HESI
a nursing is caring for a patient who is in the first stage of labor and is encouraging the patient to void every 2 hours. which of the following statement justifies the nurse's intervention
"A distended bladder reduces pelvic space needed for birth"
A nurse is reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member if the group indicates an understanding of the teaching? A. "I am glad I can have my morning coffee." B. "I should take folic acid to increase my milk supply" C. I will continue adding 330 calories per day to my diet. D. "I will continue my calcium supplements because I don't like milk."
"I will continue my calcium supplements because I don't like milk."
A client who is at 8 weeks of gestation tells the nurse that she isn't sure she is happy about being pregnant. Which of the following responses should the nurse make? a)"I will inform the provider that you are having these feelings." b)"It is normal to have these feelings during the first few months of pregnancy." c)"You should be happy that you are going to bring new life into the world." d) "I am going to make an appointment with the counselor for you to discuss these thoughts." b)"It is normal to have these feelings during the first few months of pregnancy."
"It is normal to have these feelings during the first few month of pregnancy"
A nurse is caring for a client and her partner during the second stage of labor. The client's partner asks the nurse to explain how he will know when crowning occurs. Which of the following is an appropriate response by the nurse? A. "The placenta will protrude from the vagina." B. "Your partner will report a decrease in the intensity of contractions." C. "The vaginal area will bulge as the baby's head appears." D. "Your partner will report less rectal pressure."
"The vaginal area will bulge as the baby's head appears."
A nurse in a prenatal clinic is teaching a pregnant patient about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching?
"You should empty your bladder prior to the procedure"
A nurse in a clinic is caring for a client who is to be seen by the provider for a postoperative appointment following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? A. It is good to know I won't have a tubal pregnancy in the future. B. The doctor said that this surgery can affect my ability to get pregnant again. C. I understand that one of my fallopian tubes had to be removed. D. Ovulation can still occur because my ovaries were not affected.
"it is good to know that I won't have a tubal pregnancy in the future"
A nurse is providing discharge instructions 2. A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact her provider for which of the following client findings? A. Scant, nonodorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipple with cracks and fissures D. Decreased response with sexual activityfor a patient. At 4 weeks postpartum, the patient should contact her provider for which of the following findings?
"sore nipples with cracks and fissures"
Math
0.29
the nursing is caring a postpartum client who is bleeding excessively . the nurse is about to weight the pad she just removed from the client. the pad weighs 275 grams. what is the blood loss in milliliters?
255ml
a nurse in a prenatal clinic is caring for four clients. which of the following clients weight gain should the nurse report to the provider? a. 1.8 kg (4lb) weight gain and is in her first trimester b. 3.6 (8lb) weight gain and is in her first trimester c. 6.8kg (15b) weight gain and is in her second trimester d. 11.3kg (25lb) weight gain and is in her third trimester
3.6 kg (8lb) weight gain and is in her first trimester b. the nurse should be concerned about this client because she has exceeded the expected 3 to 4lb weight gain of a client in the first trimester
1. A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia, She notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. Moderate lochia rubra B. Excessive blood loss C. Light lochia rubra D. Scant lochia serosa
A moderate lochia rubra
A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply) A. Respirations less than 12/min B. Urinary output less than 30 mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased LOC E. Flushing and sweating
A,B,D Respirations less than 12/min Urinary output less than 30mL/hr Decreased level of consciousness
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery."
A. "This is more commonly seen in newborns who have dark skin." Mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin and can be linked to genetics. "this is frequently seen in newborn who have dark skin"
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly hired nurses. Which of the following statements by a nurse indicates understanding of the teaching? A. "They are administered in an oral form." B. "They act by absorbing fluid from tissues." C."They promote dilation of the os." D."They include an amniotomy."
A. CORRECT: Chemical agents that promote cervical ripening include medications administered in oral form.
A nurse is caring for a client who is 1 hr postpartum following a vaginal birth and experiencing uncontrollable shaking. The nurse should understand that the shaking is due to which of the following factors? (Select all that apply.) A. Change in body fluids B. Metabolic effort of labor C. Diaphoresis D. Decrease in body temperature E. Decrease in prolactin levels
A. Change in body fluids B. Metabolic effort of labor A shift in body fluids during the first 2 hr puerperium can cause a postpartum chill. The work of labor can cause a postpartum chill during the first 2 hr puerperium.
A nurse is admitting client who is in labor and has HIV. Which of the following intervention should the nurse identify as contraindicated for this client? (Select all that apply.) a. Episiotomy b. Oxytocin infusion c. Forceps d. Cesarean birth e. Internal fetal monitoring
A. Episiotomy B. forceps C. internal fetal monitoring An episiotomy should be avoided for a client who is HIV + due to the risk of maternal blood exposure. The use of forceps during delivery should be avoided due to the risk of fetal bleeding. Internal fetal monitoring should be avoided due to the risk of fetal bleeding.
A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a clinical manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase (ALT) 20 fU/L D. Serum glucose 114 mg/dL
A. INCORRECT: Altered hematocrit is a clinical manifestation of hyperemesis gravidarum due to the hemoconcentration that occurs with dehydration. B. CORRECT: The presence of ketones in the urine is associated with the breakdown of proteins and fats that occurs in a client who has hyperemesis gravid arum. C. INCORRECT: Liver enzymes are elevated in a client who has hyperemesis gravid arum, and this finding is within the expected reference range. D. INCORRECT: Decreased serum glucose is anticipated in a client who has hyperemesis gravidarum, and this result is within the expected reference range
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. Preeclampsia B. Thrombophlebitis C. Placenta previa D. Hyperemesis gravidarum
A. Preeclampsia
4. A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed. B. Ask the client if she has thoughts of harming herself or her infant. C. Monitor the infant for indications of failure to thrive. D. Review the client's medical record for a history of bipolar disorder.
A. The nurse should reinforce the need to take antipsychotics as prescribed to manage the manifestations of postpartum psychosis;however, there is another action that is the nurse's priority. B. CORRECT: The nurse should identify that the greatest risk to theclient and her infant is self‑harm or harm directed toward the infant.Therefore, the priority action the nurse should take is to directly ask the client if she has thoughts of self‑harm, suicide, or harming the infant. C. The nurse should monitor the infant for indications of failure to thrive as the client who has postpartum psychosis might be unable to provide care for the infant; however, there is another action that is the nurse's priority. D. The nurse should review the client's medical record for a history of bipolar disorder as this is associated with an increased risk for postpartum psychosis; howeve
14. A woman is to receive 2.4 million units of penicillin G benzathine IM to treat syphilis. The medication is available as 1,200,000 units/mL. How many mL should the nurse administer?
ANS: 2 mL
52. The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse's next action? a. Ask the patient when she last had anything to eat or drink. b. Take a culture of the lesions to verify the involved organism. c. Ask the patient if she has had unprotected sex since her outbreak. d. Use electronic fetal surveillance to determine a baseline fetal heart rate.
ANS: A A cesarean birth is recommended for women with active lesions in the genital area, whether recurrent or primary, at the time of labor. The patient's dietary intake is needed to prepare for surgery. This patient is in active labor and the fetus is at risk for infection if the membranes rupture. The health care provider needs to be notified, and a cesarean birth needs to be performed as soon as possible. There is no need to validate the infection because the patient is well aware of the symptoms of an active infection. Although transmission to sexual partners is valid information, it is not necessary information in an urgent situation such as depicted in this scenario. Electronic fetal surveillance is the standard of care
Which intrapartal assessment should be avoided when caring for a patient with HELLP syndrome? a. Abdominal palpation b. Venous sample of blood c. Checking deep tendon reflexes d. Auscultation of the heart and lungs
ANS: A Palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the subcapsular hematoma. Assessment of heart and lungs is performed on every patient. Checking reflexes is not contraindicated. Venous blood is checked frequently to observe for thrombocytopenia.
Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa? a. Determining cervical dilation and effacement b. Monitoring FHR and maternal vital signs c. Observing vaginal bleeding or leakage of amniotic fluid d. Determining frequency, duration, and intensity of contractions
ANS: A Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage. Monitoring FHR and maternal vital signs is a necessary part of the assessment for this client. Monitoring for bleeding and rupture of membranes is not contraindicated with this client. Monitoring contractions is not contraindicated with this client.
31. Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy? a. Assessment of pain level b. Administration of methotrexate c. Administration of Rh immune globulin d. Explanation of the common side effects of the treatment plan
ANS: B The goal of medical management of an intact tube is to preserve the tube and improve the chance of future fertility. Methotrexate (a folic acid antagonist) is used to inhibit cell division and stop growth of the embryo. Assessment of pain level, administration of Rh immune globulin, and explaining common side effects of the treatment plan should be implemented in conjunction with or soon after treatment with methotrexate has begun.
A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a: a. diuretic. b. tocolytic. c. anticonvulsant. d. antihypertensive.
ANS: C Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. Diuresis is a therapeutic response to magnesium sulfate. A tocolytic drug slows the frequency and intensity of uterine contractions but is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium
A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate: a. gastrointestinal upset. b. effects of magnesium sulfate. c. anxiety caused by hospitalization. d. worsening disease and impending convulsion.
ANS: D Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent. Gastrointestinal upset is not an indication as severe as the headache and visual disturbance. She has not yet been started on magnesium sulfate as a treatment. The signs and symptoms do not describe anxiety.
A pregnant patient presents to labor and delivery with a positive Group B Streptococcus (GBS) result. The woman wants to know about this infection. What information about GBS is correct?
Antibiotic will be administered during labor before vaginal delivery to prevent the neonate from getting infection
1. A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? A. "Apply cold compresses between feedings." B. "Take a warm shower right after feedings." C. "Apply breast milk to the nipples and allow them to air dry." D. "Use the various infant positions for feedings.
Apply cold compress between feedings
a nurse is caring for a client who is pregnant and states that her last menstrual period was April 1st 2020. which of the following is the client's estimate date of delivery?
B - January 8, 2021
A maternity nurse is reviewing ways to prevent a TORCH infection during pregnancy with a group of new nurses. Which of the following statement made by a nurse indicates understanding of the teaching?
B - a woman should avoid eating undercooked meat during pregnancy : Toxoplasmosis, a TORCH infection, is contracted by consuming undercooked meat. IDK ABOUT C - a woman should avoid crowded places during pregnancy
Baby weighs 4,000 grams at birth and is admitted for dehydration. the baby now weighs 3.746 grams. Calculate the percentage weight
B 6.35%
A nurse is caring for a client who is receiving oxytocin for induction of labor and had an intrauterine pressure catheter (IUPC) Placed to monitor uterine contractions. For which of the following contraction pattern should the nurse discontinue the infusion of oxytocin? A)Frequency of every 2 min B) Duration of 90 to 120 seconds C)Intensity of 60 to 90 seconds D)Resting tone of 15 mmHG
B) Duration of 90 to 120 seconds
A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect?SATA A. Montgomery's glands B. goodell's signs C. Ballottement D. Chadwick's signs E. Quickening
B, C, D
a nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the nurse indicate understanding of the teaching? a. the newborn will have decreased muscle tone b. the newborn will have a continuous high-pitched cry c. the newborn will sleep for 2-3 hours after feeding d. the newborn will have mild tremors when disturbed
B. a continuous high-pitched cry is often an indication of CNS disturbance in . newborn who hs neonatal abstinence syndrome
A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. which of the following information should the nurse include in the teaching (SATA) A) use a disinfectant wipe to clean the lid of the formula can. B) store prepared formula in the refrigerator for up to 72? C)Place used bottles in the dishwasher D) Check the nipple for appropriate flow of formula E) Use tap water to dilute concentrate formula
C, D, E Place used bottles in the dishwater Check the nipple for appropriate flow of formula Use tap water to dilute concentrated formula
A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing
C. CORRECT: Periods of apnea lasting less than 15 seconds are an expected finding. D. CORRECT: Newborns are obligatory nose breathers A. INCORRECT: Expiratory grunting is a manifestation of respiratory distress. B. INCORRECT: Nasal flaring is a manifestation of respiratory distress. E. INCORRECT: Crackles and wheezing are symptoms of fluid or infection in the lungs.
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. "Limit the amount of time the infant nurses on each breast." B. "Nurse the infant only on the unaffected breast until resolved." C. "Completely empty each breast at each feeding or use a pump." D. "Wear a tight‐fitting bra until lactation has ceased."
Completely empty each breast at each feeding or use a pump
A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states "My water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A. place the client in the Trendelenburg position B. apply pressure to the presenting part with her fingers C. administer oxygen at 10L/min via a face mask D. call for assistance
D. call for assistance
A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? A. Inspect the introitus for a prolapsed cord. B. Perform a test to identify the ferning pattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.
Defer vaginal examination
Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication? a. Drowsiness b. Urinary output of 20 mL/hr c. Normal deep tendon reflexes d. Respiratory rate of 10 to 12 breaths/m
Drowsiness
2. a nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (select all that apply.) a. hypospadias B. hydrocele C. Family history of hemophilia d. hyperbilirubinemia e. epispadias
Epispadias family history of hemophilia hypospadias A C E "a. CORRECT: hypospadias involves a defect in the location of the urethral opening and is a contraindication to circumcision. B. hydrocele, a collection of fluid in the scrotal sac, is not a contraindication to circumcision. C. CORRECT: a family history of hemophilia is a contraindication for circumcision. d. hyperbilirubinemia is not a contraindication for circumcision. e. CORRECT: epispadias involves a defect in the location of the urethral opening and is a contraindication to circumcision."
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? a. Mongolian spots b. milia spots c. erythema toxicum d. epsteins pearls
Epstein pearls
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. Hands and knees B. Lithotomy C. Trendelenburg D. Supine with rolled towel under one hip
Hands and knees
A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Make a loud noise such as clapping hands together over the newborn's crib. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semisitting position, then allow the newborn's head and trunk to fall backward.
Hold the newborn in a semi-sitting position, then allow the head and trunck to fall backwards D. CORRECT: The Moro reflex is elicited by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backward.
A nurse is reviewing car seat safety with the parents of a newborn. Which of the following statement if made by the patent indicates further teaching is required regarding car seats safety?
I will place the infant in the front seat forward-facing
A cesearean section client who was diagnoses gestational hypertension in the labor is transferred to the postpartum unit post delivery. upon revewing the orders by the postpartum nurse, which prescription should the nurse clarify?
Ibuprofen
A nurse is teaching a 16 year old about contraception. What statement by the client indicate need for further teaching? SATA
If I take my birth control pill every other day at 4pm, it is guaranteed to work I cannot get pregnant if my partner pulls out Using spermicide during intercourse will guarantee that I will not get pregnant or sexually transmitted infections
Which instructions should the nurse include when teaching a pregnant client with Class II heart disease? a. Advise her to gain at least 30 pounds. b. Instruct her to avoid strenuous activity. c. Inform her of the need to limit fluid intake. d. Explain the importance of a diet high in calcium.
Inform her of the need to limit fluid intake
A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? A. "It is used to stimulate uterine contractions" B. "It will decrease the incidence of uterine contractions" C. "It lulls the fetus to sleep" D. "It awakens a sleeping fetus"
It awakens a sleepy fetus
. A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? A. Cover the cord with a small gauze square. B. Trickle clean water over the cord with each diaper change. C. Apply hydrogen peroxide to the cord twice a day D. Keep the diaper folded below the cord.
Keep the diaper folded below the cord
A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. Burp the newborn at the end of the feeding. B. Hold the newborn close in a supine position. C. Keep the nipple full of formula throughout the feeding. D. Refrigerate any unused formula.
Keep the nipple full of formula throughout the feeding
a nurse is caring a patient who is preterm labor and is scheduled to undergo an amniocentesis. the nurse should evaluate which of the following tests to assess fetal lung maturity?
Lecithin/spingomyelin (L/S) ration
A nurse is taking a newborn to a mother following a circumcision which of the following actions should the nurse take for security purposes? A) Ask the mother to state her full name B)Look at the name on newborn's bassinet C)match the mother's identification band with the newborns band. D) Compare name on the
Match the mother's identification band with the newborn's band
A client who is 38 weeks gestation comes to the clinic for routine examination. the nurse is preparing discharge teaching for this client. What is the priority teaching for this client in 38 weeks gestation?
Maternal nutrition
4. A nurse on the postpartum unit is planning care for a client who has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. Apply cold compresses to the affected extremity. B. Massage the affected extremity. C. Allow the client to ambulate. D. Measure leg circumferences.
Measure leg circumference
A nurse is interviewing a pregnant patient during a prenatal visit. Which patient statement might suggest a need to evaluate further for preeclampsia?
My work shoes don't fit me any more
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate
Oxygen saturation
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus. C. Grasp lower uterine segment between thumb and fingers. D. Stand facing client's feet with fingertips outlining cephalic prominence. B
Palpate the fundus of the uterus
A nurse is caring for a newborn immediately following birth. Which of the following is the highest priority action by the nurse at this time?
Performing the initial birth
1. A nurse is assessing a postpartum client who is exhibiting tearfulness insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these clinical findings? A. Postpartum fatigue B. Postpartum psychosis C. Letting-go phase D. Postpartum blues
Postpartum blues
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse recognizes the adverse effect of this contraction pattern is: A. prolonged labor. B. reduced fetal oxygen supply. C. delayed cervical dilation. D. increased maternal stress.
Reduced fetal oxygen supply
A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following? A. Reduced menstrual flow. B. Breast tenderness. C. Shortness of breath. D. Headaches.
Shortness of Breath (SOB)
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. sunken fontanels B. maculopapular skin rash C. conjunctivitis D. bronze skin discoloration
Sunken fontanels
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the client's uterus to be firm and midline and at the level of the umbilicus. The nurse interprets this finding as: A. evidence of a possible vaginal hematoma. B. an indication of a cervical or perineal laceration. C. a normal postural discharge of lochia. D. abnormally excessive lochia rub flow.
a normal postural discharge of lochia
2. A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (Select all that apply) A. Precipitous delivery B. Obesity C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments
a, c, e Precipitous delivery Inversion of the uterus Retained placental fragments
a nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and mother‐infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) a. demonstrates apathy when the infant cries B. Touches the infant and maintains close physical proximity C. Views the infant's behavior as uncooperative during diaper changing d. identifies and relates infant's characteristics to those of family members e. interprets the infant's behavior as meaningful and a way of expressing needs
a. CORRECT: This behavior demonstrates a lack of interest in the infant and impaired maternal‐infant bonding. C. CORRECT: a client's view of her infant as being uncooperative during diaper changing is a sign of impaired maternal‐infant bonding.
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? A.) Administer oxygen via nasal cannula at 2 L/min B.) Apply a warm blanket C. Assist the client to a side-lying position D.) Place an oxygen mask over the client's nose and mouth
an oxygen mask over the client's nose and mouth
A nurse is caring for a newborn who was born at 38 weeks gestation, weighs 3200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neotate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age
appropriate for gestational age
The priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to a. assess fetal heart rate (FHR) and maternal vital signs. b. perform a venipuncture for hemoglobin and hematocrit levels. c. place clean disposable pads to collect any drainage. d. monitor uterine contractions.
assess fetal heart rate and maternal vital signs
a nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following findings is seen with this condition? a. no alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus c. Serum progesterone greater than the expected reference range d. report of severe shoulder pain
d. CORRECT: a client's report of severe shoulder pain is a finding associated with a ruptured ectopic pregnancy due to the presence of blood in the abdominal cavity, which irritates the diaphragm and phrenic nerve.
A nurse in the labor and delivery unit is caring for patient in labor. The fetal heart rate is recorded 140 b/min. Contractions are occurring every 8 mins lasting 30 to 40 seconds. Vaginal exam revealed cervix 2 cm dilated, 50% effaced and -2 station. Which of the following stages and phases of labor is the patient experiencing?
first stage, active phase
26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on the knowledge that a. bed rest and analgesics are the recommended treatment. b. she will be unable to conceive in the future. c. a D&C will be performed to remove the products of conception. d. hemorrhage is the major concern.
hemorrhage is the major concern.
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A. intrauterine growth restriction B. hyperglycemia C. meconium aspiration D. polyhydramnios
meconium aspiration
