Potential

A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statement should the nurse make? A. "You can bathe and dress your baby if you'd like to." B. "If you don't hold the baby it will make letting go much harder." C. "You should name the baby so she can have an identity." D. "I'm sure you will be able to have another baby when you're ready.

"You can bathe and dress your baby if you'd like to"

A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plans to conduct? A. Group B strep culture B. 1-hr glucose tolerance test c. Rubella titer D. Blood type and Rh

1-hr glucose tolerance test

A nurse is caring for newborn immediately following birth and notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. (Move the steps into the box on the placing them in the selected order of performance. Use all the steps.) compress bulb syringe assess newborn for reflex bradycardia use bulb syringe to suction newborn's nose place bulb syringe in newborn's mouth

1. Assess the newborn for reflex bradycardia 2. Compress the bulb syringe 3. Place the bulb syringe in the newborn's mouth 4. Use the bulb syringe to suction the newborn's nose

A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority? 480 mL urine output in 24 hrs 1+ protein in the urine +2 edema of the feet BP 144/92

480 mL urine output in 24 hrs

A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2 months of pregnancy. Which of the following statements by the client indicates an understanding of the teaching. A. "I will count baby's lacks every other day. B. "I will alternate the arm use to check my blood pressure. D. I will consume 50 grams of protein daily

I will alternate the arm used to check my BP

A nurse is calculating estimated date of birth using Naegele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated delivery in the next year? a. March 14 b. March 21 c. March 28

March 28

A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate? Urine Ketones Rapid plasma reagin Prothrombin time Urine culture

Urine ketones

A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider? A. Hgb 20 g/dL B. Bilirubin 2 mg/dL C. Platelets 200 .000/mm3 D. WBC count 32.000/mm3

WBC count 32.000/mm^3

A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statements should the nurse make? A. "You will need to stay in a side-lying position for 30 minutes after each dose." B. "You will receive an IV infusion of oxytocin 1 hour after your last dose." C. " You will receive a magnesium supplement immediately following therapy." D. " You will need to have a full bladder before the therapy begins."

You will need to stay in a side-lying position for 30 min after each dose

A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol? A. A client who has active genital herpes B. A client who has gestational diabetes mellitus C. A client who has a previous uterine incision D. A client who has placenta previa

a client who has gestational diabetes mellitus

A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer? Metronidazole Penicillin Acyclovir Gentamicin

acyclovir

A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to report to the provider during pregnancy. What info should the nurse include in the teaching? a. nausea upon awakening b. blurred or double vision c. increase in white vaginal discharge d. leg cramps when sleeping

blurred or double vision

A nurse is planning to teach a group of clients who are about breastfeeding after returning to work. Which of the following infection should the nurse include in the teaching? A. "Thawed breast milk can be refrigerated for up to 72 hours." B. "Breast milk can be stored in a deep freezer for 12 months." C. Breast milk can be stored at room temperature for up to 12 hours." D. "Thawed breast milk that is unused can be refrozen."

breast milk can be stored in a deep freezer for 12 months

A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. What adverse effects should the nurse include in the teaching? elevated BP feeling of warmth generalized pruritus Hyperactivity

feeling of warmth

A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication? A. Hypnosis B. Polyuria C. Bilateral crackles D. Hyperglycemia

hypnosis

A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should position my baby's car seat at a 45 degree angle in the car." B. "I should place the car seat rear facing until my baby is 12 months old." C. "I should place the harness snugly in a slot above my baby's shoulders." D. "I should position the retainer clip at the top of my baby's abdomen.

i should position my baby's car seat at a 45 degree angle in the car

A nurse is providing teaching to a client about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber per cup? Lentils Oatmeal Cabbage Asparagus

lentils

A nurse is caring for a client who has bacterial vaginosis. Which of the following medication should the nurse expect to administer? A. Metronidale B. Fluconazole C. Acyclovir D. Tetracycline

metronidale

A client and her partner ask the nurse for information about permanent contraception. Which of the following statements should the nurse include in the counselling? Most sterilization procedures are considered irreversible A woman should use contraception for 1-2 months after a tubal ligation A man is usually sterile immediately after a vasectomy The menstrual cycle is shorter after a tubal ligation

most sterilization procedures are considered irreversible

A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures? A. Assisting a mother with breastfeeding B. Performing a newborn's initial bath C. Administering the measles, mumps, rubella vaccine D. Performing umbilical cord care

performing umbilical cord care

A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take? a. Inform the client that the law requires her to name the fetus. b. Limit the amount of time the fetus is in the client's room. c. Instruct the client that an autopsy should be performed within 24 hr. d. Prepare the client for what to expect the fetus to look like

prepare client for what to expect the fetus to look like

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate? a. This medication improves tissue perfusion. b. This medication increases cardiac output. c. This medication stabilizes the fetal heart rate. d. This medication prevents seizures.

this med prevents seizures

A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection? Unilateral breast pain Persistent abdominal striae Lochia alba WBC count 12,000/mm3

unilateral breast pain

A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse reports to the provider? A. Blood pressure 148/94mm Hg B. Respiratory rate 14mm C. Urinary output 20 mL/hr D. 2+deep tendon reflexes

urinary output 20 mL/hr

A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What action should the nurse take? a. request a script for an internal fetal scalp electrode b. auscultate the FHR with a doppler transducer c. report the nonreactive test result to the provider immediately d. use vibroacoustic stim on the client's abd for 3 seconds

use vibroacoustic stim on pts abdomen for 3 seconds

A nurse is caring for a client who is in labor and prescribed an amnioinfusion. Which of the following findings is an indication for this? Variable decelerations Early decelerations Fetl macrosomia Increased uterine tone

variable decelerations

A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse include in the teaching? a. you will be in isolation after delivery b. abstain from sexual intercourse throughout pregnancy c. breastfeed your newborn to provide passive immunity d. you should continue to take zidovudine throughout the pregnancy

you should continue to take zidovudine throughout the pregnancy

A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? A. "Your stomach will empty rapidly" B. "You should expect your uterus to double in size" C. "You should anticipate nasal stuffiness." D. "Your nipples will become lighter in color".

you should expect uterus to double in size or you should anticipate nasal stuffiness

A nurse is providing discharge teaching to a client following tubal ligation . (occlusion). Which of the following statements by the client indicates an understanding of the teaching? premenstrual tension will no longer be present. Ovulation will remain the same. Hormone replacements will be needed following this procedure. My monthly menstrual period will be shorter

ovulation will remain the same

A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium? A. ½ cup cubed avocado B. 1 large banana C. 1 medium potato D. 1 cup cooked broccoli

1 cup cooked broccoli

A nurse is providing teaching to a client about exercise safety during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply). A. "I will limit my time in the hot tub to 30 minutes after exercise." B. "I should consume three 8-ounce glasses of water after I exercise." C. "I will check my heart rate every 15 minutes during exercise sessions." D. "I should limit exercise sessions to 30 minutes when the weather is humid." E. "I should rest by lying on my side for 10 minutes following exercise."

I should consume 3 8-oz glasses of water after I exercise I will check my heart rate every 15 min during exercise sessions I should rest by lying on my side for 10 min following exercise

A nurse is assessing a newborn who was born Postterm. Which of the following findings should the nurse expect? A. Nails extending over tips of fingers B. Large deposits of subcutaneous fat C. Pale, translucent skin D. Thin covering of fine hair on shoulders and back

Nails extending over tips of fingers

A community health nurse is providing education on gestational diabetes mellitus (GDM) to a group of clients who are pregnant when discussing risk factors, which of the following ethnicities should the nurse identify as having the lowest incidence of GDM? A. Asian B. Non-Hispanic White American C. Hispanic D. African American

Non-Hispanic White American

A nurse is reviewing laboratory results for a client who is pregnant. The Nurse should expect which of the following laboratory values to increase? RBC count Bilirubin Fasting blood glucose BUN

RBC count

A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care? Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation. Use a fetal scalp electrode during labor and delivery Administer a pneumococcal immunization to the newborn within 4 hours following birth. Bathe the newborn before initiating skin-to-skin contact

administer a pneumococcal immunization to newborn within 4 hrs following birth or bathe newborn before intiating skin-to-skin contact

A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include? A. Tinnitus B. Urinary Frequency C. Breast Tenderness D. Chills

breast tenderness or tinnitus

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent deep-tendon reflexes. Which of the following medications should the nurse administer? a. Phytonadione b. Acetylcysteine c. Protamine sulfate d. Calcium gluconate

calcium gluconate

A nurse is caring for a client who is postpartum folowing the repair of a vaginal laceration. The client has a firm fundus, moderate lochia rubra, and reports moderate perineal discomfort and pressure. Which of the following actions should the nurse take? Check the perineal area Perform deep fundal massage Obtain vaginal culture Administer methylergovide 0.2mg IM

check the perineal area

A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect? A. Bulging Fontanels B. Nasal Flaring C. Length from head to heel of 40 cm (15.7 in) D. Chest circumference 2 cm (0.8 in) smaller than the head circumference

chest circumference 2 cm smaller than head circumference

A nurse in a woman's health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client's risk for developing pelvic inflammatory disease (PID)? A. Recurrent Cystitis B. Frequent Alcohol Use C. Use of Oral Contraceptives D. Chlamydia Infection

chlamydia infection

A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect? A. The client expels the placenta B. The client experiences gradual dilation of the cervix C. The client begins have regular contractions. D. The client delivers the newborn

client delivers the newborn

A nurse is caring for a client who is in active labor. Following epidural placement the nurse obtains a maternal blood pressure of 98/58 mmHg and minimal FHR variability on the fetal monitor. Which of the following images indicates the action the nurse should take? Position the client in a lateral position Administer naloxone to the client Prepare the client for an amnioinfusion Place the client in a knee chest position

connect with oxygen, rush IV fluids, check for bleeding and progress of labor or assist pt to lateral position or administer naloxone to the client

A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider? A. Contraction durations of 95 to 100 seconds B. Contraction frequency of 2 to 3 min apart C. Absent early deceleration of fetal heart rate D. Fetal heart rate is 140/min

contraction durations of 95-100 seocnds

A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding should the nurse expect? decreased urinary output fetal distress dark red vaginal bleeding increased platelet count

dark red vaginal bleeding

A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect? A. Thick, White Vaginal Discharge B. Urinary Frequency C. Vulva Lesions D. Malodorous Discharge

malodorous discharge

A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify which of the following factors places the client at risk for infection. A. Meconium - start fluid B. placenta previa C. Midline episiotomy D. Gestational hypertension

meconium - start fluids

A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? A. Urine protein concentration 200 mg/ 24 hr B. Creatnine 0.8 mg/ dL C. Hemoglobin 14.8 g/ dL D. Platelet Count 60.000/ mm3

platelet count 60.000/mm^3

A nurse is reviewing the laboratory findings of a client who is 10 weeks gestation. Which of the following findings should the nurse report to the provider? WBC 10,000 Hemoglobin 12 g/dL Creatinine 0.5 mg/dL Platelets 100,000

platelets 100,000

A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect? a. renal agenesis b. atrial septal defect c. spina bifida d. hydrocephalus

renal agenesis

A nurse is teaching a client who is 28 weeks of gestation and not up-to date on current immunization. Which of the following immunizations should the nurse inform the client to anticipate receiving following birth? A. Pneumococcal B. Hepatitis C. Human papillomavirus D. Rubella

rubella

A postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. The nurse should recommend that the client use which of the following breastfeeding positions? Side-lying Clutch hold Across-the-lap Cross-cradle

side-lying

A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene? a. Molding b. Vernix Caseosa c.Acrocyanosis d.Sternal retractions

sternal retractions

A nurse is teaching a client who is at 41 weeks of gestation about a non-stress test. Which of the following information should the nurse include in the teaching? A. "This test will confirm fetal lung maturity ". B. "This test will determine adequacy of placental perfusion". C. "This test will detect fetal infection". D. "This test will predict maternal readiness for labor"

this test will predict maternal readiness for labor

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? Mothers will receive prophylactic treatment with acyclovir prior to delivery Transmission can occur via the saliva and urine of the newborn. This infection requires airborne precautions are initiated for the newborn. Lesions are visible on the mother's genitalia.

transmission can occur via saliva and urine of the newborn

A nurse is assessing client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood glucose 110 mg/dL b. Deep tendon reflexes of 2+ c. Urine protein of 3+ d.Hemoglobin 13 g/dL

urine protein of 3+

A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? A. "your contraction will become more intense when walking" B. "you will have dilation and effacement of the cervix" C. You will have bloody show" D. "Your contraction will become temporally regular"

your contraction will become temporarily regular

A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? (pg 76) a. You will have dilation and effacement of the cervix. b. Your contractions will become temporarily regular c. You will have bloody show. d. Your contractions will become more intense when walking.

your contractions will become temporarily regular

A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect? A. Minimal arm recoil B. Popliteal angle of less than 90 C. Creases over the entire sole D. Sparse lanugo

minimal arm recoil

A nurse is caring for a client who is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM 12 hr. Available in dexamethasome 10 mg/mL. How many mL of dexamethasome should the nurse administer per dose?

0.2 mL (rounding up)

A nurse is admitting a client who is in preterm labor to the labor and delivery unit. The nurse should anticipate which of the following tests to assess for fetal lung maturity? L/S ratio Direct coombs test Biophysical prophile Chorionic villi sampling

L/S ratio

A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization? A. An Rh negative mother who has an Rh- positive infant B. An Rh -positive mother who has an Rh- negative infant C. An Rh-positive mother who has an Rh- positive infant D. An Rh- negative mother who has an Rh- negative infant

An Rh negative mother who has an Rh positive infant

A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? Blood pressure 142/92 mm Hg Urine output 100 mL in hr Pulse 58/min Respiratory rate 14/min

BP 142/92 mmHg

A nurse is discussing STIs with a newly licensed nurse. Which of the following infections should the nurse include in the teaching as an indication for a cesarean birth? HIV Chlamydia Gonorrhea Syphillis

HIV

A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. "It burns when I urinate" B. "My feet are really swollen today". C. "I didn't have lunch today, but I have breakfast this morning". D. "I have been seeing spot this morning"

I have been seeing spots this morning

A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.) Administer nitric oxide inhalation therapy to the newborn Insert an orogastric decompression tube with low wall suction. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. Measure the abdominal circumference at the level of the newborn's umbilicus every 2 hr.

administer nitric oxide inhalation therapy to the newborn

A nurse on the labor and delivery unit is caring for a client who is at 33 weeks of gestation and was admitted with placenta previa. Which of the following interventions should the nurse include in the clients plan of care? Administration of magnesium sulfate Routine vaginal exams Ambulation as tolerated Nonstress test twice weekly

administration of magnesium sulfate

A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (select all that apply). A. Amnionitis B. Urinary tract infection C. Polyhydramnios D. Leakage of amniotic fluid E. Preterm labor

amnionitis leakage of amniotic fluid preterm labor oligohydramnios

A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client? a. Intense contractions lasting 45 to 60 seconds b. An urge to have a bowel movement during contractions c. A sense of excitement and warm, flushed skin d. Progressive sacral discomfort during contractions

an urge to have a bowel movement during contractions

A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following non pharmacological comfort measures should the nurse include in the teaching? a. Wear nipple shields during the feeding. b. Use a breast binder for 2 days. c. Use plastic-lined breast pads. d. Apply cabbage leaves after feedings

apply cabbage leaves after feedings

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. What action should the nurse take? a. position the client supine with legs elevated b. instruct the client to pant during contractions c. encourage the client to soak in a warm bath d. apply pressure to the client's sacral area during contractions

apply pressure to pts sacral area during contractions

A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Instruct the client to use effleurage B. Apply counter pressure to the client sacral. C. Assist the client with patterned-paced breathing. D. Teach the client the technique of biofeedback.

assist pt with pattern-paced breathing

A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort? A. Assisting the client into squatting position B. Having the client lie in a supine position C. Applying fundal pressure during contractions D. Encouraging the client to void every 6 hr

assisting client into squatting position

A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Dress the newborn in lightweight clothing. B. Avoid using lotion or ointment on the newborn skin. C. Keep the newborn supine throughout treatment D. Measure the newborn's temperature every 8hr

avoid using lotion or ointment on newborn skin

A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first? A. A client who has diabetes mellitus and an HbA1c of 5.8% B. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L D. A client who has placenta previa and a hematocrit of 36% E. "I have been seeing spot this morning"

client who has hyperemesis gravidarum and a sodium level of 110 mEq/L

A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider? A client who has a urinary output of 300 ml in 8 hr A client who reports abdominal cramping during breastfeeding A client who is receiving magnesium sulfate and has absent deep tendon reflexes A client who reports lochia rubra requiring changing perineal pads every 3 hr

client who is receiving magnesium sulfate and has absent deep tendon reflexes

A nurse in a provider's office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Nagele's rule to calculate the estimated date of delivery

december 15th

A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions should the nurse take? a. Demonstrate how to hold the newborn and allow client to practice. b. Persuade the client to breastfeed the newborn to promote bonding. c. Offer to take the newborn to the nursery to finish his feeding. d. Insist that the mother pick up the newborn to feed him.

demonstrate how to hold the newborn and allow client to practice

A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help retrieve this common discomfort of pregnancy? a. Include 18 g of fiber in the diet each day. b. Drink 2 to 3 L of water each day. c. Add 30 mL of mineral oil to each meal. d. Tale 60 mL of magnesium hydroxide once daily

drink 2-3 L of water each day

A nurse is caring for a preterm newborn immediately after delivery. Which of the following actions should the nurse take first? Dry the infant under the radiant warmer Take the infant's temperature Weigh the infant Obtain the infants blood glucose

dry the infant under the radiant warmer

A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? a. Apply suprapubic pressure. b. Administer a diuretic to the client. c. Insert an indwelling urinary catheter. d. Encourage the client to void in the shower

encourage client to void in the shower

A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take? A. Place a snug dressing on the client's nipple when not breastfeeding. B. Ensure the newborn's mouth is wide open before latching to the breast. C. Encourage the client to limit the newborn's feeding to 10 min on each breast. D. Instruct the client to begin the feeding with the nipple that is most tender

ensure newborn's mouth is wide open before latching to the breast

A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A. Apply a thin layer of lotion to the newborn skin every 8 hrs. B. Give the newborn 1oz of glucose water every 4 hrs C. Ensure the newborn eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy

ensure newborns eyes are closed beneath the shield

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take? a. Apply an ice pack to the incision site. b. Replace the surgical dressing. c. Administer 500 mL lactated Ringer's IV bolus. d. Evaluate urinary output.

evaluate urinary output

A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following findings indicates narcotic withdrawal? Excessive crying Unequal pupils RR of 50/min Hypotonia

excessive crying

A nurse is assessing a newborn following a forceps assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method? Hypoglycemia Polycythemia Facial Palsy Bronchopulmonary dysplasia

facial palsy

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? Facial petechiae Erythema toxicum Periauricular papillomas Tetangilectatic nevi

facial petechiae

A nurse is reviewing the med record of a client who is at 39 wks gestation and has polyhydramnios. What finding should the nurse expect? a. total pregnancy wt gain of 3.6 kg b. fetal GI anomaly c. gestational HTN d. fundal height of 34 cm

fetal GI anomaly

A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heart beat. Which of the following terms should the nurse use to document this finding? a. Goodell's sign b. Funic souffle c. Quickening d. Hegar's sign

funic souffle

A nurse is receiving laboratory results for a term newborn who is 24 hr old. Which of the following results require intervention by the nurse? A. WBC count 10,000/mm3 B. Platelets 180,000/mm3 C. Hemoglobin 20g/dL D. Glucose 20 mg/dL

glucose 20 mg/dL

A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? Hyperemesis Proteinuria Hypoxia Hemorrhage

hemorrhage

A nurse is reviewing the medication prescriptions for a newborn who is 6 hours old and whose mother is HBsAg-positive. The nurse should anticipate administering which of the following medications? Hepatitis B Immune Globulin Hepatitis A immune Globulin Haemophilus iinfluenzae type B vaccine Hepatitis A vaccine

hep B immune globulin

A nurse is teaching a prenatal class about immunizations that newborns receive following birth. Which of the following immunizations should the nurse include in the teaching? A. Hepatitis B B. Rotavirus C. Pneumococcal D. Varicella

hepatitis B

A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include? A. Focusing on controlling body functions B. "Synchronized breathing will be required during hypnosis" C. "Hypnosis can be beneficial in you practiced it during the prenatal period" D. "Hypnosis does not work for controlling pain associated with labor".

hypnosis can be beneficial if you practiced it during the prenatal period

A nurse is teaching a prenatal client about listeriosis and dietary modifications due to pregnancy. Which of the following statements made by the client indicates an understanding of the teaching? I can have a mid day snack with soft cheese I can purchase a seafood salad from the grocery store I can still have a hotdog at the ball park I can eat grilled chicken on a bun at lunch time

i can eat grilled chicken on a bun at lunch time

A nurse is assessing a client who is at 37 weeks of gestation. Which of the following statement by the client requires immediate intervention by the nurse? A. "It burns when I urinate B. "My feet are really swollen today". C. "I didn't have lunch today, but I have breakfast this morning". D. " I have been seeing spots this morning"

i have been seeing spots this morning

A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following statements by the client indicates an understanding of the teaching? I should apply a warm compress after feeding I should apply lanolin to the infection site I should use a nipple shield while breastfeeding I should stop breast feeding until the infection has healed

i should apply a warm compress after feeding

A nurse is providing discharge teaching to the parent of a newborn about surgical site care following circumcision using a clamp technique. Which of the following statements by the parent indicates an understanding of the teaching? I will check the site hourly I will remove the crust with each diaper change I will wash the penis with soap and water daily I will apply petroleum jelly to the area with each diaper change

i will apply petroleum jelly to the area w/ each diaper change

A nurse is teaching a client who is post partum about car seat safety. Which of the following statements indicates understanding of the instructions? I will make sure the retainer clip is at the level of my baby's abdomen I will position the car seat in the fron passenger seat facing the front of the... I will adjust the angle of the car seat so that my baby sits at a 90 degree angle I will place the shoulder harness slightly below my babys shoulders

i will make sure retainer clip is at level of my baby's abdomen

A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? Increase the infusion rate every 30 to 60 min. Maintain the client in a supine position. Titrate the infusion rate by 4 milliunits/min. Limit IV intake to 4 L per 24 hr

increase infusion rate every 30-60 min or limit IV intake to 4 L per 24 hrs

A nurse is teaching a client who is pregnant about a new prescription for iron supplements. Which of the following instructions should the nurse include in the teaching? Increase intake of foods rich in vitamin C Take an extra pill if you miss a dose Report black stools to the provider Drink 8 ox of milk with each pill

increase intake of foods rich in vitamin C

A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take? A. Provide a stimulating environment B. Monitor blood glucose level every hr. C. Initiate seizure precautions. D. Place the infants on his back with legs extended

initiate seizure precautions

A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take? A. Administer indomethacin B. Insert a second using a 22 gauge IV catheter, C. Insert an indwelling urinary catheter. D. Administer oxygen at 4L/min via nasal cannula

insert indwelling urinary catheter

A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex? Make a loud noise above the newborn Touch the newborns cheek with a finger Turn the newborns head to one side Tap the newborns forehead with one finger

make a loud noise above the newborn

A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take? a. Lay the tape measure horizontally over the middle of the client's abdomen. b. Place the client in a left-lateral position to obtain the measurement. c. Ensure that the client has a full bladder before taking the measurement. d. Measure from the upper border of the pubis to the upper border of the fundus

measure from upper border of the pubis to the upper border of the fundus

A nurse is caring for a client who is 14 weeks of gestation. At which the following locations should the nurse place the Doppler device when assessing the fetal heart rate? A. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis B. Left Upper Abdomen C. Two fingerbreadths above the umbilicus D. Lateral at the Xiphoid Process

midline 2-3 cm above symphysis pubis

A nurse is caring for a client who has gestational hypertension and is experiencing postpartum hemorrhage. Which of the following medications should the nurse anticipate? A.Dinoprostone B.Misoprostol C.Methylergonovine D.Carboprost

misoprostol

A nurse is caring for four newborns. Which of the following newborns should the nurse assess first? A. newborn who has nasal flaring B. newborn who has subconjunctival hemorrhage of the left eye C. A newborn who has overlapping suture lines D. A newborn who has not rust-stained urine

newborn who has nasal flaring

A nurse is assessing a full term newborn 1 hr following a vaginal birth. Which of the followin is an expected assessment finding? The newborn's anterior fontanel bulges when he is quiet The newborn's head circumference is greater than the chest circumference The newborn exhibits apneic episodes of 30 seconds The newborn has a heart rate of 70/min while sleeping

newborns head circumference is greater than the chest circumference

A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy? a. Check the newborn's identification using the crib card. b. Replace the infant's identification band after his name has been recorded. c. Require visitors to wear an identification band. d. Obtain an imprint of the infant's feet prior to taking him to the nursery

obtain an imprint of the infant's feet prior to taking him to the nursery

A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take? A. Give the newborn a warm bath. B. Apply a cap to the newborn head C. Reposition the newborn. D. Obtain an oxygen saturation level

obtain an oxygen saturation level

A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take? A. Obtain a blood sample for a serum glucose level B. Feed the newborn immediately C. Administer 50 mL of dextrose solution IV D. Reassess the blood glucose level prior to the next feeding

obtain blood sample for serum glucose level or reassess blood glucose level prior to next feeding

A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask. b. Place newborn bassinets at least 3 feet apart. c. Place the newborn's foot on a sterile field during a heel stick. d. Maintain airborne precautions in the nursery

place newborn bassinets at least 3 ft apart

A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take? Decrease maintenance IV solution infusion rate. Place the client in lateral position. Administer misoprostol 25 mcg vaginally Administer oxygen via face mask at 2 L/min

place the pt in a lateral position

A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? Hemoglobin 14.8 g/dL Urine protein concentration 200 mg/24 hr Creatinine 0.8 mg/dL Platelet count 60,000/mm3

platelet count 60,000 mm^3

A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care? A. Increase the newborn's visual stimulation B. Weigh the newborn every other day C. Discourage parental interaction until after a social evaluation D. Swaddle the newborn in a flexed position

swaddle newborn in a flexed position

A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statements by client indicates an understanding of the teaching? "The medication could cause me to experience heart palpitation" "This medication could causeterm-3 me to experience blurred vision" "This medication could cause me to experience ringing in my ears" "This medication could cause me to experience frequent ..."

the medication could cause me to experience heart palpitation

A nurse is developing an educational program about hermolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hermolytic disease? A. The mother is Rh positive and the father is Rh negative B. The mother is Rh negative and the father is Rh positive C. The mother and the father are both Rh positive D. The mother and the father are both Rh negative

the mother is Rh negative and father is Rh positive

A nurse in a providers office is caring for a 20 year old client who is 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make? You cannot have an amniocentesis until you are at least 35 years of age This procedure determines if your baby has genetic or congenital disorder Your provider will schedule a chorionic villus sampling to determine the sex of the baby We can scheduel the procedure for later today if youd like

this procedure determines if your baby has genetic or congenital disorder

A nurse is reviewing signs of effective breathing with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching? A. "You should feel a tugging sensation when the baby is sucking. B. You should expect your baby to have two to three wet diapers in 24 hour period C. "Your baby's urine should appear dark and concentrated". D. "Your breast should stay firm after the baby breastfeeds".

you should feel a tugging sensation when baby is sucking