4467 AQ 1
The nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours after delivery. How would the nurse determine that the uterus is demonstrating appropriate involution? 1 The amount of lochia rubra is moderate. 2 Numerous clots are being passed vaginally. 3 Bleeding from the episiotomy has stopped. 4 Uterine cramps are absent during breast-feeding.
1 The amount of lochia rubra is moderate.
Which occurs immediately after birth that increases the risk for cardiac decompensation in a client with a compromised cardiac system? 1 Increased pressure is placed on the veins. 2 Intra-abdominal pressure is significantly increased. 3 The blood flow to the heart is decreased considerably. 4 Extravascular fluid is remobilized into the vascular compartment.
4 Extravascular fluid is remobilized into the vascular compartment.
A client at 37 weeks' gestation is in the emergency department after a motor vehicle accident. Vital signs upon admission are BP 110/72 mm Hg, HR 98 beats/min. The client begins complaining of sudden, sharp abdominal pain, and repeated vital signs are BP 90/60 mm Hg, HR 108 beats/min. Which nursing intervention is the priority at this time? 1 Apply an electronic fetal monitor. 2 Prepare for a possible cesarean birth. 3 Draw blood for a type and cross-match. 4 Assess the amount of vaginal bleeding.
1 Apply an electronic fetal monitor.
While caring for a client during labor, which would the nurse remember about the second stage of labor? 1 It ends at the time of birth. 2 It ends as the placenta is expelled. 3 It begins with the transition phase of labor. 4 It begins with the onset of strong contractions.
1 It ends at the time of birth.
For a pregnant client with type 1 diabetes, which action is most likely to reduce the risks of disease-related complications? 1 Monitor and control blood glucose levels. 2 Limit pregnancy weight gain to an average of 25 pounds. 3 Preplan for a cesarean section. 4 Attend all prenatal office visits.
1 Monitor and control blood glucose levels.
Which is the most appropriate nursing intervention for a client admitted to the high-risk prenatal unit at 35 weeks' gestation with a diagnosis of complete placenta previa? 1 Applying a pad to the perineal area 2 Having oxygen available at the bedside 3 Allowing bathroom privileges with assistance 4 Educating the client regarding the intensive care nursery
2 Having oxygen available at the bedside
Which activity would the nurse suggest for a client in labor who is having frequent painful contractions and whose cervix has been dilated 2 cm for several hours without progression? 1 Lying in bed on the right side 2 Therapeutic rest 3 Taking a walk around the labor unit 4 Using nipple stimulation to augment labor
2 Therapeutic rest
Which statement by a client who was normal weight before pregnancy indicates the need for further teaching regarding weight gain guidelines? 1 "I should gain 25 to 35 pounds total during the pregnancy." 2 "I shouldn't try to lose weight or cut calories while pregnant." 3 "I should gain 1 to 2 pounds per week through the entire pregnancy." 4 "I may need additional testing if I gain more than 6 to 7 pounds in 1 month."
3 "I should gain 1 to 2 pounds per week through the entire pregnancy."
Which finding would the nurse be most concerned about in the client receiving a bolus of magnesium sulfate intravenously for the treatment of preeclampsia? 1 Flushing 2 Diaphoresis 3 Blurred vision 4 Burning at the intravenous (IV) site
3 Blurred vision
A client who is in labor is admitted 30 hours after her membranes ruptured. Which condition is this client at increased risk for? 1 Cord prolapse 2 Placenta previa 3 Chorioamnionitis 4 Abruptio placentae
3 Chorioamnionitis
Which recommendation would the nurse provide to a pregnant woman who reports leg cramps? 1 Application of an ice pack to relax the muscle 2 Dorsiflexion of the foot until the spasm passes 3 Over-the-counter analgesics to relieve inflammation 4 Sleeping with extra pillows at night to support the legs
2 Dorsiflexion of the foot until the spasm passes
Which pregnant client would be at increased risk of placenta previa? 1 19 years old, gravida 1, para 0 2 30 years old, gravida 6, para 5 3 25 years old, gravida 2, para 1 4 29 years old, gravida 3, para 0
2 30 years old, gravida 6, para 5
Which are the primary goals of prenatal nursing care? Select all that apply. One, some, or all responses may be correct. 1 Safe birth for mother and infant 2 Pregnant woman's self-management 3 Promote health and well-being of mother and infant 4 Satisfaction of mother and family with the birth experience 5 Understand psychosocial factors that influence the woman
1 Safe birth for mother and infant 3 Promote health and well-being of mother and infant 4 Satisfaction of mother and family with the birth experience
The nurse is caring for a client whose fetus is in a breech presentation. The membranes rupture and meconium appears in the vaginal introitus. Which would the nurse recognize this indicates? 1 A potential for cord prolapse 2 Evidence of fetal heart abnormalities 3 A common occurrence in breech presentations 4 A condition requiring immediate notification of the primary health care provider
3 A common occurrence in breech presentations
Which information would the nurse include in the teaching for a client who received methotrexate? Select all that apply. One, some, or all responses may be correct. 1 Urine is considered toxic for 48 hours. 2 Avoid sexual intercourse for 72 hours. 3 Gastric distress is a possible side effect. 4 Stools will contain some residual methotrexate for 7 days. 5 Double flush the toilet with the lid down after urinating.
3 Gastric distress is a possible side effect. 4 Stools will contain some residual methotrexate for 7 days. 5 Double flush the toilet with the lid down after urinating.
A woman who is admitted to the labor suite has herpes simplex virus type 2 (HSV-2) with active lesions in the perineal area. Which action would the nurse's plan of care include? 1 Withholding oral fluid intake 2 Discussing the need for formula feeding 3 Obtaining permission for a paracervical block 4 Applying moist compresses to the perineal area
1 Withholding oral fluid intake
Which postpartum complication would the nurse monitor for in a client with hydramnios? 1 Infection 2 Hemorrhage 3 Hypertension 4 Thromboembolism
2 Hemorrhage
Which statement by a woman with preeclampsia indicates the need for further teaching about needed dietary changes? 1 "I should avoid excess salt." 2 "I should limit my fluid intake." 3 "I should eat whole grains and raw produce." 4 "I should eat 60 to 70 grams of protein each day."
2 "I should limit my fluid intake."
The pregnant client asks the nurse whether changing the cat's litter box is harmful to her or the fetus. How would the nurse reply? 1 "Cat litter is not harmful during pregnancy." 2 "Exposure to cat litter for short periods of time is not harmful." 3 "There are several factors that determine a person's response to the toxins in cat litter." 4 "Fetal abnormalities are associated with exposure to cat litter, even after minimal contact."
3 "There are several factors that determine a person's response to the toxins in cat litter."
A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How would the nurse, using the GTPAL format, document the client's obstetric history? 1 G4 T3 P2 A1 L4 2 G5 T2 P2 A1 L4 3 G5 T2 P1 A1 L4 4 G4 T3 P1 A1 L4
3 G5 T2 P1 A1 L4
For which condition are pregnant women at a five- to sixfold increased risk? 1 Bradycardia 2 Hypertension 3 Thromboembolic disease 4 Decreased cardiac output
3 Thromboembolic disease
A client at her first visit to the prenatal clinic states that she has missed three menstrual periods and thinks that she is carrying twins because her abdomen is so large. She now has a brownish vaginal discharge. Her blood pressure is increased, indicating that she may have gestational hypertension. Which condition is suggested by this client profile? 1 Renal failure 2 Placenta previa 3 Hydatidiform mole 4 Abruptio placentae
3 Hydatidiform mole
A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For which complication would the nurse assess when caring for this client? 1 Vaginal bleeding 2 Urinary tract infection 3 Prolapse of the umbilical cord 4 Meconium in the amniotic fluid
3 Prolapse of the umbilical cord
Which action would the nurse take before birth when meconium staining is present? Select all that apply. One, some, or all responses may be correct. 1 Monitoring the neonate's heart rate 2 Evaluating the neonate's muscle tone 3 Assessing the neonate's respiratory effort 4 Suctioning the neonate's mouth and nose 5 Gathering equipment for neonatal resuscitation
5 Gathering equipment for neonatal resuscitation
A pregnant client in the third trimester tells the nurse in the prenatal clinic that she is experiencing heartburn after every meal. Which explanation would the nurse provide regarding the cause of the heartburn? 1 "The esophageal sphincter relaxes and allows acid to be regurgitated." 2 "In pregnancy, gastric motility increases, causing a burning sensation." 3 "In pregnancy, gastric pH increases, causing acid to enter the esophagus." 4 "In pregnancy, the pyloric sphincter relaxes, allowing acid to enter the intestine."
1 "The esophageal sphincter relaxes and allows acid to be regurgitated."
The nurse caring for a client receiving magnesium sulfate observes respirations of 10 breaths/minute, heart rate of 68 beats/minute, and blood pressure of 88/50 mm Hg. After discontinuing the magnesium sulfate, which priority action would the nurse take? 1 Administer oxygen. 2 Initiate rescue breathing. 3 Initiate a bolus of intravenous (IV) fluid. 4 Administer calcium gluconate.
4 Administer calcium gluconate.
Which finding would the nurse be most concerned about when reviewing the chart of a client scheduled for an amniocentesis? 1 Hepatitis B 2 Prior uterine surgery 3 Active genital herpes 4 B negative blood type
4 B negative blood type
Which musculoskeletal changes directly place pregnant clients at increased risk for falls? Select all that apply. One, some, or all responses may be correct. 1 Back pain 2 Joint laxity 3 Weight gain 4 Impaired balance 5 Shifting center of gravity
2 Joint laxity 4 Impaired balance 5 Shifting center of gravity
Which complication is the pregnant client at risk for related to the dilation of renal pelves and ureters? 1 Frequent urination 2 Urinary tract infection 3 Glomerular filtration rate decreases 4 Increased urinary excretion of protein and albumin
2 Urinary tract infection
Which is the optimal nursing intervention to minimize perineal edema after an episiotomy? 1 Applying ice packs 2 Offering warm sitz baths 3 Administering aspirin as needed 4 Elevating the hips on a pillow
1 Applying ice packs
The nurse performs Leopold maneuvers on a newly admitted client in labor. Palpation reveals a soft, firm mass in the fundus; a firm, smooth mass on the mother's left side; several knobs and protrusions on the mother's right side; and a hard, round, movable mass in the pubic area with the brow on the right. On the basis of these findings, the nurse determines that the fetus is in which position? 1 LOA 2 ROA 3 LMP 4 RMP
1 LOA
Which clinical condition concerns the nurse the most for an obstetrical client with heart disease? Select all that apply. One, some, or all responses may be correct. 1 Obesity 2 Anemia 3 Hypertension 4 Hypothyroidism 5 Emotional distress
1 Obesity 2 Anemia 3 Hypertension 5 Emotional distress
Which are risk factors of diabetes in pregnancy? Select all that apply. One, some, or all responses may be correct. 1 Preterm birth 2 Hypertension 3 Cesarean birth 4 Placenta previa 5 Placental abruption
1 Preterm birth 2 Hypertension 3 Cesarean birth
A woman arrives for an appointment at an obstetrics clinic. During the visit the nurse records the following information. Which finding indicates a need for future intervention? 1 Rubella titer less than 1:8 (nonimmune) 2 No fetal heartbeat heard with fetoscope 3 Hemoglobin 11 g/dL, hematocrit 31% 4 Maternal blood type A-negative, father O-negative
1 Rubella titer less than 1:8 (nonimmune)
Which is the nurse's priority action when caring for an obstetrical client experiencing eclampsia? 1 Turn the head to one side. 2 Obtain the fetal heart rate. 3 Administer magnesium sulfate. 4 Prepare for an emergency delivery.
1 Turn the head to one side.
A client at 36 weeks' gestation has a blood pressure of 140/90. Which additional sign of preeclampsia would the nurse assess for? 1 Urine dipstick positive for protein 2 Mild ankle edema 3 Episodes of dizziness on arising 4 Weight gain of 2 lb (907 g) in 2 weeks
1 Urine dipstick positive for protein
Why is it important for the nurse to encourage a client with preeclampsia to lie in the left-lateral recumbent position? 1 Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved. 2 Intra-abdominal pressure on the iliac veins is maximized, and there is increased blood flow to the pelvic area. 3 Aortic compression is maximized, thereby decreasing uterine arterial pressure and increasing uterine blood flow. 4 Hemoconcentration is maximized, thereby reducing blood volume and cardiac output and increasing placental perfusion.
1 Uterine and kidney perfusion are maximized, and compression of the major vessels is relieved.
An electronic fetal monitor is applied to a client in labor who is dilated to 4 cm. Which assessment finding would cause the nurse to notify the health care provider? 1 Contractions every 4 minutes that last 50 seconds 2 Contractions every 1 to 2 minutes lasting 90 seconds 3 Fetal heart rate accelerations at the beginning of a contraction 4 Fetal heart rate decelerations to 110 beats/min before the peak of a contraction
2 Contractions every 1 to 2 minutes lasting 90 seconds
Which is the nurse's priority assessment for a client in the fourth stage of labor? 1 Degree of relaxation 2 Distention of the bladder 3 Extent of breast engorgement 4 Presence of mother-infant bonding
2 Distention of the bladder
Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction? 1 Massage 2 Effleurage 3 Acupressure 4 Counterpressure
2 Effleurage
Which would the nurse ask the postpartum client to do before assessing her uterine fundus? 1 Drink fluids. 2 Empty her bladder. 3 Perform the Valsalva maneuver. 4 Assume the semi-Fowler position.
2 Empty her bladder.
A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. Which statement would be the correct interpretation of these findings? 1 Infection is present. 2 Cesarean birth is necessary. 3 Precipitate birth is imminent. 4 The fetus may be compromised in utero.
4 The fetus may be compromised in utero.
On arriving in the birthing room the nurse finds the client lying on her back with her head on a pillow and the bed in a flat position. The nurse explains that it is important to avoid lying in the supine position because of which reason? 1 It may precipitate a severe headache. 2 It can impede the progression of labor. 3 It may cause nausea as labor progresses. 4 It will prevent adequate blood flow to the fetus.
4 It will prevent adequate blood flow to the fetus.
A client in active labor is admitted to the birthing room. A vaginal examination reveals that her cervix is dilated 6 to 7 cm. In light of this finding, which would the nurse expect? 1 The client may experience nausea and vomiting. 2 The client's bloody show will become more profuse. 3 The client will experience uncontrollable shaking of her legs. 4 The client's contractions will become longer and more frequent.
4 The client's contractions will become longer and more frequent.
