ATI MN

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine

A. 480 mL urine output in 24 hr

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? A. Abundant lanugo B. Good flexion C. Heel creases covering the bottom of the feet D. Dry, parchment-like skin

A. Abundant lanugo

A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? A. Copper intrauterine device B. Combination pill C. Vaginal ring D. Medroxyprogesterone injection

A. Copper intrauterine device

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take? A. Encourage the client to frequently change positions. B. Instruct the client to take breaths and hold them for 10 seconds while pushing C. Assess maternal vital signs every 1 hour D. Assist the client to the restroom

A. Encourage the client to frequently change positions.

A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Periodic numbness of fingers

A. Frequent headaches

A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth

A. Gestational diabetes

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

A. Hemoglobin 12 g/dL

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy

A. Hyperbilirubinemia

A nurse is caring for a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform? A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure B. Assess the fetal heart rate pattern for 10 min prior to the procedure C. Position the client upright and erect on the edge of the bed prior to the procedure D. Monitor vital signs every 15 min after the anesthetic is placed

A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

A. Intraventricular hemorrhage

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn

A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor

A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°

A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°

A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy? A. Nausea in the morning B. Positive home pregnancy test C. Increased sensitivity of the cervix noted upon examination D. Gestational sac observed by transvaginal ultrasound

A. Nausea in the morning

A nurse is providing care for a client who is in the second stage of labor. The fetal heart tracing indicates multiple variable decelerations. Which of the following actions should the nurse take? A. Prepare an amnioinfusion B. Place the client in a supine position C. Administer oxygen 2 L/min via nasal cannula D. Give a glucocorticoid

A. Prepare an amnioinfusion

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin

A. Small, pinpoint, reddish-purple spots on the chest

A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take? A. Stop the oxytocin infusion B. Apply oxygen at 2 L/min via nasal cannula C. Administer methylergonovine intramuscularly D. Prepare for an emergent cesarean birth

A. Stop the oxytocin infusion

A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should notify the provider about which of the following assessment findings? A. The client reports a frequent cough. B. The client reports that none of her shoes fit anymore. C. The client reports a weight gain of 2 lb in a 2-week period. D. The client reports leg cramps in the evening.

A. The client reports a frequent cough.

A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? A. The fundal height measures greater than gestational age. B. A rigid abdomen is noted on palpation. C. The client reports a pain level of 8 on a 0-to-10 pain scale. D. A urine drug screen is positive for cocaine.

A. The fundal height measures greater than gestational age.

A nurse is performing a physical assessment of a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward

A nurse is caring for a client at 37 weeks gestation who is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? A. Use vibroacoustic stimulation on the client's abdomen for 3 sec B. Report the nonreactive test result to the provider immediately C. Request a prescription for an internal fetal scalp electrode D. Auscultate the FHR with a Doppler transducer

A. Use vibroacoustic stimulation on the client's abdomen for 3 sec

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? A. Uterine tone B. Fetal heart rate C. Blood pressure D. Amount of bleeding

A. Uterine tone

A nurse is caring for a client who is in labor. The client speaks a different language than the nurse and is grimacing. Which of the following actions should the nurse take while waiting for an interpreter? A. Administer pain medication B. Change the client's position C. Insert an indwelling urinary catheter D. Prepare for an epidural insertion

B. Change the client's position

A nurse is providing discharge instructions for a client who had a cesarean birth 4 days ago. The client's hemoglobin level is 9.2 g/dL, and the provider has prescribed an iron supplement. Which of the following foods should the nurse recommend to help increase the client's iron intake? A. Spinach B. Citrus fruit C. Milk D. Whole-grain bread

B. Citrus fruit

A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitor tracing? A. Contractions that last for 60 sec each with a 4 min rest between contractions B. Contractions that last for 60 sec each with a 3 min rest between contractions C. A contraction that lasts for 4 min followed by a period of relaxation D. Contractions that last for 45 sec each with a 3 min rest between contractions

B. Contractions that last for 60 sec each with a 3 min rest between contractions

A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation? A. Breathing techniques B. Counter-pressure C. Biofeedback D. Use of a focal point

B. Counter-pressure

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability

B. Decreased blood glucose

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication? A. Slow respirations B. Decreased blood pressure C. Bradycardia D. Flushed skin

B. Decreased blood pressure

A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can only be obtained from continuous electronic fetal monitoring? A. Determination of a baseline B. Determination of variability C. Presence of accelerations D. Presence of decelerations

B. Determination of variability

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age. B. Discard opened cans of formula after 48 hr refrigeration. C. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet. D. Bottles and nipples can be hand-washed in hot, soapy water.

B. Discard opened cans of formula after 48 hr refrigeration.

A nurse is assessing a client who is pregnant and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort? A. Relaxin B. Estrogen C. Progesterone D. Human chorionic somatomammotropin (HCS)

B. Estrogen

A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus

B. Feeling of warmth

A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority? A. Blood pressure 90/52 mmHg B. Ketones 2+ C. Specific gravity 1.035 D. Sodium 130 mEq/L

B. Ketones 2+

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic diseas

B. Menorrhagia

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? A. Administer the oxytocin with manual IV tubing B. Monitor the fetal heart rate every 15 minutes initially C. Begin the infusion at 10 milliunits/min D. Titrate the dosage until the client has 1 contraction every minute

B. Monitor the fetal heart rate every 15 minutes initially

A nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include? A. Count the fetal heart rate for 15 seconds after contractions B. Palpate and count the maternal radial pulse while listening to the fetal heart rate C. Place the listening device over the fetal chest to hear the fetal heart rate D. Percuss the maternal abdomen to verify the position of the fetus

B. Palpate and count the maternal radial pulse while listening to the fetal heart rate

A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth

B. Preterm labor

A nurse is planning care for a client in active labor whose fetus is in an occipital brow presentation. Which of the following complications should the nurse anticipate as a result of this fetal presentation? A. Precipitous labor B. Prolonged labor C. Hypertonic uterine dysfunction D. Umbilical cord prolapse

B. Prolonged labor

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

B. Renal agenesis

A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmHg. Which of the following actions should the nurse take? A. Repeat the measurement immediately using the opposite arm B. Repeat the measurement after allowing the client to sit for 5 to 10 minutes C. Repeat the measurement after repositioning the client so that her feet are off the floor D. Repeat the measurement while ensuring the client's arm is dangling at her side

B. Repeat the measurement after allowing the client to sit for 5 to 10 minutes

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

B. Retinopathy

A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention? A. Withhold analgesics to prevent urinary retention B. Run water in the sink while the client sits on the toilet C. Perform Credé's maneuver every 4 hours D. Restrict oral hydration

B. Run water in the sink while the client sits on the toilet

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge bathe the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46° and 49°C (115° and 120°F)

B. Sponge bathe the newborn every other day

A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take? A. Ensure the client has a full bladder B. Stand at the client's right side if the nurse is right-handed C. Assist the client onto her back with knees extended. D. Palpate the outline of the fetus's head with the palms of the hands

B. Stand at the client's right side if the nurse is right-handed

A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Ask the client to lie on her back with her knees flexed. Place a hand just above the client's symphysis pubis. Position a hand around the top of the client's fundus. Rotate the upper hand to massage the client's uterus. Use slight downward pressure to compress the client's fundus.

A nurse is teaching a prenatal class about nonpharmacological comfort measures during labor. Which of the following statements should the nurse identify as an indication that the instructions have been understood? A. "I can have my partner apply counterpressure to my upper abdomen." B. "My baby will be monitored with a Doppler device during hydrotherapy." C. "I can have the nurse apply acupressure to my lower abdomen." D. "My TENS unit will not help with lower back pain during early labor."

B. "My baby will be monitored with a Doppler device during hydrotherapy."

A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include? A. "The fibroid will shrink during the pregnancy." B. "The fibroid can increase the risk of postpartum hemorrhage." C. "You will receive an injection of medroxyprogesterone acetate to shrink the fibroid." D. "You will have to undergo a cesarean birth because of the fibroid."

B. "The fibroid can increase the risk of postpartum hemorrhage."

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common for expectant fathers in early pregnancy." C. "I'm sure that accepting this situation is challenging when it's your baby, too." D. "You should speak to a therapist about these feelings."

B. "These feelings are common for expectant fathers in early pregnancy."

A nurse is caring for a primigravid client who is at 8 weeks gestation with twins. The client states that even though she and her husband planned this pregnancy, she is experiencing ambivalent feelings about it. Which of the following responses should the nurse make? A. "Have you told your husband about these feelings?" B. "These feelings are quite normal at the beginning of pregnancy." C. "Perhaps you should see a counselor to discuss these feelings." D. "I am quite concerned about these feelings. Could you explain more?"

B. "These feelings are quite normal at the beginning of pregnancy."

A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide? A. "This test will determine if you are likely to deliver within the next week." B. "This test will help determine if your baby is healthy." C. "This test can see how your baby responds when you have contractions." D. "This test will determine if your baby's lungs are mature."

B. "This test will help determine if your baby is healthy."

A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I feel like I cannot breathe when I walk up the stairs."

B. "When my water broke, it was not clear."

A nurse is teaching a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include? A. "Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions." B. "You will learn how to prevent pain during labor by focusing your mind to control your breathing." C. "During labor, you will be encouraged to disassociate by using an internal focal point." D. "During labor, you will use conscious relaxation and levels of progressive breathing."

B. "You will learn how to prevent pain during labor by focusing your mind to control your breathing."

A nurse is caring for a client who is pregnant with a male child and expresses concern to the nurse about the possibility of the child having hemophilia. The client is a carrier of the gene mutation for this condition. Which of the following percentages represents the chance that the child will have this disorder? A. 25% B. 50% C. 75% D. 100%

B. 50%

A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week-old newborn who needs another phenylketonuria screening test B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy C. A 10-day-old newborn who is small for gestational age and requires daily weighing D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge

B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy

A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives? A. A client who smokes 2 packs of cigarettes per week B. A client who is breastfeeding a 7-month-old infant C. A client who is taking an anticonvulsant medication D. A client who is taking anti-HIV protease inhibitors

B. A client who is breastfeeding a 7-month-old infant

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care for the infant D. Collect a cord blood specimen to test for the presence of HIV

B. Administer the hepatitis B vaccine prior to discharge

A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take? A. Assess the client's reflexes B. Assess the newborn for respiratory depression C. Assess the client for bradycardia D. Assess the newborn for signs of opiate withdrawal

B. Assess the newborn for respiratory depression

A nurse is caring for a client who had pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will I be able to deliver vaginally?" Which of the following responses should the nurse make? A. "The shape of your pelvis will make vaginal childbirth difficult, but it is still possible." B. "The shape of your pelvis will require a cesarean delivery." C. "The shape of your pelvis is ideal for vaginal childbirth." D. "The shape of your pelvis will change as you near delivery, and the provider will determine if vaginal delivery is possible

C. "The shape of your pelvis is ideal for vaginal childbirth."

A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to brush your teeth gently." D. "Avoid taking acetaminophen while receiving this medication."

C. "Use a soft toothbrush to brush your teeth gently."

A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching? A. "You should expect to increase your insulin dosage during the first trimester of pregnancy." B. "You should expect to decrease your insulin dosage during the second and third trimesters of pregnancy." C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." D. "You will need to increase your insulin dosage if you are breastfeeding."

C. "You should expect to decrease your insulin dosage immediately after you deliver your baby."

A nurse is assessing a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first? A. Administer analgesia B. Administer carboprost IM C. Assist the client to the toilet D. Obtain a blood specimen to test Hct and Hgb levels

C. Assist the client to the toilet

The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant

C. Autosomal recessive

A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? A. Swaddle the infant with arms and legs extended B. Administer naloxone IM C. Avoid eye contact during feedings D. Discourage the mother from handling the infant during the withdrawal phase

C. Avoid eye contact during feedings

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

C. Baker's yeast

A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern? A. Pink, mucoid vaginal discharge B. Brownish vaginal discharge C. Contractions lasting 100 seconds D. Contractions occurring every 4 to 5 minutes

C. Contractions lasting 100 seconds

A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Soy-based formula is recommended to decrease colic. B. Amino acid formula is recommended to increase the newborn's protein intake. C. Cow's milk-based formula is recommended for healthy newborns. D. Low-iron formula is recommended to prevent excess iron intake.

C. Cow's milk-based formula is recommended for healthy newborns.

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30° angle D. Place the client in a semi-Fowler's position

C. Elevate the client's legs to a 30° angle

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremities D. Leathery cracked skin

C. Extended extremities

A nurse is providing care to a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the nurse? A. Intense contractions lasting less than 30 seconds B. Rest periods between contractions lasting longer than 90 seconds C. Fetal heart rate decreased by 15/min D. Maternal temperature of 37.8°C (100°F) after ruptured membranes

C. Fetal heart rate decreased by 15/min

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 52/min B. Weight 2500 grams (5.5 lb) C. Head circumference 28 cm (11 in) D. Blood glucose 48 mg/dL

C. Head circumference 28 cm (11 in)

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability

C. Impaired placental perfusion

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection

A nurse at a prenatal clinic is assessing an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes the client's clitoris and labia minora were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take? A. Report the findings to the local authorities B. Ask the client who performed the cutting C. Inform the client that giving birth vaginally might not be possible D. Prepare the client for the increased risk of spontaneous abortion

C. Inform the client that giving birth vaginally might not be possible

A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O negative. Which of the following actions should the nurse take? A. Administer a dose of Rho(D) immune globulin B. Request a prescription for an antibiotic until delivery C. Instruct the client to obtain a rubella immunization after delivery D. Inform the client that she will need to deliver via cesarean birth

C. Instruct the client to obtain a rubella immunization after delivery

A nurse is caring for a client in active labor whose fetus is in a persistent occiput posterior position. Which of the following actions should the nurse take to promote rotation of the fetal head? A. Apply counterpressure to the client's back B. Place heat on the client's lower back C. Instruct the client to squat during contractions D. Encourage the client to ambulate in the hall

C. Instruct the client to squat during contractions

A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following? A. Effacement B. Dilation C. Lightening D. Quickening

C. Lightening

A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take? A. Assess fetal heart rate and contraction pattern every 15 min after insertion B. Thaw the frozen gel in a warm water bath prior to insertion C. Maintain the client in a side-lying position for 30 min after insertion D. Initiate an oxytocin infusion for induction 1 hr after gel insertion

C. Maintain the client in a side-lying position for 30 min after insertion

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A. Measure the newborn's length from the anterior fontanel to the heel B. Measure the newborn's weight while he is wearing a clean diaper C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows D. Measure the circumference of the newborn's chest with a tape measure 2 cm (0.79 in) below the nipple line

C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows

A nurse is caring for a client at 36 weeks gestation who has pre-eclampsia. Which of the following findings should the nurse identify as the priority? A. 1+ proteinuria B. Blood pressure 140/98 mmHg C. Nonreactive nonstress test D. Fundal height 33 cm

C. Nonreactive nonstress tes

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take? A. Encourage the client to bear down with contractions B. Request a prescription to initiate oxytocin C. Offer the client hydrotherapy D. Assist the client with ambulation

C. Offer the client hydrotherapy

A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine

C. Oxytocin

A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen

C. Progesterone

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

C. Prolapsed umbilical cord

A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take? A. Increase the rate of intravenous fluid infusion B. Discontinue the infusion of oxytocin C. Re-evaluate the FHR tracing in 15 minutes D. Request a prescription for an amnioinfusion

C. Re-evaluate the FHR tracing in 15 minutes

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes

C. Respiratory distress syndrome

A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately? A. Vaginal leukorrhea B. Shortness of breath C. Swelling of the face and fingers D. Lower back pain

C. Swelling of the face and fingers

A nurse is caring for a client who is scheduled to receive intravenous oxytocin for the induction of labor. The client has a Bishop score of 10. Which of the following findings should the nurse expect? A. The client will require dinoprostone for ripening of the cervix. B. The client will experience lower back pain during labor. C. The client will experience a successful induction of labor. D. The client will require a vacuum- or forceps-assisted delivery.

C. The client will experience a successful induction of labor.

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? A. Breast engorgement B. Hypothermia C. Urinary retention D. Rupture of membranes

C. Urinary retention

A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control." B. "A birth control pill that contains only estrogen is available for use while you are breastfeeding." C. "Condoms are the only method of contraception that is appropriate while you are breastfeeding." D. "A progestin-only pill or injection is available for use while you are breastfeeding."

D. "A progestin-only pill or injection is available for use while you are breastfeeding."

A nurse is teaching a female client about nutrition during pregnancy. Which of the following instructions should the nurse include in the teaching? A. "Plan to double your normal caloric intake during the last trimester of pregnancy." B. "Expect to gain 10 to 15 lb during pregnancy." C. "Restrict your intake of sodium throughout pregnancy." D. "Do not eat swordfish, shark, or king mackerel while you are pregnant."

D. "Do not eat swordfish, shark, or king mackerel while you are pregnant."

A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis? A. "I will wear an underwire bra to provide support when my milk comes in." B. "I will apply petroleum jelly if my nipples become cracked." C. "I will apply warm compresses to my breasts twice a day." D. "I should avoid waiting too long between feedings."

D. "I should avoid waiting too long between feedings."

A nurse is providing nutritional teaching for a pregnant client who had a prepregnancy body mass index (BMI) of 38. Which of the following statements by the client demonstrate an understanding of the teaching about her recommended weight gain during pregnancy? A. "I should plan to gain 12.7 to 18.1 kg during my pregnancy." B. "I should plan to gain 11.3 to 15.9 kg during my pregnancy." C. "I should plan to gain 6.8 to 11.3 kg during my pregnancy." D. "I should plan to gain 5 to 9.1 kg during my pregnancy."

D. "I should plan to gain 5 to 9.1 kg during my pregnancy."

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "My baby's head will be cone-shaped for about 2 months." B. "My doctor performed this procedure because I didn't dilate past 6 centimeters." C. "The doctor performed this procedure because my hemoglobin was low." D. "My baby has a higher risk of developing jaundice."

D. "My baby has a higher risk of developing jaundice."

A nurse is caring for an adolescent who is in the second trimester of pregnancy. The client states, "I've gotten used to the idea of this pregnancy. It will be fun to have a little baby around the house." Which of the following is the appropriate response by the nurse? A. "Babies are not fun. They're a lot of work." B. "I'm so glad to see you're happy about the baby." C. "How are your parents reacting to the pregnancy?" D. "Tell me how you think your life will be after the baby is born."

D. "Tell me how you think your life will be after the baby is born."

A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? A. "This medication can cause your blood pressure to rise." B. "This medication can cause dry mouth." C. "This medication can cause you to urinate excessively." D. "This medication can make you sleepy."

D. "This medication can make you sleepy."

A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make? A. "This type of monitoring is necessary for timing the frequency of your contractions." B. "This type of monitoring is noninvasive, so it is the best way to monitor your labor contractions." C. "This type of monitor allows us to evaluate your baby's heart rate while you are in labor." D. "This type of monitoring will allow us to measure the intensity of your contractions."

D. "This type of monitoring will allow us to measure the intensity of your contractions."

A nurse is providing teaching about exercise to a client who is pregnant. Which of the following pieces of information should the nurse include? A. "You can continue participating in whatever sports or activities you did prior to becoming pregnant." B. "Intermittent exercise is a great way to stay healthy during pregnancy." C. "You should limit your exercise to walking if you did not exercise prior to becoming pregnant." D. "Vigorous exercises should be limited and should not be performed in hot, humid weather."

D. "Vigorous exercises should be limited and should not be performed in hot, humid weather."

A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Breastfeed your newborn to provide passive immunity." B. "Abstain from sexual intercourse throughout the pregnancy." C. "You will be in isolation after delivery." D. "You should continue to take zidovudine throughout the pregnancy."

D. "You should continue to take zidovudine throughout the pregnancy."

A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. "You will have to drink 3 to 5 8-oz glasses of water to fill your bladder." B. "This procedure will not rupture your membranes or cause premature labor." C. "You might feel light pressure during the collection of a blood sample from the baby." D. "You will feel some mild discomfort during the procedure."

D. "You will feel some mild discomfort during the procedure."

A nurse is creating a plan of care for a client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse include? A. Encourage the client to listen to music B. Instruct the client how to use informational biofeedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower

D. Assist the client into a warm shower

A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. Distended abdomen B. Increased blood pressure C. Generalized petechiae D. Barrel-shaped chest

D. Barrel-shaped chest

A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching? A. Nausea upon awakening B. Leg cramps while sleeping C. Increased white vaginal discharge D. Blurred or double vision

D. Blurred or double vision

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula if the newborn is gaining weight too quickly B. Prop the bottle with a blanket for the last feeding of the day C. Discard unused refrigerated formula after 72 hr D. Boil water for powdered formula for 1-2 min

D. Boil water for powdered formula for 1-2 min

A nurse is caring for a client who is at 39 weeks gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep all 4 side rails up while the client is in bed B. Monitor the fetal heart rate every hour C. Insert an indwelling urinary catheter D. Check the cervix prior to analgesic administration

D. Check the cervix prior to analgesic administration

A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take? A. Teach the client to lie on her side B. Request a prescription for an opioid analgesic C. Offer a sitz bath to the client D. Encourage the client to interact with the newborn

D. Encourage the client to interact with the newborn

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? A. Fundal height of 34 cm (13.4 in) B. Total pregnancy weight gain of 3.6 kg (8 lb) C. Gestational hypertension D. Fetal gastrointestinal anomaly

D. Fetal gastrointestinal anomaly

A nurse is providing education to a female client of child-bearing age. The nurse should state that which of the following structures expels the mature ovum? A. Blastocyst B. Fallopian tube C. Corpus luteum D. Graafian follicle

D. Graafian follicle

A nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. The client reports a lightheaded feeling and tingling of the fingers. Which of the following actions should the nurse take? A. Instruct the client to hold her breath and bear down B. Ensure that the client's breathing rate is more than twice her normal rate C. Apply counter-pressure to the client's lower back D. Have the client breathe into a paper bag

D. Have the client breathe into a paper bag

An adolescent reports abdominal cramping due to dysmenorrhea. Which of the following analgesics should the nurse expect the provider to prescribe? A. Fentanyl B. Acetaminophen and oxycodone C. Acetaminophen and hydrocodone D. Ibuprofen

D. Ibuprofen

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine

D. Methylergonovine

A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following factors is the nurse's priority to evaluate? A. Psychological readiness B. Partner support C. Socioeconomic status D. Nutritional status

D. Nutritional status

A nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client to home B. Administer betamethasone C. Perform an amnioinfusion D. Prepare for delivery of the infant

D. Prepare for delivery of the infant

A nurse is caring for a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart rate tracing. Which of the following actions should the nurse take? A. Discontinue oxytocin infusion and apply oxygen B. Increase oxytocin infusion rate by 2 mu/min C. Administer terbutaline 0.25 mg subcutaneously D. Reposition the client in a side-lying position and continue to monitor

D. Reposition the client in a side-lying position and continue to monitor

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement? A. Self-hypnosis B. Biofeedback C. Acupuncture D. Slow-paced breathing

D. Slow-paced breathing

A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority? A. The client reports a pain level of 8 on a scale from 0 to 10 during contractions. B. The client's blood pressure is 148/92 mmHg. C. The client's temperature is 38.3°C (101°F). D. The fetal heart rate is 90/min.

D. The fetal heart rate is 90/min.

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. Abduction and extension of the arms are asymmetric. B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated. C. Toes hyperextend with dorsiflexion of the great toe. D. The legs move in a similar pattern of response to the arms.

D. The legs move in a similar pattern of response to the arms.

A nurse is caring for a client in the third trimester of pregnancy who reports difficulty sleeping. Which of the following instructions should the nurse provide? A. Eat a high-fat snack before bed. B. Exercise in the evening before bed. C. Sleep in the supine position. D. Use additional pillows to support extremities and abdomen.

D. Use additional pillows to support extremities and abdomen

A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation? A. Calcium B. Iron C. Vitamin D D. Vitamin C

D. Vitamin C

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching? A. "Drop by the clinic any day this week so we can count your baby's kicks." B. "Count fetal kicks once a day for a total of 30 minutes." C. "Before bedtime is a good time to start counting the kicks." D. "Wear loose clothing when performing the kick count."

C. "Before bedtime is a good time to start counting the kicks."

A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? A. "Nitrous oxide could make my baby sleepy when he is born." B. "I should inhale the nitrous oxide between contractions." C. "I will feel the effects of the nitrous oxide almost immediately." D. "Nitrous oxide can make me feel disoriented."

C. "I will feel the effects of the nitrous oxide almost immediately."

A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions."

A. "Call me so I can check your baby's latch the next time you breastfeed."

A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? A. "Carbohydrates should make up 55% of your diet." B. "Protein should make up 70% of your diet." C. "Fats should make up 45% of your diet." D. "Fiber should make up 10% of your diet."

A. "Carbohydrates should make up 55% of your diet."

A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include? A. "Crib slats should be less than 2.25 inches apart." B. "Share your bed with your baby for the first few weeks." C. "Place your baby on his stomach for naps." D. "You can position your baby's crib next to a heating vent for warmth."

A. "Crib slats should be less than 2.25 inches apart."

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? A. "Do not become pregnant for at least 1 year." B. "Seek genetic counseling for yourself and your partner prior to getting pregnant again." C. "You should have an hCG level drawn in 6 weeks." D. "Have your blood pressure checked weekly for the next month."

A. "Do not become pregnant for at least 1 year."

A nurse is teaching a prenatal class about pain management during labor. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I can apply a heating pad to my back to relieve back pain." B. "I can have a low spinal block to help with labor pain." C. "I can have butorphanol every 2 hours during labor." D. "My time limit for staying in the hydrotherapy tub is 30 minutes."

A. "I can apply a heating pad to my back to relieve back pain."

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner? A. "Lightly stroke the upper thighs." B. "Steadily apply pressure to the sacrum." C. "Gently massage the mid-abdominal area." D. "Firmly squeeze both hips."

A. "Lightly stroke the upper thighs."

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? A. "Losing 2.2 pounds each month would be acceptable." B. "Losing 4.4 pounds each month would be acceptable." C. "Losing 5.5 pounds each month would be acceptable." D. "Losing 6.6 pounds each month would be acceptable."

A. "Losing 2.2 pounds each month would be acceptable."

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include? A. "Notify your provider if you notice cracking on your nipples." B. "Notify your provider if you have not had a bowel movement within 5 days." C. "Notify your provider if your breasts leak when you shower." D. "Notify your provider if your vaginal discharge is a brownish-red color."

A. "Notify your provider if you notice cracking on your nipples."

A nurse is teaching a client about squatting exercises during pregnancy. Which of the following statements should the nurse include? A. "These exercises should be done for 15 minutes each day to strengthen the perineal muscles." B. "Squatting exercises can tone your abdomen, helping you lose weight faster following delivery." C. "Practicing squatting exercises during pregnancy will reduce lower back pain during labor." D. "Doing squatting exercises 3 times per week will improve your overall fitness."

A. "These exercises should be done for 15 minutes each day to strengthen the perineal muscles.

A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? A. "True contractions will begin irregularly and then become regular in timing." B. "True contractions will go away with ambulation." C. "False contractions increase in frequency and duration the closer you are to your due date." D. "False contractions are first felt in the pelvic area and then in the lower back and abdomen."

A. "True contractions will begin irregularly and then become regular in timing."

A nurse is performing a routine prenatal examination of a client who is in the second trimester. The client reports backaches with no other symptoms and refuses medication. Which of the following responses should the nurse make? A. "Try pelvic tilt exercises." B. "Limit your physical activity." C. "Soak in a warm bubble bath." D. "Lie flat on your back for 1 hour."

A. "Try pelvic tilt exercises."

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. "You should slightly increase your exposure to sunlight." B. "You will need extensive dermatological treatment for this condition after you deliver your baby." C. "Your provider will schedule weekly lab testing to monitor your liver function." D. "Your provider will prescribe isotretinoin cream."

A. "You should slightly increase your exposure to sunlight."

A nurse is caring for a client during her first prenatal visit and notes that she is lactose-intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? A. Collard greens B. Cottage cheese C. Orange juice D. Broccoli

A. Collard Greens

A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. "Your provider will insert a hand into your uterus and turn your baby around." B. "You will receive a medication to relax your uterus prior to the procedure." C. "This procedure will be performed in the clinic at your next visit." D. "Your baby's heartbeat will be monitored occasionally throughout the procedure."

B. "You will receive a medication to relax your uterus prior to the procedure."

A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent

B. Assess the newborn's blood glucose level

A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding? A. 800 mg B. 400 mg C. 1,000 mg D. 2,000 mg

C. 1,000 mg

A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record? A. Transverse B. Breech C. Vertex D. Mentum

C. Vertex