Synthesis exam 4

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine tenderness

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

You are reviewing the complete blood count for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the physician before surgery?

White blood cell count of 16,000/mm3

The nurse is caring for a client admitted to the surgical nursing unit following right modified radical mastectomy. The nurse includes which of the following in the nursing plan of care for this client?

check the right posterior axilla area when assessing the surgical dressing

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?

Delivery of the fetus

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin (Pitocin).

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal wellbeing.

The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?

Fetal heart rate of 180 beats/minute

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up?

Fetal heart rate of 180 beats/minute

Which assessment finding following an amniotomy should be conducted first?

Fetal heart rate pattern

While assessing a 29-year-old G2P2 patient who had a normal spontaneous vaginal delivery 30 minutes ago, you note a large amount of red vaginal bleeding. What would be your first priority nursing action?

Firmly massage the uterine fundus.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

G = 2, T = 1, P = 0, A = 0, L = 1

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice?

Hemoglobin 9.1 g/dL

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?

Hypotonic

As a home health nurse, you are obtaining an admission history for a patient who has DVT and is taking warfarin 2mg daily. Which statement by the patient is the best indicator that additional teaching about warfarin may be needed?

I have started to eat more healthy foods like green salads and fruit.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action?

Increase hydration by encouraging oral fluids.

The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester?

Increase in pulse rate

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy?

Increased efficiency of contractions

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate?

Inform the client that these contractions are common and may occur throughout the pregnancy.

The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action?

Initiate a gentle upward tap on the cervix.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate?

Instruct the client to request help when getting out of bed.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

Isoniazid plus rifampin (Rifadin) will be required for 9 months.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart?

July 26, 2015

While you are working in the clinic, a healthy 32 year old woman whose sister is a carrier of the BRCA gene asks you which form of breast cancer screening is the most effective for her. Which response is best?

MRI is recommended in addition to annual mammography

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate?

Massage the fundus until it is firm.

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate

What are the signs/symptoms of Phenylketonuria (PKU) in infants?

Musty odor of the urine

A 26-year old multigravida is 14 weeks' pregnant and is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does the alpha-fetoprotein test indicate?" The nurse bases a response on the knowledge that this test can detect:

Neural tube defects

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP).

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the health care provider.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise?

Persistent non-reassuring fetal heart rate

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?

Place the client in Trendelenburg's position.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?

"What can I do for you?"

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps?

"Bend your foot toward your body while extending the knee when the cramps occur."

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?

"I need to lie flat on my back to perform the procedure."

The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction?

"I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions?

"I should avoid eating foods that produce gas and fatty foods."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I should avoid exercise because of the negative effects on insulin production."

The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions?

"I should wear knee-high hose, but I should not leave them on longer than 8 hours."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1. "I will watch for the evidence of the passage of tissue."

"I will maintain strict bed rest throughout the remainder of the pregnancy."

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity."

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client?

"The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence."

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

. Administer oxygen via face mask.

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area?

1 cm above the ischial spine

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? Select all that apply.

1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily.

The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy? Select all that apply.

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.

1. Proteinuria 2. Hypertension 4. Generalized edema

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.

2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding?

30 cm

. The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply.

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age.

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation?

A gravida II who has just been diagnosed with dead fetus syndrome

A 39-year-old multigravida client at 39 weeks gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to:

Remain in a side lying position with the head elevated

You are working on the PACU caring for a 32 year old client who has just arrived after undergoing dilation and curettage to evaluate infertility. Which assessment finding should be immediately communicated to the surgeon?

Sharp, continuous, level 8 (out of 10) abdominal pain

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant.

As the charge nurse in the labor and delivery unit, you need to assign two patients to one of the RNs because of a staffing shortage. Normally on your unit the nurse-patient ratio is 1:1. Which two patients would you assign to the RN?

A. 30-year-old G1P0 woman, 40 weeks, 2 cm/90% effaced/-1 station B. 17-year-old G1P0 woman with premature rupture of membranes, no labor at 35 weeks

A 24-year-old G1P0 patient, who is receiving oxytocin (Pitocin), is in labor at 41 weeks' gestation. Which are appropriate nursing actions in the presence of late fetal heart rate decelerations? (Select all that apply.)

A. Discontinue the oxytocin. B. Administer oxygen to the mother by mask. C. Notify the provider.

You are caring for a patient with in indwelling catheter. The patient complains of spasm like pain in the catheter insertion site. Which of the following options below are other signs and symptoms that the patient could experience or the nurse could observe if a urinary tract infection is present? Select all that apply.

A. Increased WBC B. Feeling need to void even though catheter is present C. Dark and cloudy urine D. Cramping

A 36-year-old G1P0 patient has received an epidural anesthetic. Her cervix is 6 cm dilated. Her blood pressure is currently 60/38 mm Hg. Which would be appropriate priority nursing actions? (Select all that apply.)

A. Turn the patient to a lateral position. B. Notify the anesthesiologist.

A 32- year- old patient with sickle cell anemia is admitted to the hospital during a sickle cell crisis. Which action prescribed by the health care provider will you implement first?

Administer 100% oxygen using a NRB mask

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?

Administer oxygen, 8 to 10 L/minute, via face mask.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

You are the charge nurse on the oncology unit. Which client is best to assign to an RN who has floated from the ED?

Client with metastatic prostate cancer who requires frequent assessment and treatment for breakthrough pain

A 22-year-old woman is 6 weeks postpartum. In the clinic she admits to crying every day, feeling overwhelmed, and sometimes thinking that she may hurt the baby. What would be the priority nursing action at this time?

Contact the provider to evaluate the patient before allowing her to leave the clinic.

A 68 year old client who is ready for discharge from the ED has a new prescription for nitroglycerin 0.4 mg sublingual as needed for angina. Which client information has the most immediate implications for teaching?

The client uses sildenafil (Viagra) several times weekly for erectile dysfunction

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action?

The client with lochia that is red and has a foul-smelling odor.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

14 and 18

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)?

A client who has a history of intravenous drug use

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

A normal test result

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic?

A softening of the cervix

A 19-year-old G1P0 patient at 40 weeks' gestation who is in labor is being treated with magnesium sulfate for seizure prophylaxis in preeclampsia. Which are priority assessments with this medication? (Select all that apply.)

A. Check deep tendon reflexes. B. Check the respiratory rate. C. Note the urine output.

You have received orders to initiate phototherapy on a 36-hour-old newborn with an elevated bilirubin level. What instructions will you give the student nurse who is assisting in the care of the infant? (Select all that apply.)

A. Cover the infant's eyes with a mask. B. Monitor the infant's temperature closely.

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss?

An increase in the pulse from 88 to 102 BPM

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate.

Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. You find that the wound edges are open and loops of intestine are protruding. Which action should you take first?

Cover the wound with saline soaked dressings

alkylating agents (making nursing judgment) What should the nurse monitor with alkylating agents?

I/O and blood counts

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding?

Normal

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell that client that which exercise is safest?

Swimming

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?

The cervix is dilated completely.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider?

The client complains of a headache and blurred vision.

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease

The nurse in the outpatient clinic is assessing a 22 year old who required a splenectomy after a recent motor vehicle accident. Which information obtained during the assessment will be of most immediate concern to the nurse

The oral temperature is 100 degrees F

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide?

Wash the breasts with warm water and keep them dry.