Care Exam 3 Practice Questions

b. Decreased blood glucose **Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery.

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. Which 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

d. A urine test for the presence of human chorionic gonadotropin

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant, and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy? a. A blood test for the presence of estrogen b. A blood test for the amount of circulating progesterone c. A urine test for the presence of human chorionic somatomammotropin d. A urine test for the presence of human chorionic gonadotropin

d. "A weight gain of about 25 to 35 pounds is good" **A gain of 4 lb in the first trimester and 12 lb each for the second and third trimester is recommended.

A nurse in a prenatal clinic is caring for a client who is within the recommended guidelines for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make? a. "Your provider can discuss an appropriate amount of weight gain with you" b. "A weight gain of about 14 pounds each trimester is suggested" c. "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant" d. "A weight gain of about 25 to 35 pounds is good"

a. Instruct the client about vena cava syndrome and measures to prevent it **This is the typical finding of vena cava syndrome, or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side lying position promotes uterine perfusion and fetoplacental oxygenation.

A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I become very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take? a. Instruct the client about vena cava syndrome and measures to prevent it b. Arrange for the client to come to the clinic for an assessment c. Check the client's chart for gestational diabetes mellitus d. Schedule a nonstress test for the client

a. obtain blood samples for baseline lab values **obtain samples of client's blood for baseline testing of hemoglobin and hematocrit levels.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. What action should the nurse take? a. obtain blood samples for baseline lab values b. place a spiral electrode on the fetal presenting part c. prepare the client for a transvaginal ultrasound d. perform a vaginal exam to determine cervical dilation

a. continue routine monitoring

A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion

a. this will resolve within 3-6 wks without treatment **This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum, that will resolve within 2 to 6 weeks.

A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? a. this will resolve within 3-6 wks without treatment b. this will resolve on its own within 3-4 days c. this is expected at birth so you don't need to worry about it d. the provider might drain this area with a syringe

b. place the naked newborn on the mothers bare chest and cover both with a blanket **Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.

A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings

c. Ask the client when she last voided **The fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.

A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take? a. Report the vital signs to the provider b. Massage the fundus c. Ask the client when she last voided d. Administer an oxytocic agent

d. Presence of ketones in the urine **Ketonuria due to inadequate dietary intake, resulting in the breakdown of protein and stored fat

A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? a. Elevated serum potassium level b. Rapid weight gain c. Peripheral edema d. Presence of ketones in the urine

d. assist the client to empty her bladder

A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder

b. Measure the height of the fundus in fingerbreadths in relation to the umbilicus

A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? a. Press down and forward with the hand that is placed on the base of the uterus b. Measure the height of the fundus in fingerbreadths in relation to the umbilicus c. Place the client in a semi-Fowler's position prior to checking the uterus d. Massage the fundus with gentle palpation until it becomes soft to touch

c. dark red vaginal bleeding

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

a. 480 mL urine output in 24 hrs

A nurse is assessing a client who is at 35 weeks of gestation and has mild preeclampsia without severe features. What finding should the nurse identify as the priority? a. 480 mL urine output in 24 hrs b. 1+ protein in the urine c. +2 edema of the feet d. BP 144/92

d. urinary output 20 mL/hr **can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity

A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to the provider? a. DTR 2+ b. resp 16 c. BP 150/96 d. urinary output 20 mL/hr

a. uterine contractions

A nurse is assessing a client who is at 37 weeks gestation and has a suspected pelvic fracture due to blunt and trauma. What findings should the nurse expect? a. uterine contractions b. bradycardia c. seizures d. bradypnea

b. Proteinuria

A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? a. Severe hypotension b. Proteinuria c. Elevated platelet count d. Seizures

c. slow trickle of bright vaginal bleeding and a firm fundus **The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? a. a gush of rubra lochia when the nurse massages the uterus b. continuous lochia flow and flaccid uterus c. slow trickle of bright vaginal bleeding and a firm fundus d. report of increasing pain and pressure in the perineal area

b. Urinary output 40 mL in 2 hours **Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is less than 30 mL/hr.

A nurse is assessing a client who is receiving magnesium sulfate as treatment for preeclampsia. Which of the following clinical findings is the nurse's priority? a. Respiration 16/min b. Urinary output 40 mL in 2 hours c. Reflexes 2+ d. FHR 158/min

a. Nausea in the morning

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. Palpated fetal movement by provider

b. jaundice of the sclera

A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? a. acrocyanosis b. jaundice of the sclera c. resp rate 50/min d. blood glucose 60 mg/dL

b. 9 **Assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.

A nurse is assessing a newborn 1 min after birth and notes a HR of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What APGAR score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7

b. Obtain a stat prescription for a bilirubin level

A nurse is assessing a newborn who is 12 hours old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? a. Administer Phytonadione IM b. Obtain a stat prescription for a bilirubin level c. Obtain a bagged urine specimen d. Perform a gestational age assessment

c. Lightening

A nurse is assessing a pregnant client who is at 38 weeks gestation. The client reports 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

a. Palpable fetal movement

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? a. Palpable fetal movement b. Chadwick's sign c. Positive pregnancy test d. Amenorrhea

c. Palpating the client's fundus **this will reduce postpartum hemorrhage and uterine atony

A nurse is caring for a client who had a precipitous delivery. Which of the following is the priority during the fourth stage of labor? a. Obtaining the client's temperature b. Inspecting the client's perineum c. Palpating the client's fundus d. Checking the client for hemorrhoids

b. methergine

A nurse is caring for a client who has a soft uterus and increased lochia. What meds should the nurse plan to administer to promote uterine contractions? a. mag sulfate b. methergine c. terbutaline d. nifedipine

d. Methergine

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. Methergine

d. Pelvic inflammatory disease (PID) **Most cases of an ectopic pregnancy are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk for an ectopic pregnancy.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? a. Anemia b. Frequent urinary tract infections c. Previous cesarean birth d. Pelvic inflammatory disease (PID)

b. Massage the fundus

A nurse is caring for a client who is 2 hours postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? a. Check for a full bladder b. Massage the fundus c. Measure vital signs d. Administer Carboprost IM

d. Instruct the client to apply cold compresses

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? a. Encourage the client to pump the breasts b. Instruct the client to take a warm shower twice per day c. Tell the client to massage her breasts d. Instruct the client to apply cold compresses

c. you should walk for at least 30 minutes every day

A nurse is caring for a client who is at 26 wks gestation and reports constipation. What responses by the nurse is appropriate? a. you should drink 1 ounce of mineral oil every morning b. you should eat at least 3 ounces of red meat/day c. you should walk for at least 30 minutes every day d. you should stop taking your prenatal vitamins

a. Betamethasone **administer betamethasone to stimulate fetal lung maturity and thereby prevent respiratory depression

A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? a. Betamethasone b. Misoprostol c. Methylergonovine d. Cytotec

d. "My heart feels as if it is racing"

A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? a. "My ankles are swollen at the end of the day" b. "I can feel the baby kicking my ribs, and it is very uncomfortable" c. "I'm growing more and more worried every day" d. "My heart feels as if it is racing"

a. daily weights

A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia. What assessment provides the most accurate info regarding the client's fluid and electrolyte status? a. daily weights b. blood pressure c. severity of edema d. intake and output

a. auscultate for a FHR **presence of a fetal heart rate is a reassuring manifestation of fetal well-being --> auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for 24 hr. What action should the nurse take? a. auscultate for a FHR b. reassure the client that a term fetus is less active c. have the client drink orange juice d. palpate the uterus for fetal movement

d. Check the cervix prior to analgesic administration **Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.

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

c. uteroplacental insufficiency **late deceleration in the FHR results from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.

A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor. The nurse observes late decels in the FHR. What finding should the nurse identify as the cause of late decels? a. umbilical cord compression b. fetal head compression c. uteroplacental insufficiency d. fetal ventricular septal defect

b. "These feelings are quite normal at the beginning of pregnancy" **This client needs reassurance that these feelings are normal and there is no reason for concern.

A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many 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?"

c. prepare equipment needed for newborn resuscitation **the nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse take? a. prepare the client for emergency c-section b. perform endotracheal suctioning as soon as the fetal head is delivered c. prepare equipment needed for newborn resuscitation d. prepare the client for an ultrasound exam

b. Counterpressure

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. Counterpressure c. Biofeedback d. Use of a focal point

c. hypotension

A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block? a. nausea and vomiting b. tachycardia c. hypotension d. respiratory depression

c. Fetal asphyxia **oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? a. Diarrhea b. Thromboembolism c. Fetal asphyxia d. Oliguria

a. "Reduce the amount of food you eat during meals"

A nurse is caring for a client who is in the first trimester of pregnancy and asks how to manage heartburn. Which of the following responses should the nurse make? a. "Reduce the amount of food you eat during meals" b. "Sip carbonated beverages between meals" c. "Lie down and rest immediately after meals" d. "Drink iced tea with meals"

d. apply pressure to the client's sacral area during contractions **The nurse should provide counter pressure to the sacral area with a palm during contractions. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain.

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

b. Provide a sitz bath with warm water for the client **Sitz bath can decrease episiostomy discomfort by providing warm, moist, and direct heat to the incision area

A nurse is caring for a client who is postpartum and reports her episiostomy incision is pulling and stinging. Which of the following actions should the nurse take? a. Encourage the client to ambulate b. Provide a sitz bath with warm water for the client c. Instruct the client to perform kegel exercises d. Apply anesthetic cream topically each hour while the client is awake

a. "You should eat some crackers before rising from bed in the morning" **Morning sickness is caused by the buildup of hCG in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client? a. "You should eat some crackers before rising from bed in the morning" b. "You should eat foods served at warm temperatures" c. "You should sip whole milk with breakfast" d. "You should brush your teeth immediately after meals"

c. calcium gluconate

A nurse is caring for a client who is receiving mag sulfate by continuous IV. What meds should the nurse have available at bedside? a. naloxone b. protamine sulfate c. calcium gluconate d. atropine

c. fundal consistency **Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? a. pulse rate b. blood pressure c. fundal consistency d. output

c. Manually apply upward pressure intravaginally on the presenting part **greatest risk to this client is fetal CNS injury or death from fetal hypoxia due to cord compression, so the first nursing action would be to take a gloved hand, insert into vagina, and apply upward pressure to the presenting part to move it away from the cord

A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first? a. Place the client in an extreme Trendelenburg position b. Increase the IV fluid infusion rate c. Manually apply upward pressure intravaginally on the presenting part d. Administer 8-10 L/min of oxygen

d. assist the client to ambulate in the hallway

A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillow c. have the client drink fluids through a straw d. assist the client to ambulate in the hallway

b. april 15

A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule, the nurse should identify the client's estimated DOB as what? a. oct 15 b. april 15 c. oct 1 d. april 1

a. Turn the client onto her left side **Late decelerations indicate that the client is experiencing uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.

A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? a. Turn the client onto her left side b. Palpate the client's uterus c. Administer oxygen to the client d. Increase the client's IV fluids

d. Minimal FHR variability and late decelerations

A nurse is caring for a laboring client who just received systemic medication for labor pain. Which fetal heart rate pattern would require further action by the nurse? a. Increased fetal heart rate (FHR) variability and early decelerations b. Moderate variability is present c. Occasional variable decelerations d. Minimal FHR variability and late decelerations

a. place the newborn directly on the client's chest

A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment

c. Continue to routinely monitor the newborn **This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

A nurse is caring for a newborn who has irregular respirations of 52/minute with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? a. Administer oxygen b. Place the newborn in an isolette c. Continue to routinely monitor the newborn d. Assess the newborn's blood glucose

b. 1.8

A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh? a. 2.4 b. 1.8 c. 0.8 d. 3.6

a. Respiratory depression

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? a. Respiratory depression b. Hypothermia c. Hypoglycemia d. Jaundice

a. A newborn who is large for gestational age **One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia.

A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia? a. A newborn who is large for gestational age b. A newborn who has an Rh incompatibility c. A newborn who has pathologic jaundice d. A newborn who has fetal alcohol syndrome

b. Hypoglycemia

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? a. Tachycardia b. Hypoglycemia c. Flushed skin d. Generalized petechiae

c. Persistent vomiting **Fetal movement is not expected during the 1st trimester. Quickening is the first perception of fetal movement, and occurs starting at 14-16 weeks gestation. Persistent vomiting can lead to hyperemesis gravidarum

A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client report to the provider during the first trimester? a. Breast tenderness b. Urinary frequency c. Persistent vomiting d. No fetal movement

c. Group B streptococcus B-hemolytic **Obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection.

A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? a. Rubella titer b. Blood type c. Group B streptococcus B-hemolytic d. 1-hour glucose tolerance test

d. at 28 weeks of gestation

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Globulin? a. while the client is in labor b. following an episode of influenza during pregnancy c. prior to a blood transfusion d. at 28 weeks of gestation

a. 0.25

A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer? a. 0.25 b. 25 c. 50 d. 0.50

a. IV narcotics administered to the mother during labor

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? a. IV narcotics administered to the mother during labor b. Maternal drug use c. Hyaline membrane disease d. Meconium aspiration

a. Continue to monitor the fetal heart tracings **Early decels reflect fetal head compression and are a normal finding during labor

A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take? a. Continue to monitor the fetal heart tracings b. Elevate the client's legs c. Increase the rate of the maintenance IV fluid d. Administer oxygen

c. "Your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery"

A nurse is providing teaching for a client postpartum who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? a. "You should supplement your baby with formula until you notice that your breasts become firm and full" b. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat" c. "Your milk supply will noticeably increase in volume around the 3rd or 4th day after delivery" d. "It is typical for your nipples to hurt for the first few weeks while you are breastfeeding"

a. "I should feed my baby 8-12 times a day, based on feeding cues"

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? a. "I should feed my baby 8-12 times a day, based on feeding cues" b. "My baby should have 6 or 7 wet diapers a day during the first week" c. "I should switch my baby to the other breast after 15 minutes of feeding" d. "My nipple pain should go away after a few weeks of breastfeeding"

c. it is normal for my baby to sometimes feed every hr for several hours in a row **The mother should follow her newborn's cues and feed her 8-12 times per day

A nurse is providing teaching to a client who is planning to breastfeed her newborn. What statement by the client indicates an understanding of the teaching? a. I must drink milk every day in order to assure good quality breast milk b. drinking lots of fluids will increase my breast milk production c. it is normal for my baby to sometimes feed every hr for several hours in a row d. after the first few weeks, my nipples will toughen up and breastfeeding wont hurt anymore

b. place ice packs on your breasts

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? a. stand under hot shower with your breasts exposed b. place ice packs on your breasts c. limit fluid intake to 1 L per day d. wear a loose-fitting, comfortable bra

c. I will place my baby on his back when it is time for him to sleep

A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm

a. instruct the client to obtain a rubella immunization after delivery

A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type O neg. What action should the nurse take? a. instruct the client to obtain a rubella immunization after delivery b. request a script for an antibiotic until delivery c. inform the client that she will have to deliver via c-section d. administer a dose of Pho(D) immune globulin

b. perform a vaginal exam **when a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os. The nurse should clarify this prescription bc any manipulation can cause tearing of the placenta/increased bleeding.

A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta previa and bleeding. What scripts should the nurse clarify with the provider? a. insert a large-bore IV catheter b. perform a vaginal exam c. perform continuous external fetal monitoring d. obtain a blood sample for lab testing

b. "These feelings are common to expectant fathers in early pregnancy"

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 to expectant fathers in early pregnancy" c. "I'm sure that it's really hard to accept this when it's your baby, too" d. "It would be wise for you to speak to a therapist about these feelings"

b. feeling of warmth

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

c. swelling of the face **can indicate a hypertensive disorder or preeclampsia.

A nurse is teaching a client who is at 12 wks gestation about manifestations of potential complications that she should report to her provider. What info should the nurse include in the teaching? a. intermittent nausea b. white vaginal discharge c. swelling of the face d. urinary frequency

c. vaginal bleeding **might indicate a complication such as placental abruption, placenta previa, or preterm labor. choice A is not right because the client should feel the fetus move at least 3 times per hour, so 10 is acceptable

A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. What finding should the nurse include in the teaching? a. 10 fetal movements per hour b. mild constipation c. vaginal bleeding d. nasal congestion

b. Contractions that last for 60 seconds each with a 3-min rest between contractions **A contraction interval is how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.

A nurse receives report on a client who is in labor and is experiencing contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. Contractions that last for 60 seconds each with a 4-min rest between contractions b. Contractions that last for 60 seconds each with a 3-min rest between contractions c. A contraction that lasts 4 min followed by a period of relaxation d. Contractions that last 45 seconds with a 3-min rest between contractions

b. Respirations of 10 breaths/minute d. Urine output of 20 mL in an hour **signs of toxicity: respiratory depression, loss of DTRs, sudden decline in FHR and maternal HR and BP, respiratory rate <12/min, urine output <25 mL/hr

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? (Select all that apply) a. Proteinuria of 3+ b. Respirations of 10 breaths/minute c. Presence of deep tendon reflexes d. Urine output of 20 mL in an hour e. Serum magnesium level of 4 mEq/L

c. Elevated hCG levels

A pregnant patient in her first trimester is complaining of nausea. The patient asks why she feels so sick. The nurse explains that anorexia and nausea are common in the first trimester of pregnancy because why? a. Low iron levels b. Nocturia c. Elevated hCG levels d. Heartburn and constipation

b. Seizures do not occur

A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective? a. Scotomas are present b. Seizures do not occur c. Ankle clonus is noted d. The blood pressure decreases

b. Mood swings most likely are the result of worries about finances and a changed lifestyle, as well as profound hormonal changes

In understanding and guiding a woman through her acceptance of pregnancy, a maternity nurse should be aware of which of the following? a. Nonacceptance of the pregnancy very often equates to rejection of the child b. Mood swings most likely are the result of worries about finances and a changed lifestyle, as well as profound hormonal changes c. Ambivalent feelings during pregnancy usually are seen only in emotionally immature or very young mothers d. Conflicts such as not wanting to be pregnant or childrearing and career-related decisions need not be addressed during pregnancy because they will resolve themselves naturally after birth

b. Blood pressure

Methergine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? a. Uterine tone b. Blood pressure c. Amount of lochia d. Deep tendon reflexes

b. nifedipine

Nurse is caring for a pt who is at 28 weeks gestation and experiencing preterm labor. Which of the following medications should the nurse plan to administer? a. oxytocin b. nifedipine c. dinoprostone d. misoprostol

b. Taking Hold Phase

On the end of the first postpartum day, the nurse is discussing routine infant care with Laura and her husband, Tom. The nurse notes that Laura asks few questions and prefers to focus on her perineal pain and complaints of hunger. Laura asks Tom to hold the baby, as she is "just too tired". Which phase is Laura in at this time? a. Letting Go Phase b. Taking Hold Phase c. Taking In Phase

a. In a side-lying position

The nurse caring for a pregnant woman knows that her health teaching regarding fetal circulation has been effective when the woman reports that she has been sleeping in which way? a. In a side-lying position b. On her back with a pillow under her knees c. With the head of the bed elevated d. On her abdomen

c. Decreased uterine bleeding **used to prevent or control postpartum hemorrhage by contracting the uterus

The nurse in the postpartum unit notes that a new mother was given Methergine intramuscularly following delivery. What assessment finding indicates that the medication was effective? a. Lochia that is serous b. Normal blood pressure c. Decreased uterine bleeding d. Decreased uterine contractions

a. Assess for signs and symptoms of labor.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client? a. Assess for signs and symptoms of labor. b. Assess the client's temperature every 2 hours. c. Schedule a daily ultrasound to assess fetal movement. d. Schedule a non-stress test every 4 hours to assess fetal well-being.

b. A fetal heart rate of 90 beats/min

The nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? a. Increased urinary output b. A fetal heart rate of 90 beats/min c. Three contractions occurring within a 10-minute period d. Adequate resting tone of the uterus palpated between contractions

a. Healthy eating b. Teaching about body changes c. Establishment of baseline data e. Taking prenatal vitamins

The nurse is caring for a patient who presents to the clinic for her first prenatal visit. What should the nurse focus on teaching? a. Healthy eating b. Teaching about body changes c. Establishment of baseline data d. Parenting skills e. Taking prenatal vitamins f. Breastfeeding benefits

c. Continuous electronic fetal monitoring

The nurse is preparing to care for a client in labor. The health care provider has prescribed an IV infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? a. An IV infusion of antibiotics b. Placing the client on complete bed rest c. Continuous electronic fetal monitoring d. Placing a code cart at the client's bedside

b. The cardiovascular system

The student nurse is studying the changes a woman goes through during pregnancy. The student nurse knows that which body system undergoes the most dramatic changes during pregnancy? a. The skin b. The cardiovascular system c. The urinary system d. The gastrointestinal system

b. Hydrocodone/acetaminophen (Norco) c. Acetaminophen with codeine (Tylenol #3)

What are some medications commonly used for moderate pain control in the postpartum period? (Select all that apply) a. Ibuprofen and Tylenol ES b. Hydrocodone/acetaminophen (Norco) c. Acetaminophen with codeine (Tylenol #3) d. Oxycodone/Acetaminophen (Percocet)

d. Measure from the symphysis pubis notch to the top of fundus

What is the method of measuring a pregnant patient's fundus? a. Measure from the symphysis pubis to the umbilicus b. Measure across the abdomen laterally c. A pelvimeter is used to measure fundal height d. Measure from the symphysis pubis notch to the top of fundus

a. Induction of labor b. Augmentation of labor d. After delivery of the placenta

When is oxytocin/pitocin used during the labor and delivery process? (Select all that apply) a. Induction of labor b. Augmentation of labor c. Cervical ripening d. After delivery of the placenta

d. All of the above

When is oxytocin/pitocin used during the labor and delivery process? (Select all that apply) a. Induction of labor b. Augmentation of labor c. After delivery of the placenta d. All of the above

c. Cervidil **used for cervical ripening

Which of the following medications is NOT used to manage postpartum bleeding? a. Pitocin b. Misoprostol c. Cervidil d. Methergine e. Carboprost (Hemabate)

b. Meconium can cause infection during the birth process d. The foramen ovale is a hole between the right and left atria

Which of the following statements are correct? (Select all that apply) a. The neonatal period includes the first 2 years b. Meconium can cause infection during the birth process c. The ductus arteriosus connects the right and left atria d. The foramen ovale is a hole between the right and left atria

a. The father goes through three phases of acceptance of his own

With regard to the father's acceptance of the pregnancy and preparation for childbirth, the maternity nurse should know which of the following? a. The father goes through three phases of acceptance of his own b. The father's attachment to the fetus cannot be as strong as that of the mother because it does not start until after birth c. In the last 2 months of pregnancy, most expectant fathers suddenly get very protective of their established lifestyle and resist making changes to the home d. Typically, men remain ambivalent about fatherhood right up to the birth of their child

b. Crying increases the distribution of air in the lungs

With regard to the respiratory development of the newborn, nurses should be aware of which of the following? a. Surfactant increases surface tension and pressure required to keep the alveoli open b. Crying increases the distribution of air in the lungs c. Newborns are instinctive mouth breathers d. Seesaw respirations are no cause for concern in the first hour after birth