a total abd. hysterectomy with bilateral salpingo-oophorectomy due to uterine cancer. The patient is talking continuously and has a hard time maintaining eye contact. What is the best response by the nurse?

"What are your concerns about the surgery?"

The nurse prepares the client for a total abdominal hysterectomy with bilateral salpino-oophorectomy due to uterine cancer. The nurse observes that the client is talking continuously and has difficulty maintain eye contact. Which response by the nurse is BEST? 1. What are your concerns about the surgery 2. Why isn't your husband here with you 3. Are you afraid that you are going to die? 4. You seem to be coping with the surgery very well

"What are your concerns about the surgery?"

The horse makes a home visit to a postpartum client and the two week old infant. The client is breastfeeding and tells the nurse the baby nurses 8-9 times per day, has regained all of the lost birth weight, has 6-8 wet diapers per day, and usually has one bowel movement per day. Which response by the nurse is best?

"Your baby is doing very well. Keep up the good work!"

A couple comes to the fertility clinic after trying for several years to have children. The woman has a regular 28-day menstrual cycle. The nurse explains to her she is MOST likely to become pregnant 1. 10-14 days after the onset of her menstrual period 2. 16 days before the onset of her menstrual period 3. the last 8 days of her cycle 4. 18-20 days after the first day of her menstrual cycle

10-14 days after the onset of her menstrual period

A client is in active labor and as labor progresses the client becomes irritable and reports feeling increasingly uncomfy. The client is dilated to 8cm. What is the first action made by the nurse?

Coaches the client in proper breathing and relaxation techniques .

The nurse instructs a new mother about how to care for her newborn's umbilical cord. The nurse determines teaching is effective if the client makes which statement? 1. I am going to bathe my baby in the new tub tomorrow 2. I will keep the cord covered with the diaper 3. I will clean the cord and skin around it with water 4. I will contact my physician if there is a white or yellow discharge from the cord. 5. I will pull the cord off when it becomes loose 6. I will apply petroleum jelly to the base of the cord

3. I will clean the cord and skin around it with water 4. I will contact my physician if there is a white or yellow discharge from the cord.

An infant is born by vaginal delivery. At birth, the infant is crying and respiration and pulse rate are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At five minutes after birth, the extremities are pink. The nurse should record the baby's one-minute and five-minute Apgar scores a which of the following? 1. 8 and 9 respectively 2. 8 and 10 respectively 3. 9 and 10 respectively 4. 9 and 7 respectively

9 and 10 respectively

The nurse provides care for a 4lb 10oz (2100.13g) infant delivered at 32 weeks gestation. The nurse notes the infant has mottling of the skin, and lab values indicate metabolic and respiratory acidosis. The nurse recognizes these findings are signs of which problem?

Cold stress

Nurse instructs a group of expectant clients how to recognize onset of labor. Nurse knows further teaching is necessary if a client makes which statement? A. my baby will move more when I go into labor B. I may feel a gush of water at beginning of labor C. I may have blood-tinged vaginal discharge D. I will have regular uterine contractions that become stronger

A Fetal movement remains unchanged during true labor

A client at 29 weeks gestation comes to emergency department reporting vaginal bleeding. Nurse identifies which client statement as indicative of a placenta previa? A. bleeding scares me, other than that I feel fine B. I've been more nauseated during past few weeks C. bleeding started after I carried in four bags of groceries D. I've been having severe abdominal cramps

A Painless vaginal bleeding indicates placenta previa; placenta previa is a placenta that is abnormally implanted in lower uterine segment; client will be treated w/bedrest, no vaginal exams, IVs to restore blood volume, monitor fetal well-being

A client in active labor shouts, "I HAVE TO PUSH!" The nurse determines the client is 8cm dilated. What is the first action the nurse should take?

Encourage the client to pant with pursed lips.

The nurse notes that a 2 day old infant shows a tendency to bleed. The nurse understands this is MOST likely caused by which of the following? 1. Hemophilia 2. Absence of intestinal bacteria needed for the production of Vitamin K 3. Immature liver that is unable to synthesize clotting factors 4. Excessive breakdown of RBC's coupled with a delayed production of new ones.

Absence of intestinal bacteria needed for the production of Vitamin K newborns don't produce Vitamin K until the 8th day.

A woman asks the nurse if she can safely drink wine while nursing her baby. Which of the following is the BEST response by the nurse? 1. The wine you drink will not be present in the breast milk 2. A moderate amount of wine will help you relax 3. Alcohol has a CNS depressant effect on the baby 4. Drink beer rather than wine while you are breastfeeding

Alcohol has a CNS depressant effect on the baby

A woman is in active labor when her membranes rupture. She expresses a concern to the nurse she is afraid of having a 'dry labor'. Which of the following responses by the nurse is MOST appropriate? 1. Amniotic fluid does not function as lubrication for the labor process 2. The sac actually impedes the progress of labor and if it had not ruptured, the doctor would have to do it artificially. 3. Labor is only slightly more difficult with early rupture of the amniotic sac. 4. Now that there is limited amniotic fluid, you may have to have a cesarean section.

Amniotic fluid does not function as lubrication for the labor process

The nurse provides care for a client six hours after a vaginal delivery and assists the client to perform perineal care. Fifteen minutes later the nurse notes the perineal pad is soaked and there is blood underneath the client's buttocks. Which action does the nurse take first!

Assess the fundus

Nurse cares for a client in labor. Nurse notes client appears more peaceful and there is an increase in bloody show. Nurse identifies client is in which stage of labor? A. first stage B. second stage C. third stage D. fourth stage

B A short period of peace and an increase in bloody show occur immediately before baby is born at beginning of second stage of labor

Nurse explains to a client at 6 weeks gestation which of following periods of pregnancy is most critical time for fetal development? A. first two weeks B. first three months C. fourth through sixth month D. last month

B It is during first trimester, or first three months, that all major systems of fetus are developed; exposure of mother to noxious environmental agents can interfere w/proper development of fetus

Nurse starts labor induction w/oxytocin. Nurse stops infusion if which activity occurs? A. contractions are at 3 min intervals and last more than 60 seconds B. contractions are at 2 min intervals and last more than 90 seconds C. contractions are at 2.5 min intervals and last more than 90 seconds D. contractions are at 2 min intervals and last more than 60 seconds

B It's extremely important for nurse to continually assess contractions for client receiving an oxytocin drip; if contractions occur too frequently (at intervals of less than 2 min) or last too long (more than 90 seconds), they may endanger client and fetus; nurse should stop infusion and notify health care provider

Nurse observes interactions of mother and infant born three hours ago. Mother had gestational diabetes and delivered by cesarean delivery at 37 weeks gestation. Infant's Apgar scores were 6 and 8, birth weight 10 lbs (4535.9 g), HR 122 bpm, and respirations 35/min. Mother tells nurse, "I don't know why my health care provider was worried about my baby. My baby looks so big and healthy!" Which response by nurse is *best*? A. you need to ask your parents if you were also a large baby B. baby's large size is due to amount of glucose received in utero C. it is great that you are starting to rely on your maternal instinct already! D. you must be relieved that baby looks so healthy

B Macrosomia of insulin-dependent diabetic mothers is caused by poor maternal glucose control; infant has round face, chubby body, and a flushed complexion; infant at risk for hypoglycemia, hypocalcemia, and hyperbilirubinemia

Nurse leads a prenatal class about breastfeeding. Which of following statements, if made by nurse, accurately describes nutritional needs of a woman during lactation as compared to nutritional needs of pregnancy? A. more calories, protein, and calcium are needed during lactation than are needed during pregnancy B. more calories but same amount of protein, calcium, and fluids are needed C. fewer calories and less protein are needed during lactation than are needed during pregnancy, but more calcium is needed D. only more fat is needed during lactation than is needed during pregnancy

B More calories but same amount of protein and calcium are needed during lactation

Nurse understands health care provider is *most* likely to prescribe which medication for a client diagnosed w/gonorrhea? A. penicillin vaginal suppositories B. penicillin G benzathine IM in divided doses once a week C. ceftriaxone IM plus doxycycline for seven days by mouth D. ampicillin by mouth

C CDC recommended tx for gonorrhea; instruct client how to prevent transmission of STIs

Client is pregnant for third time. Client has one living child and has had one abortion. Which description does nurse record? A. gravida III, para II B. gravida II, para II C. gravida III, para I D. gravida II, para III

C Client is experiencing third pregnancy (gravida III), but in only one pregnancy did fetus reach age of viability (para I)

Home care nurse makes a home visit to a client diagnosed w/type 1 diabetes at 29 weeks gestation. Client states that she has been nauseated for 24 hours. It is MOST important for nurse to ask which question? A. have you vomited? B. what was your last blood glucose reading? C. have you taken your insulin today? D. when did you last eat?

C Important that client take prescribed insulin even though may not be eating regularly because insulin needs are increased during illness

Nurse performs a home visit on a new mother and her two week old son. Mother is breastfeeding. She tells nurse that baby nurses 8-9 times per day, has regained all of lost birth weight, has 6-8 wet diapers per day, and usually has one bowel movement per day. Which of following responses by nurse is BEST? A. your baby should be gaining more weight B. I'm concerned about number of daily bowel movements C. your baby is doing great D. decrease number of times you feed baby each day

C Infant has regained initial weight loss; well-hydrated infants should have 6-8 diapers per day; record results in client record

Nurse cares for newborn delivered by a client addicted to narcotics. At which time is nurse *most* likely to observe symptoms of narcotic w/drawal? A. immediately at birth B. w/in 12 hours after birth C. w/in 24-72 hours after birth D. after 2 weeks

C Infant will be jittery and hyperactive, high-pitched cry; diaphoresis, tachypnea

Nurse assesses client in family planning clinic. Which client statement suggests client has been exposed to gonorrhea? A. my partner has a sore on penis B. I have a cheesy, white vaginal discharge C. my partner has drip D. I have a rash

C Men report urethritis and epididymitis; women are frequently asymptomatic; diagnosed by culture of discharge from cervix or urethra; tx is ceftriaxone and doxycycline

Nurse cares for client six hours after a vaginal delivery and assists client to perform perineal care. Fifteen minutes later nurse notes perineal pad is soaked and there is blood underneath client's buttocks. Which action does nurse take first? A. obtains client's BP B. notifies health care provider C. assesses fundus D. administers oxygen at 8-10 L/min

C Need to assess for uterine atony; start IV w/lactated Ringer's or normal saline if no IV; may need to give oxytocin

Nurse cares for client immediately after delivery and administers oxytocin. Nurse knows this medication is used for which purpose? A. relieve discomfort and pain B. anesthetize area of episiotomy C. stimulate firm contraction of uterus D. prevent breast engorgement

C Stimulates smooth muscles of uterus to contract; used to treat and prevent postpartum hemorrhage

Nurse instructs new parent how to care for newborn's umbilical cord. Nurse determines teaching is effective if client makes which statements? (select all that apply) A. I am going to bathe my baby in new tub tomorrow B. I will keep cord covered w/diaper C. I will clean cord and skin around it w/water D. I will contact my health care provider if there is a white or yellow discharge from cord E. I will pull cord off when it becomes loose F. I will apply petroleum jelly to base of cord

C and D Clean cord and surrounding area w/water or solution preferred by health care provider; report redness, drainage, or foul odor

The nurse provides care for a client receiving an oxytocin infusion to induce labor. The nurse stops the infusion if which occurs?

Contractions are at 2 minute intervals and last 90 to 120 seconds.

Nurse prepares a client for a gynecological examination. Nurse explains that physician will perform a pelvic examination and will obtain a Pap smear. Nurse explains Pap smear is: A. taken from exudates of vagina and cervix B. a sample of tissue used to locate a lesion C. an x-ray film taken from various angles D. a specimen of cells used to identify abnormal cells

D A Pap smear is a routine procedure to identify infectious processes, processes, presence of abnormal cells, and hormonal changes

Nurse cares for a client 12 hours after delivery of a 3,200 g newborn. Nurse notes fundus is approximately 1 cm above umbilicus. It is *most* important for nurse to take which action? A. encourage client to void B. assess for amount and character of lochia C. bring infant to client for breastfeeding D. document results in client's record

D Fundus is about at or 1 cm above umbilicus w/in 12 hours of birth. After this time, it should descend 1-2 cm each day

Nurse places drops in a newborn's eyes. Nurse explains to parent drops are used for which purpose? A. help baby see well B. remove blood and mucus from baby's eyes C. prevent neonatal conjunctivitis D. protect against infections that could lead to blindness

D Legal requirement in US; instill erythromycin or tetracycline

A client comes to hospital in labor. Membranes rupture at 0410. Which action does nurse take *first*? A. identifies amniotic fluid by testing it for alkalinity B. contacts health care provider and prepares for immediate delivery C. notes time of rupture of membranes D. observes for a prolapsed cord or meconium-stained fluid

D Signs of possible life-threatening complications to fetus that may require emergency delivery

The nurse assesses the fundus of a client 12 hours after delivery of a 7lb 2oz (3,240g) newborn. Which action should the nurse take if the fundus is noted to be approximately 1cm above the the umbilicus?

Document the results in the client's record.

The nurse provides care for a client in labor. This client's labor progresses with regular contractions until the cervix is 9cm dilated. The nurse identifies the client is in which stage of labor?

First stage.

While in active labor, the multigravid client received magnesium sulfate for treatment of gestational hypertension. Due to the effects of magnesium sulfate, which newborn symptom is expected?

Hypotonia

The nurse provides care for a client in the second stage of labor. The nurse notes the client is tiring after a few hours of pushing, and is no longer making progress. Which does the nurse anticipates the health care provider will ask for?

Forceps and vacuum.

The client is pregnant for the third time. The client has one living child and has had one abortion. Which description does the nurse record?

Gravida III, para I.

The home care nurse makes a home visit to a client diagnosed with type 1 diabetes at 29 weeks gestation. The client states that she has been nauseated for 24 hours. It is MOST important for the nurse to ask which question? 1. Have you vomited 2. What was your last blood glucose reading 3. Have you taken your insulin today 4. When did you last eat

Have you taken your insulin today

The nurse counsels clients in the prenatal clinic. The nurse is MOST concerned if the client makes which statement? 1. I take my dog for a 30 min walk every other day 2. I plan to take an 8 hour car trip next week 3. I drink 3 liters of liquids every day 4. I clean the cat's litter box daily

I clean the cat's litter box daily (Toxoplasmosis [protozoan infection] caused by eating infected undercooked meat or after handling infected kitty litter)

The nurse teaches prenatal classes in the antepartum clinic. Which of the following statements, if made by a client to the nurse, indicates that further teaching is necessary? 1. I may feel hot flashes and chills 2. I may experience constipation 3. I may have leg cramps during the night 4. I may feel irregular, painless contractions

I may feel hot flashes and chills

the nurse teaches prenatal classes in the antepartum clinic. which client statement indicates further teaching is necessary?

I may feel hot flashes and chills

The nurse instructs a prenatal client about the warning signs of pregnancy. The determines that teaching is successful if the client states the following? 1. I should contact the physician if I notice swelling in my face and fingers. 2. It's not unusual that I might have a little vaginal spotting 3. As long as my headaches go away after I take aspirin, I'm okay 4. I should report any uterine contractions that I may feel

I should contact the physician if I notice swelling in my face and fingers.

The nurse teaches a class about gonorrhea. Which of the following statements, if made by a client, indicates that teaching is successful? 1. I've heard that having gonorrhea can make you unable to have children 2. They say this disease can affect your brain and make you go crazy 3. I've heard you can't get rid of gonorrhea. You keep getting it over and over again 4. My mother said that you need to have cesarean deliveries after this infection.

I've heard that having gonorrhea can make you unable to have children

By her fifth month of pregnancy, a 32 y/o multipara of average prenatal height and weight has gained 14lbs. Which of the following actions by the nurse is MOST important? 1. advise the client she has gained too much weight and her diet should be reevaluated 2. advise the client she has not gained enough weight and her diet should be reevaluated. 3. Inform the client her weight gain is appropriate and she should continue on her present diet. 4. Inform the client she may have difficulties later in pregnancy and more frequent visits to the physician are indicated.

Inform the client her weight gain is appropriate and she should continue on her present diet.

By the fifth month of pregnancy, a 32-year-old multipara client of average prenatal height and weight has gained 14 pounds. Which action by the nurse is most important?

Inform the client the weight gain is appropriate and the present diet should be maintained.

The nurse provides care for a client in labor. The nurse is most concerned the fetus is experiencing distress if which heart rate pattern is observed?

Late decelerations

The health care provider orders a colposcopy for the client. The nurse explains to the client that which is the purpose of this procedure? 1. Magnify the tissue for examination 2. Directly examine ovaries, fallopian tubes, uterus, and small intestine 3. View structures in the pelvis cavity 4. Visualize the bladder

Magnify the tissue for examination

A client receives magnesium sulfate intravenously for treatment of preeclampsia. The client's assessments reveals: BP 110/70 mm Hg, P 98 beats/minute, hyproreflexia, and a urine output of 20 mL/hour. Which analysis by the nurse is best?

Maternal toxicity has occurred.

The nurse leads a prenatal class about breastfeeding. Which of the following statements, if made by the nurse, accurately describes the nutritional needs of a woman during lactation is compared tot he nutritional needs of pregnancy? 1. More calories, protein, and calcium are needed during lactation than are needed during pregnancy. 2. More calories but the same amount of protein, calcium, and fluids are needed. 3. Fewer calories and less protein are needed during lactation than are needed during pregnancy, but more calcium is needed. 4. Only more fat is needed during lactation than is needed during pregnancy.

More calories but the same amount of protein, calcium, and fluids are needed.

A nurse accidentally bumps into a newborn's bassinet. The newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which of the following reflexes? 1. Tonic neck 2. Moro's 3. Babinski's 4. Rooting

Moro's

The nurse instructs a group of expectant mothers about the advantages of breastfeeding. The nurse should intervene if an expectant mother makes which of the following statements? 1. My baby will grow faster and sleep more with breast milk 2. My baby will receive protective immune factors from the breast milk 3. My baby will not need any other foods or milk until he is four months old 4. At first, I may feed my baby about 10x/day

My baby will grow faster and sleep more with breast milk

The nurse instructs a group of expectant mothers about how to recognize the onset of labor. The nurse knows that further teaching is necessary if a client makes which statement? 1. My baby will move more when I go into labor 2. I may feel a gush of water at the beginning of labor 3. I may have blood tinged vaginal discharge 4. I will have regular uterine contractions that become stronger

My baby will move more when I go into labor

The nurse assesses a client in the family planning clinic. Which of the following statements, if made b a client, suggests to the nurse that the client has been exposed to gonorrhea? 1. My boyfriend has a sore on his penis 2. I have a cheesy, white vaginal discharge 3. My boyfriend has a drip 4. I have a rash

My boyfriend has a drip

A woman comes to the hospital in labor. Her membranes rupture at 4:10AM. Which of the following actions should the nurse take FIRST? 1. Identify the amniotic fluid by testing it or alkalinity 2. Contact physician and prepare for immediate delivery. 3. Note the time of rupture 4. Observe for a prolapsed cord or meconium stained fluid.

Observe for a prolapsed cord or meconium stained fluid.

The nurse cares for the client immediately after a normal vaginal delivery. Which action should the nurse take FIRST? 1. Observe the lochial flow 2. Palpate the fundus 3. Obtain a warming blanket 4. Obtain vital signs.

Observe the lochial flow

The client comes to the hospital in labor. The membranes rupture at 0410. Which action does the nurse take first?

Observes the amniotic fluid for any signs of infection or meconium.

The nurse provides care for a client in active labor and who is 6cm dilated. The client is now ready for epidural anesthesia. Which position will the nurse assist the client?

On the left side, shoulders parallel, legs flexed, and back arched.

The nurse observes a staff member palpate uterine contractions. The nurse determines the staff member is using the correct technique if which of the following is observed? 1. place the palm of one hand on the fundus and move the palm of the other hand around the abdomen during contractions. 2. Place the heels of both hands on the lower abdomen and press lightly 3. Place one hand on the abdomen over the fundus and with the fingertips press gently 4. Place the palms of the hands on either side of the abdomen and press firmly.

Place one hand on the abdomen over the fundus and with the fingertips press gently

To assess an apical pulse on a 8lb, 4oz newborn infant, the nurse should take which of the following actions? 1. Place the diaphragm of the stethoscope between the nipple line and the sternal notch 2. Place the diaphragm of the stethoscope between the second and third intercostal spaces, the midaxillary line 3. Place the bell of the stethoscope between the fourth and fifth intercostal spaces, midclavicular line 4. Place the bell of the stethoscope between the second and third intercostal spaces, the midsternal line.

Place the bell of the stethoscope between the fourth and fifth intercostal spaces, midclavicular line

The parents of a preterm infant visit the infant in the newborn nursery. They see their infant resting comfortably in the isolette and express concern about disturbing the baby. Which of the following responses by the nurse is BEST? 1. Preterm infants have an immature immune system and handling them increases the risk of an infection 2. Preterm infants need to conserve their strength, so it is best if you do not pick the infant up 3. Preterm infants need to develop a sense of trust and security and holding the infant promotes this 4. Preterm infants can become irritable if handled while sleeping, so first wake the infant up.

Preterm infants need to develop a sense of trust and security and holding the infant promotes this

The nurse instructs a client who recently had a modified radical mastectomy. The nurse tells the patient it is very important for the client to exercise the affected arm. What statement by the nurse is the most important rational for the client to exercise the arm?

Prevents Lymphedema.

The nurse instructs a client who recently had a modified radical mastectomy. Which statement by the nurse is the most important reason for the client to exercise her arm?

Prevents lymphedema

The nurse observes four newborns. Which of the following characteristics, if noted by the nurse, are MOST common in a preterm infant? 1. Red, wrinkled skin, lanugo, and hypotonic muscles 2. Vernix caseosa, silky hair, and faical edema 3. Absent nose bridge, depressed fontanels, and absent lanugo 4. Mottled skin, meconium stools, and hypertonic muscles

Red, wrinkled skin, lanugo, and hypotonic muscles vernix is the white substance covering baby's skin. Meconium stool is normal. herptonia is not seen with preterm infants.

The nurse cares for clients in the prenatal clinic. The nurse identifies which of the following pregnant woman is MOST likely to have a problem with Rh incompatibility with her fetus? 1. RH-positive woman w/Rh-negative man, been pregnant twice, has received RhoGAM 2. Rh-negative woman w/Rh-positive man, who has Rh antibodies 3. Rh-positive woman w/Rh-positive man, previous aborted 12wk fetus, didn't receive RhoGAM 4. Rh-negative woman w/Rh-negative man, never received RHoGAM

Rh-negative woman w/Rh-positive man, who has Rh antibodies

A woman complains to the nurse that during the client's menstrual period she gains weight and gets muscle cramps. The nurse should suggest which of the following measure to alleviate the client's symptoms? 1. Take OTC analgesics, restrict caffeine, exercise moderately 2. Avoid analgesics and exercise 3. Restrict fluid intake, exercise moderately, increase caffeine intake. 4. Restrict sodium intake, restrict exercise, sedatives

Take OTC analgesics, restrict caffeine, exercise moderately

The nurse performs a home care visit on a mother who delivered a baby three days ago. The client expresses alarm when she hears that her baby has lost 8oz. Which of the following responses by the nurse is MOST appropriate? 1. Perhaps you don't have enough milk for the baby and need to supplement the diet with formula 2. That is normal weight loss. Sometimes babies lose as much as 10% of the birth weight. 3. Babies usually lose some weight, but that's more than usual. He may need an intravenous infusion. 4. Most babies immediately lose their intrauterine water deposits and 20% of their birth weight.

That is normal weight loss. Sometimes babies lose as much as 10% of the birth weight.

The nurse prepares a client for a cesarean section. The client asks how the anesthesia is going to affect her baby. Which answer by the nurse is best? 1. The overall dosage of anesthesia is lower for a client undergoing cesarean section 2. The dosages of sedatives and hypnotics are lower for a client undergoing cesarean section 3. The amount of narcotic given is decreased in a client undergoing cesarean section 4. all medications are routinely withheld prior to the cesarean section.

The amount of narcotic given is decreased in a client undergoing cesarean section

A young mother delivers a healthy 7lb 12oz boy. She confides to the nurse that she concerned about the two "soft spots" she found on her baby's head. The nurse's response should be based on which of the following? 1. both the baby's fontanels should close within the first month 2. both the baby's fontanels should close within six months 3. The baby's posterior fontanel should close after one year 4. The baby's anterior fontanel should close after about a year and a half.

The baby's anterior fontanel should close after about a year and a half.

A woman at 29 wks gestation comes to the ER complaining of vaginal bleeding. The nurse identifies which of the following patient statements as indicative of placenta previa? 1. The bleeding scares me, other than that I feel fine 2. I've been more nauseated during the past few weeks 3. The bleeding started after I carried in 4 bags of groceries 4. I've been having sever abdominal cramps

The bleeding scares me, other than that I feel fine

The home care nurse visits a 17 y/o who delivered a full term infant 2 wks ago. Although the client appears mature, the nurse knows the client's age may interfere with positive mothering because of which of the following ? 1. The client is not in a stable relationship with the father 2. The client has yet to finish school 3. The client's parents want her to place the baby in foster care 4. The client is still experiencing the dependency of childhood

The client is still experiencing the dependency of childhood

The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's BP is 150/96, edema of the face and hands is noted, 3+ protein in the urine, and serum albumin level is 3 gm/dL. Which of the following instructions by the nurse is MOST important? 1. The client should decrease caloric intake 2. The client should eliminate all salt from her diet 3. The client should ensure adequate protein 4. The client should increase her intake of iron

The client should ensure adequate protein Client has preclampsia; bedrest on left side. proteins restore osmotic pressure.

The 20 y/o woman arrives at the hospital in active labor. The client asks the nurse what is the purpose of fetal monitoring. Which response by the nurse is BEST? 1. The purpose of the fetal monitor is to evaluate the progress of labor 2. the purpose is to assess the strength and duration of contractions 3. The purpose is to determine if the fetus is receiving adequate amounts of oxygen 4. The purpose is to allow the health care provider to decide if an oxytocin drip should be started.

The purpose is to determine if the fetus is receiving adequate amounts of oxygen

After a newborn circumcision, the nurse should take which of the following actions? 1. leave the area open to air 2. use disposable diapers to avoid irritation and facilitate healing 3. apply petroleum gauze and observe carefully for bleeding 4. administer prophylactic antibiotics

apply petroleum gauze and observe carefully for bleeding

The nurse admits a patient to the postpartum unit two hours after a vaginal delivery. Three hours after admission the nurse ambulates the patient to the bathroom, and the patient states there is a sudden gush of bleeding from her vagina. The nurse understands that the increase in amount of bleeding is due to which of the following? 1. The lochia pooled in the patient's vagina when she was lying in bed 2. The patient has a tear in her cervix that needs to be repaired. 3. The patient's fundus is relaxed and requires massaging. 4. The patient's bladder is distended because she needs to void.

The lochia pooled in the patient's vagina when she was lying in bed

A woman arrives at the hospital in labor. The midwife states that the client is 4 cm dilated and 60% effaced. The nurse explains the the client this means which of the following? 1. The opening of the cervix is 4cm wide and the cervical canal is 60% shorter than normal 2. The cervix is 4cm short in dilation and 60% thinner than normal 3. The walls of the cervix ar 4cm thick and 60% shorter than normal 4. The cervix is 4cm long and 60% wider than normal

The opening of the cervix is 4cm wide and the cervical canal is 60% shorter than normal

The nurse provides care for a client in labor about to deliver twins. For which complication does the nurse identify that this client is at higher risk?

Urine dysfunction

The nurse cares for the client six hours after a vaginal delivery and assists the client to perform perineal care. Fifteen mins later the nurse notes that the perineal pad is soaked and there is blood underneath the client's buttocks. Which action should the nurse perform first? 1. obtain the client's BP 2. notify the HCP 3. assess the fundus 4. administer O2 8-10L/min

assess the fundus

The nurse observes the interactions of mother and infant born three hours ago. The mother had gestational diabetes and delivered by cesarean section at 37 weeks gestation. The infant's Apgar scores were 6 and 8, birth weight 10lbs, heart rate 122 bpm, and respirations 35/min. The mother tells the nurse, "I don't know why my physician was worried about my baby. She looks so big and healthy!". Which response by the nurse is BEST? 1. You need to ask your mother if you were also a large baby 2. They baby's large size is due to the amount of sugar the she received in utero 3. It is great that you are starting to rely on your maternal instinct already! 4. You must be relieved that the baby looks so healthly

They baby's large size is due to the amount of sugar the she received in utero

The nurse prepares a client for an abdominal hysterectomy. The client asks why she has to have a Foley catheter. Which statement by the nurse is MOST appropriate? 1. This will help you since you will be temporarily incontinent 2. This will enable us to measure your output accurately 3. This will allow you to heal by keeping your bladder decompressed 4. This will allow your bladder to recover after the surgery.

This will allow you to heal by keeping your bladder decompressed

The nurse care for a woman in labor. Which method should the nurse use to measure the frequency of a uterine contraction? 1. timing the contractions from end of one contraction to the end of the next contraction. 2. Timing the contraction from beginning of one to end of same contraction 3. Timing the contraction from peak of one to the beginning of next 4. Timing the contraction from beginning of one to beginning of next

Timing the contraction from beginning of one to beginning of next

During auscultation of the fetal heart rate (FHR) during labor. The nurse assesses a rate of 59 beats/min. Which actions should the nurse take FIRST? 1. Turn the mother on her right side, open the IV line and call the HCP 2. Turn the mother on her left side, administer O2 NC and start and IV 3. Call the HCP 4. Place the mother in Trendelenburg, administer O2 and force fluids.

Turn the mother on her left side, administer O2 NC and start and IV

The nurse provides care for a newborn delivered by a client addicted to narcotics. At which time is the nurse most likely to observe symptoms of narcotic withdrawal?

Within 24-72 hours after birth.

On the evening before a modified radical mastectomy, a 29 y/o patient tells the nurse she is afraid that her husband will not find her sexually attractive if her breasts are removed. Which of the following responses by the nurse is BEST? 1. You shouldn't think about that tonight, you have plenty to worry about. 2. If your husband really lovers you, it won't bother him. 3. You're worried about how he'll react to the change in your body. 4. Reconstructive surgery can be done so that your breast will look the same.

You're worried about how he'll react to the change in your body.

The nurse performs a home visit on a new mother and her two week old son. The mother is breastfeeding. She tells the nurse that the baby nurses 8-9 times a day, has regained all the lost birth weight, has 6-8 wet diapers and usually has one bowel movement at day. Which of the following responses by the nurse is BEST? 1. Your baby should be gaining more weight 2. I'm concerned about the number of daily bowel movements 3. Your baby is doing great 4. Decrease the number of times you feed the baby each day

Your baby is doing great

The nurse cares for a patient 24 hours after delivery, and the patient states that she has been voiding large amounts of urine. Which of the following responses by the nurse is BEST? 1. You probably have a UTI 2. Your body is getting rid of the increased fluid 3. You must be drinking copious amounts of fluid 4. Your blood sugar is probably elevated.

Your body is getting rid of the increased fluid

A nurse prepares a client for a gynecological examination. The nurse explains that the physician will perform a pelvis examination will obtain a Pap smear. The nurse explains the Pap smear is 1. taken from exudates of the vagina and cervix 2. a sample of tissue used to locate a lesion 3. an xray film taken from various angles 4. a specimen of cells used to identify abnormal cells

a specimen of cells used to identify abnormal cells

A multipara woman in her fifth month of pregnancy complains to the nurse that her breasts are sensitive and sore. The nurse should make which of the following suggestions? 1. apply a warm compress and take aspirin 2. gently massage with lotion twice a day and wear loose fitting, comfortable clothing 3. apply cold compresses and wear a well fitting, supportive bra 4. take a diuretic once a day

apply cold compresses and wear a well fitting, supportive bra

The nurse understands that the physician is most likely to prescribe which of the following drugs to a client diagnosed with gonorrhea?

ceftriazone IM plus doxycycline for seven days, PO

The nurse understands that the physician is most likely to prescribe which of the following drugs to a client diagnosed with gonorrhea? 1. penicillin vaginal suppositories 2. penicillin G benzthine intramuscularly in divided doses once a week 3. ceftriazone IM plus doxycycline for seven days, PO 4. ampicillin, PO

ceftriazone IM plus doxycycline for seven days, PO

A 28 y/o woman delivers a baby boy. In order to monitor complications, the nurse should be MOST alert to which of the following findings? 1. complaints of pain 2. changes in blood pressure and pulse 3. ambivalent feelings about being a mother 4. the number of previous delivers

changes in blood pressure and pulse

The nurse cares for a patient 12 hours after delivery of a 3,200 g infant. The nurse notes that the fundus is approximately 1 cm above the umbilicus. It is most important for the nurse to take which of the following actions? 1. encourage the client to void 2. assess for the amount and character of the lochia 3. bring the infant to the mother for breastfeeding 4. chart the results in the patient's chart

chart the results in the patient's chart

The nurse instructs a pregnant woman with gestational diabetes about her diet. The nurse determines that teaching is effective is the client selects which of the following desserts? 1. apple pie 2. ice cream 3. cheese and fresh fruit 4. granola bar and milk

cheese and fresh fruit

The woman tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The nurse should recommend the client eat which food? 1. chicken livers 2. pork 3. hamburger 4. tofu

chicken livers liver is an excellent source of iron.

A woman is in active labor. As labor progresses, she becomes irritable and complains of feeling increasingly uncomfortable. She is 8 cm dilated. Which of these actions should the nurse take first? 1. contact the physician 2. coach the patient, in proper breathing and relaxation techniques 3. administer and analgesic 4. remove the fetal monitor to allow the client to move around

coach the patient, in proper breathing and relaxation techniques

The nurse cares for 4lb, 10oz infant delivered at 32 weeks gestation. The nurse notes the infant has mottling of the skin, and lab values indicate metabolic and respiratory acidosis. The nurse recognized these findings are signs of which of the following? 1. Respiratory distress syndrome 2. cold stress 3. perinatal asphyxia 4. hypovolemia

cold stress

During labor induction with oxytocin, the nurse should stop the infusion if which of the following occurs? 1. contractions are at 3 min intervals and last more than 60 secs 2. contractions are at 2 min intervals and last more than 90 secs 3. contractions are at 2.5 min intervals and last more than 90 secs 4. contractions are at 2 min intervals and last more than 60 secs

contractions are at 2 min intervals and last more than 90 secs

When administering phototherapy to a newborn with jaundice, it is MOST important for the nurse to take which of the following actions? 1. expose only the infant's back to the light 2. remove the infant from the light for 15 mins each hour 3. cover the infant's eyes with protective pads during therapy 4. check the infant's temp every hour

cover the infant's eyes with protective pads during therapy

The nurse cares for a client receiving magnesium sulfate IV, and the nurse notes that the client's deep tendon reflexes are decreased. Which action should the nurse take first? 1. document the results in the client's chart 2. place the call light within reach of the client 3. dim the lights prior to leaving the room 4. discontinue the IV infusion

discontinue the IV infusion

The nurse monitors a client at 30 weeks gestation, and the client states that she has periodic heartburn. It is MOST important for the nurse to make which of the following recommendations? 1. lie down after eating a meal 2. eat frequent small meals 3. take alka-seltzer as needed 4. sip iced tap water

eat frequent small meals

The nurse cares for a patient in labor. The patient suddenly shouts, "I have to push! I have to push!" The nurse determines that the patient is 8 cm dilated. Which of the following actions should the nurse take first? 1. instruct the patient to take a deep breath and bear down 2. apply pressure to the patient's fundus 3. coach the patient in relaxation techniques 4. encourage the patient to pant with pursed lips

encourage the patient to pant with pursed lips (pant to prevent pushing...)

In the delivery room, the nurse places drops in a newborn's eyes. The nurse explains to the mother the drops 1. help the baby see well 2. remove blood and mucus from the baby's eyes 3. prevent neonatal conjunctivitis 4. protect against infections that could lead to blindness

protect against infections that could lead to blindness

Meconium stained amniotic fluid should alert the nurse to the possibility of which? 1. fetal distress and perinatal asphyxia 2. fetal distress and hyperbilirubinemia 3. abruptio placenta and asphyxia 4. placenta previa and perinatal sepsis

fetal distress and perinatal asphyxia

A client contacts the nurse and describes some soft and movable masses she felt in her breasts that become enlarged during menstruation. The nurse should be aware that the client is most likely describing which of the following? 1. cancer of the breast 2. fibroids of the breast 3. fibrocystic disease of the breast 4. hyperplasia of the breast

fibrocystic disease of the breast

The nurse palpates the fundus of a woman after the third stage of labor. The nurse should expect the fundus to be... 1. soft and discoid 2. firm and discoid 3. soft and globular 4. firm and globular

firm and globular

The nurse is caring for a patient in labor. The patient's labor progresses with regular contractions until her cervix is 9 cm dilated. The nurse identifies the patient is in which stage of labor? 1. first stage 2. second stage 3. third stage 4. fourth stage

first stage

The nurse explains to a client at 6 wks gestation which of the following periods of pregnancy is the most critical time for fetal development? 1. first two weeks 2. first three months 3. fourth through sixth month 4. the last month

first three months

A 32 y/o woman is pregnant for the third time. She has one living child and had one abortion. Which description does the nurse record? 1. gravida III, para II 2. gravida II, para II 3. gravida III, para I 4. gravida II, para III

gravida III, para I Gravida = pregnancies Para = full term fetus

The nurse should place the HIGHTEST priority on monitoring a woman after a cesarean section for which of the following? 1. infection and pain 2. hemorrhage and shock 3. hemorrhage and pain management 4. dehydration and infection

hemorrhage and shock

A nurse counsels a couple who have had difficulty conceiving a child. The nurse explains infertility is defined as which of the following? 1. inability to conceive after at least three months of unprotected intercourse 2. inability to conceive after at least six months of unprotected intercourse 3. inability to conceive after at least one year of unprotected intercourse 4. inability to conceive after at least two years of unprotected intercourse

inability to conceive after at least one year of unprotected intercourse

A 25 y/o primigravida diagnosed with type 1 diabetes mellitus reviews insulin regimen with the nurse. The nurse reinforces the importance of regular prenatal care and explains changes in insulin requirements will include which of the following? 1. insulin requirements will increase during pregnancy and decrease after delivery 2. insulin requirements will decrease during pregnancy and increase after delivery 3. insulin requirements will increase during pregnancy and remain increased after delivery. 4. insulin requirements decrease during pregnancy and remain decreased after delivery.

insulin requirements will increase during pregnancy and decrease after delivery

The nurse cares for a woman in labor. The nurse is MOST concerned the fetus is experiencing distress if which is observed? 1. late decelerations 2. early decelerations 3. irregular heart rate 4. variable decelrations

late decelerations

The nurse prepares a client for placement of internal radiation, The nurse understands the client will receive and indwelling foley catheter and a tap water enema for which of the following reasons? 1. prevent displacement of the implant 2. make the patient more comfortable during the treatment 3. maintain an uncontaminated work area 4. avoid excessive bladder and bowel irradiation

prevent displacement of the implant

The nurse instructs a patient who recently had a modified radical mastectomy. The nurse states that it is important that the patient exercise her arm postoperatively to 1. increase muscle strength and diameter 2. maintain body balance 3. limit full range of motion 4. prevent lymphedema

prevent lymphedema

The nurse cares for a client diagnosed with cervical cancer. The nurse notes that the client appears to have a poor appetite. Which of the following interventions by the nurse is BEST? 1. provide high fat snacks 2. provide small, frequent feedings 3. provide additional fluid at meals 4. provide food when the client requests it.

provide small, frequent feedings

The nurse knows that a preterm infant is at greatest risk for developing which disorder? 1. hypoglycemia 2. respiratory distress syndrome 3. hydrocephalus 4. scoliosis

respiratory distress syndrome

The nurse instructs the woman about how to prevent conception using the basal body temp method. The nurse explains that during ovulation, the woman's basal body temp will change in which direction? 1. lowers significantly 2. rises significantly 3. is unchanged 4. rises slightly

rises slightly

Which of the following measures is MOST effective in protecting the nursing staff from harmful exposure to radiation when caring for a patient with a radiation implant? 1. rotate the staff members assigned to the patient 2. wear a gown and mask when in contact with the patient 3. leave the patients room at least every 10 mins 4. place the patient in a room with private bathroom

rotate the staff members assigned to the patient

The nurse cares for a patient in labor. The nurse notes that patient appears more peaceful and there is an increase in bloody show. The nurse identifies the patient is in which stage of labor? 1. first 2. second 3. third 4. fourth stage

second stage

The nurse cares for a client immediately after delivery and administers oxytocin. The nurse knows that the purpose of the medication is 1. relieve discomfort and pain 2. anesthetize the area of the episiotomy 3. stimulate firm contraction of the uterus 4. prevent breast engorgement

stimulate firm contraction of the uterus

A fetal heart tracing shows and early deceleration pattern. The nurse is aware that this indicates which interpretation? 1. the FHR slows early in the contraction, which is a normal finding 2. the FHR slows early in the contraction, which is an abnormal finding 3. the FHR slows at the peak of the contraction, which is a normal finding. 4. the FHR slows at the peak of the contraction, which is an abnormal finding.

the FHR slows early in the contraction, which is a normal finding (deceleration occurs when the FHR falls below baseline for 15 s or more, followed by a return; early deceleration occurs before the peak of the contraction is is a reassuring fetal heart pattern)

A patient is admitted to the hospital and is scheduled to have a modified radical mastectomy. The patient asks the nurse about the surgical procedure. Which of the following explanations should the nurse give? 1. only the tissue is removed, leaving all the muscles and lymph nodes 2. the breast, axillary nodes and superior apical nodes are removed but he muscles are preserved. 3. the breast, axillary nodes, and the major and minor pectoral muscles are preserved. 4. The sternum will be split and lymph nodes will be dissected from the mediatinum

the breast, axillary nodes and superior apical nodes are removed but he muscles are preserved.

The nurse supervises care for a client with a radioactive implant. The nurse should intervene if which of the following is observed? 1. The assistant gives the client a pan of water so the client can bathe herself 2. the assistant offers the client an analgesic for pain 3. the client's mother walks up to the client inside of her room 4. the staff wears a dosimeter film badge when interacting with the client

the client's mother walks up to the client inside of her room

The nurse cares for 6lb, 7oz baby girl delivered two hours ago. The nurse knows which of the following occurrences initiates the changes that take place in the newborn circulatory system after birth? 1. the space constraints of the uterus are removed 2. the infant begins pulmonary ventilation 3. the infant is exposed to excessive sensory stimuli 4. the ambient temperature of the infant is reduced.

the infant begins pulmonary ventilation

The school nurse attends a soccer game at the local high school. The nurse notes a pregnant woman has grabbed her throat, indicates that she is choking, and is unable to speak. Which of the following actions if taken by the nurse is BEST? 1. the nurse stand behind the woman and performs chest thrusts 2. the nurse inspects the client's mouth and throat for an obstruction 3. the nurse embraces the client from behind and performs abdominal thrusts 4. the nurse stays with the client calls for help

the nurse stand behind the woman and performs chest thrusts

A woman comes to the clinic pregnant with her second child. She questions the nurse about the amount of exercise that is acceptable for her to perform during her pregnancy. Which of the following is MOST important response by the nurse?

what is your usual type of exercise

A woman comes to the clinic pregnant with her second child. She questions the nurse about the amount of exercise that is acceptable for her to perform during her pregnancy. Which of the following is MOST important response by the nurse? 1. you can continue your activities but rest when you get tired. 2. you should take a brisk walk daily 3. you can exercise as much as you want but limit household activities 4. what is your usual type of exercise

what is your usual type of exercise

The nurse cares for newborn delivered by a mother addicted to narcotics. During which of the following times is the nurse MOST likely observe symptoms of narcotic withdrawal? 1. immediately at birth 2. within 12 hours after birth 3. within 24-72 hours after birth 4. after 2 weeks

within 24-72 hours after birth

A client is in active labor when her membranes rupture. The client states, "I am afraid of having a 'dry labor'." What is the best response by the nurse?

"Amniotic fluid does not function as lube for the labor process."

A client comes to the prenatal clinic for her first visit. The nursing history reveals that the client's last menstrual period was five months ago, and the client is sure she is pregnant because she has been feeling the baby move. Which of the following responses by the nurse is BEST?

"Lie down so that I can listen for fetal heart tones with the Doppler."

A pregnant client comes to the clinic. The client asks the nurse about the amount of exercise that is acceptable during the pregnancy. What is the most important response by the nurse?

"What is your usual type of exercise?"

a nurse teaches the client about birth control methods. how long does the nurse advise the client to leave a diaphragm in place after intercourse?

6 hours

The nurse cares for clients in the prenatal clinic. The nurse identifies which of the following pregnant woman is MOST likely to have a problem with Rh incompatibility with her fetus?

An Rh-negative client who conceived with a Rh-positive partner and gave birth 3 years ago to a rH positive infant

The nurse identifies which pregnant woman as most likely to have an issue with Rh incompatibility with the baby?

An Rh-negative client who conceived with a Rh-positive partner and gave birth 3 yrs ago to an Rh-positive infant.

A woman has a simply vulvectomy. Postoperatively, nurse instructs her to take a sitz bath and keep area clean and dry. Nurse understands reason for these measures is A. to debride area and prevent wound infection B. to increase circulation to area and promote wound healing C. to prevent swelling of surrounding lymph nodes D. to cleanse area and diminish possibility of postoperative bleeding

B Both of these measures can be done to increase circulation to a vascular region such as vulva, helping to promote wound healing

During auscultation of FHR during labor, nurse assesses a rate of 59 beats/min. Which actions does nurse take *first*? A. turns client on right side, opens IV line, and calls health care provider B. turns client on left side, administers oxygen by nasal cannula, and assures IV access C. places client in semi-Fowler's position, provides ice, and calls health care provider D. places client in Trendelenburg position, administers oxygen, and forces fluids

B Bradycardia indicates fetal distress; persistent bradycardia may indicate cord compression or separations of placenta

The woman tells the nurse that she always had a heavy period and needs extra iron. The nurse should recommend which food to the client?

Chicken livers.

A woman is in active labor. As labor progresses, she becomes irritable and complains of feeling increasingly uncomfortable. She is 8 cm dilated. Which of these actions should the nurse take FIRST?

Coach the patient in proper breathing and relaxation techniques.

The nurse cares for a patient in labor. The patient suddenly shouts, "I have to push! I have to push!" The nurse determines that the patient is 8 cm dilated. Which of the following actions should the nurse take first?

Coaches the client in proper breathing and relaxation techniques

When administering phototherapy to a jaundice newborn, what is the most important action to take?

Cover the infants eyes with protective pads during therapy.

A young adult client delivers a term newborn. Client confides to nurse of concerns about two "soft spots" found on baby's head. Nurse's response is based on which information? A. both baby's fontanels should close w/in first month B. both baby's fontanels should close w/in six months C. baby's posterior fontanel should close after one year D. baby's anterior fontanel should close after about a year and a half

D Anterior fontanel is diamond-shaped. It is junction of sagittal, coronal, and frontal sutures. Anterior fontanel closes by 18 months of life

Nurse counsels clients in prenatal clinic. Nurse is *most* concerned if client makes which statement? A. I take my dog for a 30 minute walk every other day B. I plan to take an 8 hour car trip next week C. I drink 3 liters of liquids every day D. I clean cat's litter box daily

D Toxoplasmosis (protozoan infection) caused by eating infected undercooked meat or after handling infected kitty litter; infection can cross placenta and infect fetus; pregnant woman should not clean litter box, if she must, wear latex gloves and wash hands well afterward

The nurse monitors a client at 30 wks gestation, and the client reports having periodic heartburn. It is most important for the nurse to make which recommendation?

Eat frequent small meals.

the nurse instructs a prenatal client about the warning signs of complications during pregnancy. the nurse determines teaching is successful if the client makes which statement?

I should contact the HCP if I notice swelling in my face and fingers

By the fifth month of pregnancy, a 32 year old multipara client of average prenatal height and a weight gain of 14 lbs. What action is most important by the nurse?

Inform the client the weight gain is appropriate and the present diet should be maintained.

A primigravida diagnosed with Type 1 Diabetes mellitus reviews the insulin regimen with the nurse. The nurse explains which changes with insulin needs will occur in pregnancy?

Insulin requirements increase during pregnancy and decrease after birth.

A nurse accidentally bumps into a newborn's bassinet. The newborn jumps and pulls the extremities into the trunk. The nurse identifies the newborn is demonstrating which of the following reflexes?

Moro

The nurse assess an apical pulse on a 8lb 4oz baby. The nurse takes which action?

Places the bell of the stethoscope at the 4th intercostal space at the left midclavicular line.

The nurse observes four newborns. Which of the following characteristics, if noted by the nurse, are MOST common in a preterm infant?

Red, wrinkled skin, lanugo, and hypotonic muscles

The nurse instructs the woman how to prevent conception using the BBT method. The nurse explains that during ovulation, the woman's basal body temp will change in which direction?

Rises slightly

The nurse in the prenatal clinic assesses a client at 31 weeks gestation. The client's BP is 150/96, edema of the face and hands is noted, 3+ protein in the urine, and serum albumin level is 3 gm/dL. Which of the following instructions by the nurse is MOST important?

The client should ensure adequate protein

The nurse in the prenatal clinic assess a client at 31 wks gestation. The clients BP is 150/96, serum albumin level is 3g/dL, 3+ protein found in urine, and the clients hand and face are edematous. What instruction is most important?

The client should ensure adequate protein.

A client reports weight gain and muscle cramps during the menstrual period. The nurse suggests which measures to the client to alleviate these symptoms?

Use a mild analgesic, restrict caffeine, exercise moderately.

The nurse provides care for a client in labor. The fetus is displaying occasional cat. 3 FHR patters on the monitor. What is the first action for the nurse to perform?

When the fetal heart rate is baseline perform fetal stimulation to assess for heart rate acceleration.

The woman tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The nurse should recommend the client eat which food?

chicken livers bananas spinach

the nurse provides care for a client receiving mag sulfate IV and assesses that the clients deep tendon reflexes are decreased. which action does the nurse take first?

discontinues the IV infusion

meconium-stained amniotic fluid alerts the nurse to the possibility of which problem?

fetal distress and perinatal asphyxia

the nurse palpates the fundus of a client after the 3rd stage of labor. the nurse expects the fundus to have which characteristics?

firm and globular

the nurse provides care for a neonate born 2 hours ago. which occurrence initiates the changes that take place in the neonates circulatory system after birth?

the newborn begins pulmonary ventilation

a client is in active labor with external monitoring in use. the nurse notes abrupt and rapid fluctuations in the FHR from baseline to 90bpm and back to baseline on the monitoring device. the fluctuations in FHR occur with no relationship to the contraction pattern. the client watches the monitor and asks "is there something wrong with my baby?" which response by the nurse is best?

this is a potential problem that requires a position change

The nurse prepares a client for an abdominal hysterectomy. The client asks why she needs a foley cath. What statement by the nurse is most appropriate?

this will promote healing by decompressing your bladder

A woman complains to the nurse that during the client's menstrual period she gains weight and gets muscle cramps. The nurse should suggest which of the following measures to alleviate the client's symptoms?

use mild analgesics, restrict caffeine, exercise moderately

on the evening before a modified radical mastectomy, a 29 YO client states " I am afraid my spouse will not find me sexually attractive after my breast is removed". which response by the nurse is best?

you're worried about how your spouse will react to the change in your body

A client comes to the prenatal clinic for the first visit. The nursing history reveals the clients last period was 5 months ago and the client is certain of pregnancy and reports feeling the baby move. Which response by the nurse is best?

"Lie down so that I can listen for fetal heart tones with the Doppler."

An infant is born by vaginal delivery. At birth, the infant is crying and respiration and pulse rate are good. One minute after birth, the baby is noted to have slightly cyanotic extremities. At five minutes after birth, the extremities are pink. The nurse should record the baby's one-minute and five-minute Apgar scores a which of the following?

9 and 10 respectively

The nurse asses an infant delivered vaginally. At birth the infant is crying and moving all extremities, resp. and HR are good. 1 minute after birth the baby is noted to have slightly cyanotic limbs. After 5 mins the limbs are pink. What the APGAR score for the baby at 1 and 5 minutes?

9&10 respectively

Nurse cares for client in labor. Nurse is *most* concerned fetus is experiencing distress if which HR pattern is observed? A. late decelerations B. early decelerations C. irregular HR D. variable decelerations

A Fall in fetal HR after peak of contraction; indicates fetal hypoxia; position client on left side, administer oxygen by mask, start IV or increase flow rate, stop oxytocin if appropriate

Nurse is caring for a client in labor. Client's labor progresses w/regular contractions until cervix is 9 cm dilated. Nurse identifies client is in which stage of labor? A. first stage B. second stage C. third stage D. fourth stage

A From beginning of labor until cervix is completely dilated is first stage; divided into phase 1 (latent, 0-3 cm), phase 2 (active, 4-7 cm), phase 3 (transition, 8-10 cm)

Nurse teaches a class about gonorrhea. Which client statement, indicates teaching is successful? A. I've heard that having gonorrhea can make you unable to have children B. they say this disease can affect your brain and make you go crazy C. I've heard you can't get rid of gonorrhea. You keep getting it over and over again D. my parent said you need to have cesarean deliveries after this infection

A Gonorrhea causes pelvic inflammatory disease, which is one of most common causes of sterility; gonorrhea is treated w/antibiotics

A couple comes to fertility clinic after trying for several years to have children. Woman has a regular 28 day menstrual cycle. Nurse explains to her she is MOST likely to become pregnant: A. 10-14 days after onset of her menstrual period B. 16 days before onset of her menstrual period C. last 8 days of her cycle D. 18-20 days after first day of her menstrual cycle

A In a regular menstrual cycle of 28 days, time of ovulation is usually around 14th day; if pt has intercourse 2 or 3 days before this time or 2 or 3 days after, it is possible that she will become pregnant, since sperm live for about 48 hours

A infant shows a tendency to bleed two days after birth. The nurse knows this is most likely caused by what?

Absence of intestinal bacteria and vitamin K.

Nurse cares for a 4 lb, 10 oz infant delivered at 32 weeks gestation. Nurse notes infant has mottling of skin, and lab values indicate metabolic and respiratory acidosis. Nurse recognizes these findings are signs of which of following? A. respiratory distress syndrome B. cold stress C. perinatal asphyxia D. hypovolemia

B Excessive loss of heat that results in increased respirations and nonshivering thermogenesis; metabolic acidosis occurs; place in heated environment

A pt is admitted to hospital and is scheduled to have a modified radical mastectomy. Pt asks nurse about surgical procedure. Which of following explanations should nurse give? A. only tissue is removed, leaving all muscles and lymph nodes B. breast, axillary nodes, and superior apical nodes are removed, but muscles are preserved C. breast, axillary nodes, and major and minor pectoral muscles are preserved D. sternum will be split and lymph nodes will be dissected from mediastinum

B In a modified radical mastectomy, breast, axillary nodes, and superior apical nodes are removed, but major and minor pectoral muscles are preserved

The nurse should place the HIGHEST priority on monitoring a woman after a cesarean section for which of the following?

Hemorrhage and shock

A client had a C-section. The nurse places the highest priority on monitoring for what potential problem?

Hemorrhage and shock.

The nurse ambulates a postpartum client to the bathroom for the first time after the client gave birth 3 hours ago. The client reports feeling a sudden "gush" of bleeding from the vagina while walking. Which is the most likely cause of this?

Lochia has pooled in the client's vagina.

The health care provider orders a colposcopy for the client. The nurse explains to the client that which is the purpose of this procedure?

Magnifies the tissue for examination

A client is prescribed a colposcopy. The nurse tells the client what information about the purpose of this procedure?

Magnifies the tissue for examination.

When the nurse 'accidentally' bumps into the babies bassinet, the newborn jumps and pulls the extremities into the trunk. Which reflex is the newborn demonstrating?

Moro

The nurse cares for a client after a breast biopsy. After the procedure, it is most important for the nurse to take which action?

Observe for bleeding.

The nurse cares for the client immediately after a normal vaginal delivery. Which action should the nurse take FIRST?

Observe the lochial flow

The nurse provides care for a client immediately after a normal vaginal deliver. What action doe the nurse take first?

Observes lochial flow.

A client arrives at the hospital in labor. The client is dilated to 4cm and 60% effaced. Which statement does the nurse give the client to explain the meaning of this information?

The opening of the cervix is 4cm wide and the cervical canal is 60% shorter than normal.

A woman arrives at the hospital in labor. The midwife states that the client is 4 cm dilated and 60% effaced. The nurse explains the the client this means which of the following?

The walls of the cervix is 4cm wide and the cervical canal is 60% shorter than normal

the nurse counsels a couple in their early 30's who have has difficulty conceiving a child. the couple states that they are worried they are infertile. the nurse teaches the couple that infertility testing is usually done when?

after 1 year of unprotected intercourse and the inability to conceive

which action should the nurse take immediately after the newborn is circumcised?

applies petroleum gauze and observes carefully for bleeding.

a multipara client in the 7th month of pregnancy reports to the nurse that the breasts are sensitive and sore. the nurse makes which suggestions?

apply cold compresses and wear a well-fitting, supportive bra

a client delivers a baby. In order to monitor for maternal complications, the nurse is most alert for which finding?

changes in blood pressure and pulse

A client visiting a community clinic describes some soft and moveable masses in the breast that become enlarged during menstruation. The nurse is aware that the client is most likely describing which condition?

fibrocystic breast diseas

he nurse instructs a pregnant client diagnosed with gestational diabetes about the appropriate diet. the nurse determines the teaching is effective if the client selects which dessert?

fresh fruit

A primigravida diagnosed with type 1 diabetes mellitus reviews insulin regimen with the nurse. The nurse reinforces the importance of regular prenatal care and explains changes in insulin requirements will include which of the following?

insulin requirements will increase during pregnancy and decrease after delivery

A nurse prepares a client for a gynecological examination. The nurse explains that the physician will perform a pelvis examination will obtain a Pap smear. The nurse explains the Pap smear is

it is a scraping of the cervix used to identify abnormal cells

a client calls the clinic and reports a fever, fatigue and has a hard reddened area in 1 breast. the client is breastfeeding. which condition does the nurse understand that this client is most likely experiencing?

mastitis

The nurse cares for a patient after a breast biopsy. After the procedure, it is MOST important for the nurse to take which of the following actions?

observe for bleeding

the nurse observes the staff member palpate a clients uterine contractions. the nurse determines the staff member is using the correct technique if which observation is made?

places one hand on the abdomen over the fundus and presses gently with the fingertips

The parents of a preterm infant visit the infant in the newborn nursery. when they see the infant resting comfortably in the isolette and express concern about disturbing the baby to hold it. Which response by the nurse is BEST?

preterm infants need to develop a sense of trust and security and holding the infant promotes this

the nurse provides care for a client diagnosed with cervical cancer. the nurse notes the client appears to have a poor appetite. which intervention by the nurse is best?

provide small, frequent feedings

the nurse knows a preterm infant is at greatest risk for developing which disorder?

respiratory distress syndrome

The nurse instructs the woman how to prevent conception using the basal body temperature (BBT) method. The nurse explains that during ovulation, the woman's basal body temperature will change in which direction?

rises slightly

a fetal heart rate (FHR) tracing shows an early deceleration pattern. the nurse is aware that this indicates which interpretation?

the FHR slows early in the contraction, which is a normal finding.

the nurse prepares a client for an emergency c-section delivery. the client asks how the anesthesia is going to affect the baby. which answer by the nurse is best?

the anesthesia is not administered until immediately prior to the cesarean incision.

the home care nurse visits an adolescent client who delivered a full-term infant 2 weeks ago. although the client appears mature, the nurse knows the clients age may interfere with positive mothering because of which factor?

the client is still experiencing the dependency of childhood

a client who is multipara is diagnosed with premature labor requiring bedrest in the healthcare facility for an extended amount of time. Which interventions does the nurse include in the clients care plan? (select all that apply)

the client needs to be positioned on the left side and drink fluids the client needs to eat highly nutritious meals

the school nurse attends a soccer game at the local high school. the nurse sees a pregnant woman grab her throat, indicating she is choking, and is unable to speak. which action is best for the nurse to take?

the nurse stands behind the woman and performs chest thrusts

the client arrives in the hospital in active labor. the client asks the nurse what is the purpose of the fetal monitor. which response by the nurse is the best?

the purpose of the fetal monitor is to determine if the fetus is receiving adequate amounts of O2

the nurse makes a home care visit to a client who delivered an 8lb 5oz (3770.5g) baby 3 days ago. the client expresses alarm when hearing the baby has lost 8 oz (226.8g). which response by the nurse is most appropriate?

this is a normal weight loss. sometimes babies lose as much as 10% of their birth weight