HESI med surg 23
A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is the most important to report? A. History of IBS B. pain scale of 9/10 C. last menstrual period 7 weeks ago. D. Reports white, curly vaginal discharge.
C.
A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner?
foul smelling lochia
A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician?
urine output 200 ml for last 8 hours
A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored?
uterine atony
A multigravida client in labor is receiving oxytocin Pitocin 4mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringers 1,000 ml with Pitocin 20 units. The nurse should program the infusion pump to deliver how many ml/hr? ANS: 12 ml
12 mL
A 32- week primigravida who is in preterm labor receives a prescription for an infusion of D5W 500 ml with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hour should the nurse program the infusion pump?
25 mL
A 32- week primigravida who is in preterm labor receives a prescription for an infusion of D5W 500 ml with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hour should the nurse program the infusion pump?
25 mL
The nurse is counseling a client who is at 6 weeks gestation and is experiencing morning sickness but does not want to take any drugs for this discomfort. Which herbal supplement is likely to help this client with the nausea she is experiencing? A. Ginko B. Chamomile C. Peppermint D. Ginger
D ginger
The nurse if caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus if firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first? A. Heart rate and blood pressure B. Abdominal contour and bowel sounds C. Urinary output and IV fluid intake D. Hemoglobin and Hematocrit
A
The nurse is caring for a postnatal patient who is exhibiting symptoms of spinal headaches 24 hours following delivery of a normal newborn. Prior to anesthesiologist's arrival on the unit, which action should the nurse perform? A. Place procedure equipment at bedside B. Apply an abdominal binder C. Cleanse the spinal injection site D. Insert an indwelling foley catheter
A
A newborn infant is receiving immunization prior to discharge. Which action should the nurse implement?
Obtain consent from the mother for admistration of hep B vaccine.
A woman who delivered a normal newborn 24 hours ago complains, " I seem to be urinarting every hour or so. Is that ok?". Which action should the nurse implement? A. Catheterize the client for residual urine volume B. Measure the next voiding, then palpate the clients bladder C. Evaluate for normal involution, then massage the fundus D. Obtain a specimen for urine culture and sensitivity
B
An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? A. Prepare the client for an echocardiogram B. Document in the client's record C. Notify the healthcare provider D. Limit the client's fluids
B
A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor. What is the priority nursing action for this client? A. Observe for signs of uterine hemorrhage B. Encourage direct contact with the infant C. Assess the blood pressure for hypertension D. Gently massage fundus every four hours
A
A client at 20 weeks gestation comes to the antepartum clinic complaining of vaginal warts (HPV). What information should the nurse provide? A. Treatment options, while limited during pregnancy, are available. B. The client should be treated with Penicillin G. C. This client should be treated with acyclovir. D. Termination of pregnancy should be considered.
A
A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and no contractions are noted on the external monitor. Which intervention should the nurse implement? A. Weight of perineal pads. B. Weight daily. C. Measure I and O D. ambulate 15 min QID
A
A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide? A. When there is no significant vaginal bleeding. B. When ambulating to void does not cause dizziness. C. After the vitamin K injection is given. D. After the baby no longer demonstrates acrocyanosis.
A
A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings f the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first? A. Determine current cervical dilation B. Request placement of the epidural C. Give bolus of intravenous fluids D. Decrease the oxytocin infusion rate
A
A diabetic client delivers a full term large for gestational age infant who is jittery. What action should the nurse take first? A. Obtain a blood glucose level B. Administer oxygen C. Feed the infant glucose water (10%) D. Decrease environmental stimuli
A
Calculated by Naegele's rule, a primigravida client is at 28 weeks gestation. She is moderately obese and carrying twins and the nurse measures her fundal height at 27 cm. During the previous visit 3 weeks ago, the fundal height measured at 28 cm. Based on these findings, what should the nurse conclude? A. Fundal height measurement may indicate intrauterine growth retardation B. The healthcare provider needs to be notified immediately since this fundal height measurement is greater than expected C. Confirm the fundal height measurement with another nurse D. Recognize this as a reasonable fundal height measurement for this client
A
The nurse is performing a gestational age assessment on a full term newborn during the first hour of transition using the Ballard scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse id to determine if the neonate is small for gestational age? SATA A. admission weight of 4 lbs 15 ounces B. head to heel length of 17 inches C. frontal occipital circumference of 12.5 inches. D. skin smooth with visible veins and abundant vernix. E. Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position.
A B C
Four clients arrive at the labor and delivery nurses' station at the same time. Which pt should the nurse assess first? A. A 3-week multigravida with a prescription for serial blood pressures. B. A 39-week primigravida with biophysical profile score of 5/8 C. a 38-week primigravida who reports contractions occurring every 10 minutes. D. A 41-week multigravida who is scheduled induction of labor today.
B
The nurse is assessing a 38- week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extra-uterine life? A. Flexion of all four extremities B. Cries vigorously when stimulated C. Heart rate of 22 beats/minute D. A positive Babinski reflex
B
A 3 hour old male infant's hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best for the nurse to implement? A. Perform a heel- stick to monitor blood glucose level B. Gradually warm the infant under a radiant heat source C. Administer oxygen by mask at 2L/minute D. Notify the pediatrician of the infants unstable vital signs
B
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV pitocin is infused. When notifying the health care provider of the clients' condition, what information is most for the nurse to provide? A. Total amount of Pitocin infused. B. Maternal blood pressure. C. Maternal apical pulse rate. D. Time pitocin infusion completed.
B
The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance the day before. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? a) "Sometimes babies just don't deliver the way we expect them to." b) "With all of your preparations, it must have been disappointing for you to have had a cesarean." c) "I know you had to have surgery, but you are very lucky that your baby was born healthy." d) "At least your husband was able to be with you when the baby was born."
B
The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? A. Encourage the parents to report this to the healthcare provider B. Explain the newborns normal stepping reflex C. Acknowledge the parents observation D. Schedule the newborn for further neurological testing
B
Which topic is most important for the nurse to include in a nutrition teaching program for pregnant teenagers? A. Gestational diabetes B. Iron-deficieny anemia C. Excessive weight gain D. Elevated cholesterol
B
Vaginal prostaglandin gel is used to induce labor for a woman who is at 42 weeks gestation. Thirty minutes after insertion of the gel, the client complains of vaginal warmth, and is experiencing 90 second contractions with fetal heart rate decelerations. What action should the nurse implement first? A. Notify the hcp B. Assess the maternal vital signs C. Turn to a side-lying position D. Increase the IV infusion rate
C
A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman?
Postpartum hemorrhage
At 40-week gestation, a laboring client who is lying in a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? A. Place a pillow under the client's head and knees. B. Place a wedge under the client's right hip. C. Encourage the client to turn on her left side. D. Explain to the client that her position is not safe.
B. Place a wedge under the client's right hip.
After breastfeeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborns diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first? A. Wipe away the spit-up and assist the mother with the diaper change. B. Turn the newborn to the side and bulb suction the mouth and nares. C. Sit the newborn up and burp by rubbing or patting the upper back. D. Place the newborn in a position with he head lower than the feet.
B. Turn the newborn to the side and bulb suction the mouth and the nares.
A multiparous woman at 38-weeks gestation with a history of rapid progression of labor is admitted for induction due to signs and symptoms of preeclampsia. One hour after the Pitocin infusion is initiated, she complains of a headache. Her contractions are occurring every 1 to 2 minutes, lasting 60 to 75 seconds, and a vaginal exam indicates that her cervix is 90% effaced and dialted to 6 cm. What intervention is most important for the nurse to implement? A. Turn the client on her left side B. Discontinue the Pitocin infusion C. Prepare for immediate delivery D. Measure deep tendon reflexes
C
A primigravida at 36 weeks gestation, who is Rh negative, experienced abdominal trauma in a MVA. Which assessment finding is the most important for the nurse to report? A. Fetal heart rate of 162 bpm B. trace of protein in the urine C. positive fetal hemoglobin test D. mild contractions every 10 minutes
C
At 0600 while admitting a woman for a scheduled repeat c section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. What action should the nurse take first? A. Ensure preoperative lab results are available B. Start prescribed IV with Lactated Ringers C. Inform the anesthesia care provider D. Contact the clients obstetrician
C
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heartrate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first?
Change the maternal position.
A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time?
Dress the baby in a t-shirt and swaddle the baby in a receiving blanket.
During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client's side. Which action should the nurse implement first?
Encourage client to void.
A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate?
Encourage woman to breastfeed frequently.
Which of the following is a priority nursing diagnosis for a woman, G10P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage?
Fluid volume deficit related to blood loss.
The nurse if caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus if firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
HR and BP
On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client?
How many stairs are in your home?
Which topic is most important for the nurse to include in a nutrition teaching program for pregnant teenagers?
Iron-deficiency anemia
A multiparous client at 38- weeks gestation is admitted to labor and delivery with a compliant of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. What action should the nurse take first?
Push call light for help.
A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus?
absent bowel sounds
A client who is receiving oxytocin (Pitocin) to augment early labor begins to experience hypersystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement? Reposition the fetal monitor transducers
Turn off the pitocin infusion
At 34- weeks gestation, a primigravida is assessed at her bimonthly clinic visit,. Which assessment finding is important for the nurse to report to the hcp?
Weight gain of 7 lbs.
A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which information is most important for the nurse to provide the client?
When there is no significant vaginal bleeding.
The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which assessment finding warrants immediate intervention by the nurse?
bluish tinge to tongue
A client who is in active labor is receiving magnesium sulfate and begin to experience slurred speech and decreased reflexes. Which action should the nurse implement first? A. Obtain a serum magnesium level B. Measure the clients hourly urinary output C. Provide an emesis basin for vomiting D. Turn off the magnesium sulfate infusion
D
The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? a. White blood cells—12,500 cells/mm3. b. Red blood cells—4,500,000 cells/mm3. c. Hematocrit—26%. d. Hemoglobin—11 g/dL
c
The nurse asks a 31-week gestation client to lie on the examining table during a prenatal examination. In which of the following positions should the client be placed? a) Orthopneic. b) Lateral-recumbent. c) Sims'. d) Semi-Fowler's.
d
The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds at 36- weeks gestation. This amniocentesis is being performed to obtain which information? A. Presence of a neural tube defect B. Gender of the fetus C. Fetal lung maturity D. Chromosomal abnormalities
C
The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? a) Provide the client with a nutritious meal. b) Encourage the client to take a nap. c) Assist the client with activities of daily living. d) Assure the client that she is an excellent mother.
d
A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to patient's safety, which short-term goal should the nurse include in the plan of care? A) Attends one group activity per day. B) Sleeps at least 6 hours per night. C) Engages in one client-to-client interaction daily. D) Consumes 3 meals and 1500 mL of fluid per day.
D
One hour after delivery the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umblilicus and obtains current vital signs. Which intervention should the nurse implement? A. Document the number of pad changes in the last hour. B. Increase the rate of the oxytocin infusion. C. Palpate the suprapubic area for bladder distention. D. Provide bedpan to void if unable to ambulate.
C. Palpate the suprapubic area for bladder distention.
During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client's side. Which action should the nurse implement first? A. Encourage the client to void. B. Massage the fundus until firm. C. Catheterize for residual urinary volume. D. Provide additional oral replacement fluids.
A
Following the vaginal delivery of a large for gestation age (LGA) infant, a woman is admitted to the ICU due to post-partum hemorrhaging. The client's medical record describes Jehovah's Witness notes as her religion. What action should the nurse take next? A. Inform the client of the critical need for a blood transfusion B. Obtain consent from the family to infuse packed red blood cells C. Clarify the clients wishes about receiving blood products D. Prepare to infuse multiple units of fresh frozen plasma
A
The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? A. Position a firm wedge to support pelvis and thorax at 30 degree tilt. B. Apply oxygen by mask after opening the airway. C. Apply less compression force to reduce aspiration. D. Give continuous compression with a ventilation ration at 20:3.
A
A client who is receiving oxytocin (Pitocin) to augment early labor begins to experience hypersystolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement? Reposition the fetal monitor transducers A. Alert the charge nurse to the patient's condition B. Turn off the Pitocin infusion C. Decrease the rate of the Pitocin infusion
B
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide? A) An abdominal binder can be worn daily to reduce the protrusion. B) This hernia is a normal variation that resolves without treatment. C) The quarter should be secured with an elastic bandage wrap. D) Restrictive clothing will be adequate to help the hernia go away.
B
A new infant is receiving positive pressure ventilation after delivery. Based on which assessment finding should the nurse initiate chest compressions? A. Apgar score 7 B. Heart rate 54 C. Limp muscle tone D. Central cyanosis
B
A new mother, who is lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge? A. Avoid using lanolin-based nipple cream or ointment. B. Continue prenatal vitamins with B12 while breast feeding. C. Offer iron-fortified supplemental formula daily. D. Weigh the baby weekly to evaluate the newborn's growth.
B
A term multigravida, who is receiving oxytocin (Pitocin) for labor augmentation, is requesting pain medication. Review of the clients record indicates that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the clients cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement? A. Medicate the client with an additional 1 mg of Stadol IV push B. Instruct the client to use deep breathing during a contraction C. Discontinue the Pitocin infusion D. Notify the healthcare provider
B
The father of a 3- day- old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cried for no apparent reason. What information is most important for the nurse to provide to this father? A. A fluctuation in hormones in the early postpartum period can cause mood changes B. Recommend giving supplemental bottle feedings to the baby between breast feeding C. Contact the clinic if the behaviors continue for more than two weeks or become worse D. Tell the father to count the newborns number of soiled diapers over the next few days
C
The health care provider hands a newborn to the nurse after a vaginal delivery. What action is most important for the nurse to implement? A. Allow the mother to touch the infant B. Complete a physical assessment C. Place the infant under a warming unit D. Determine the APGAR score
C
The nurse is assessing a postpartum client who delivered a 10 pound infant vaginally two hours ago. The clients fundus is 2 fingerbreadths above the umbilicus, deviated to the right side, and boggy. After the client voids 250 ml of urine using a bedpan, what action should the nurse implement? A. Re-evaluate the client in 15 minutes B. Assist the client to the bathroom to void C. Palpate the suprapubic region for distention D. Encourage the client to breastfeed
C
The nurse is caring for a newborn infant who was recently diagnosed with a congenital heart defect. Which assessment finding warrants immediate intervention by the nurse? A. Sweating during feedings. B. Weak peripheral pulses. C. Bluish tinge to the tongue. D. Increased RR.
C
The nurse is assessing a 38- week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extra-uterine life?
Cries vigorously when stimulated.
A multiparous client at 38- weeks gestation is admitted to labor and delivery with a compliant of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. What action should the nurse take first? A. Inspect the clients perineum B. Turn on the infant warmer C. Notify a healthcare provider D. Push the call light for help
D
A newborn infant is receiving immunization prior to discharge. Which action should the nurse implement? A. Give the first dose of the vaccine for Rotavirus if any sibilings have diarrhea now B. Ask the mother if she wants the infant immunized for Haemophilus influenza C. Prepare the first dose for Diphtheria, tetanus toxoid and acellular pertussis (DTap) D. Obtain signed consent from the mother for administration of hepatitis B vaccine
D
At 34- weeks gestation, a primigravida is assessed at her bimonthly clinic visist,. Which assessment finding is important for the nurse to report to the hcp? A. Increased appetite B. Fetal heart rate of 110 beats/minute C. Fundus below the xiphoid D. Weight gain of 7 pounds
D
During a Women's Health Fair, which assignment is best for the practical nurse (PN) who is working with a registered nurse (RN)? A. Encourage a woman at risk for cancer to obtain a colonoscopy. B. Present a class on bread self-examination. C. Explain the follow up needed for a client with prehypertension. D. Prepare a woman for a bone density screening.
D
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. What action should the nurse implement? A. Assess neurological vital signs every 4 hours B. Apply direct pressure to the caput succedaneum (THIS ONE CROSSES THE SUTURE LINES) C. Submit a request for a stat CT scan of the head D. Notify the pediatrician of the cephalhematoma (THIS ONE DOES NOT CROSS THE SL & IS MORE CRITICAL)
D
The nurse is assessing a 35 week primigravida with a breech presentation who is experiencing moderate uterine contraction every 3-5 minutes. During the examination the client tells the nurse, "I think my water just broke". Inspection of the perineal area reveals the umbilical cord protruding from the vagina. After activating the call bell system for assistance, what intervention should the nurse implement? A. Administer oxygen at 10 liters via face mask B. Don gloves and push the cord back into the vagina C. Wrap the umbilical cord with sterile gauze D. Position the client into a knee-chest position
D
The nurse is assessing a newborn who was precipitously delivered at 38 weeks gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement? A. Determine reactivity of neonatal reflexes B. Perform gestational age assessment C. Weight and measure the newborn D. Obtain a drug screen for cocaine
D
The nurse is discussing involution with a post-partum client. Which statement best indicates that the client understands the effect of breastfeeding on the resumption of menstrual cycle? A. "My period will most likely return in 6 to 8 months" B. "I should expect my period to return in 6 to 8 weeks" C. "My period started as soon as the baby was born" D. "While I am breastfeeding, my period may be delayed"
D
The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instruction should the nurse provide the mother about feedings? A. Alternate milk with water during feedings. B. Squeeze the nipple base to introduce milk into the mouth. C. Position the baby in the left lateral position during feeding. D. hold the newborn in an upright position.
D
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heartrate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first? A. Prepare for a potential cesarean B. Allow the client to begin pushing C. Administer oxygen at 10/L by mask D. Change the maternal position
D
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. What action should the nurse implement?
Notify pediatrician of the cephalhematoma (Does not cross SL and is more critical.)
A multiparous woman at 38-weeks gestation with a history of rapid progression of labor is admitted for induction due to signs and symptoms of preeclampsia. One hour after the Pitocin infusion is initiated, she complains of a headache. Her contractions are occurring every 1 to 2 minutes, lasting 60 to 75 seconds, and a vaginal exam indicates that her cervix is 90% effaced and dialted to 6 cm. What intervention is most important for the nurse to implement?
Prepare for immediate delivery
A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client?
Provide the client with supervised instruction on baby care skills.
A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity?
Serial grip strength
A nurse is assessing a 1 day-postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10 point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
She should be assessed by her doctor.
A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and no contractions are noted on the external monitor. Which intervention should the nurse implement?
Weigh perineal pads.
A woman, who wishes to breastfeed, advises the nurse that she has had breast augmentation surgery. Which of the following responses by the nurse is appropriate?
Women who have implants are often able to exclusively breastfeed.
A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? a) Assure the woman that frequent urination is normal after delivery. b) Obtain an order for a urine culture. c) Assess the urine for cloudiness. d) Ask the woman if she is prone to urinary tract infections.
a
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? a) Respiratory rate 8 rpm. b) Complaint of thirst. c) Urinary output of 250 cc/hr. d) Numbness of feet and ankles.
a
A nurse has brought a 2-hour-old baby to a mother from the nursery. The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first? a) Compare mother's and baby's identification bracelets. b) Help the mother into a comfortable position. c) Teach the mother about a proper breast latch. d) Tickle the baby's lips with the mother's nipple.
a
Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? a. Provide the woman with warm blankets. b. Put the woman in Trendelenburg position. c. Notify the primary health care provider. d. Increase the intravenous infusion.
a
The nurse asks a woman about how the woman's husband is dealing with the pregnancy. The nurse concludes that counseling is needed when the woman makes which of the following statements? a) "My husband is ready for the pregnancy to end so that we can have sex again." b) "My husband has gained quite a bit of weight during this pregnancy." c) "My husband seems more worried about our finances now than before the pregnancy." d) "My husband plays his favorite music for my belly so the baby will learn to like it."
a
The obstetrician has ordered that a post-op cesarean section client's patient-controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? a) Discard the remaining medication in the presence of another nurse. b) Recommend waiting until her pain level is zero to discontinue the medicine. c) Discontinue the medication only after the analgesia is completely absorbed. d) Return the unused portion of medication to the narcotics cabinet.
a
Which finding would the nurse view as normal when evaluating the laboratory reports of a 34-week gestation client? a) Anemia. b) Thrombocytopenia. c) Polycythemia. d) Hyperbilirubinemia.
a
Which of the following nursing interventions would be appropriate for the nurse to perform in order to achieve the client care goal: The client will not develop postpartum thrombophlebitis? a) Encourage early ambulation. b) Promote oral fluid intake. c) Massage the legs of the client twice daily. d) Provide the client with high fiber foods.
a
A nurse is working in the prenatal clinic. Which of the following findings seen in third-trimester pregnant women would the nurse consider to be within normal limits? Select all that apply. a) Leg cramps. b) Varicose veins. c) Hemorrhoids. d) Fainting spells. e) Lordosis.
a b c e
During a postpartum assessment, it is noted that a G1P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. a) The client should use a sitz bath daily as a relief measure. b) The client should digitally replace external hemorrhoids into her rectum. c) The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. d) The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. e) The client should apply topical anesthetic as a relief measure.
a b e
A woman is receiving Paxil (paroxetine) for postpartum depression. In order to prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following?
alcohol
12. A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? a) The nurse measures the fundal height using a paper centimeter tape. b) The nurse stabilizes the base of the uterus with his or her dependent hand. c) The nurse palpates the fundus with the tips of his or her fingers. d) The nurse precedes the assessment with a sterile vaginal exam.
b
A 3-month-old baby has been diagnosed with cystic fibrosis. The mother states, "How could this happen? I had an amniocentesis during my pregnancy and everything was supposed to be normal!" What does the nurse understand about this situation? a) Cystic fibrosis cannot be diagnosed by amniocentesis. b) The baby may have an uncommon genetic variant of the disease. c) It is possible that the laboratory technician made an error. d) Instead of obtaining fetal cells the doctor probably harvested maternal cells.
b
A 36-week gestation gravid lies flat on her back. Which of the following maternal signs/symptoms would the nurse expect to observe? a) Hypertension. b) Dizziness. c) Rales. d) Chloasma.
b
A client, G1P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? a) Notify the woman's primary health care provider. b) Massage the woman's fundus. c) Escort the woman to the bathroom to urinate. d) Check the quantity of lochia on the peripad.
b
A client, in her third trimester, is concerned that she will not know the difference between labor contractions and normal aches and pains of pregnancy. How should the nurse respond? a) "Don't worry. You'll know the difference when the contractions start." b) "The contractions may feel just like a backache, but they will come and go." c) "Contractions are a lot worse than your pregnancy aches and pains." d) "I understand. You don't want to come to the hospital before you are in labor."
b
A post-cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? a) The woman needs a stronger narcotic order. b) The woman is high risk for severe constipation. c) The woman's breast milk volume may drop while taking the medicine. d) The woman's newborn may become addicted to the medication.
b
A woman asks the obstetrician's nurse about cord blood banking. Which of the following responses by the nurse would be best? a) "I think it would be best to ask the doctor to tell you about that." b) "The cord blood is frozen in case your baby develops a serious illness in the future." c) "The doctors could transfuse anyone who gets into a bad accident with the blood." d) "Cord blood banking is very expensive and the blood is rarely ever used."
b
The nurse discusses the results of a 3-generation pedigree with the proband who has breast cancer. Which of the following information must the nurse consider? a) The proband should have a complete genetic analysis done. b) The proband is the first member of the family to be diagnosed. c) The proband's first degree relatives should be included in the discussion. d) The proband's sisters will likely develop breast cancer during their lives.
b
The nurse informs a postpartum woman that ibuprofen (Advil) is especially effective for afterbirth pains. What is the scientific rationale for this? a) Ibuprofen is taken every two hours. b) Ibuprofen has an antiprostaglandin effect. c) Ibuprofen is given via the parenteral route. d) Ibuprofen is administered in high doses.
b
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? a) Moderate serosanguinous drainage. b) Well-approximated edges. c) Ecchymotic area distal to the episiotomy. d) An area of redness adjacent to the incision.
b
The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? a) Teach baby care skills like diapering. b) Discuss the labor and birth with the mother. c) Discuss contraceptive choices with the mother. d) Teach breastfeeding skills like pumping.
b
The nurse is interviewing a 38-week gestation Muslim woman. Which of the following questions would be inappropriate for the nurse to ask? a) "Do you plan to breastfeed your baby?" b) "What do you plan to name the baby?" c) "Which pediatrician do you plan to use?" d) "How do you feel about having an episiotomy?"
b
The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? a) "Okay. I must be palpating your uterus." b) "I understand but I still would like you to try to urinate." c) "You still must be numb from the local anesthesia." d) "That is a problem. I will have to catheterize you."
b
A third-trimester client is being seen for routine prenatal care. Which of the following assessments will the nurse perform during the visit? Select all that apply. a) Blood glucose. b) Blood pressure. c) Fetal heart rate. d) Urine protein. e) Pelvic ultrasound.
b c d
One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. a) The client will drink sufficient quantities of fluid. b) The client will have a stable white blood cell count. c) The client will have a normal temperature. d) The client will have normal-smelling vaginal discharge. e) The client will take two or three sitz baths each day.
b c d
24.On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was assessed at 11.0 gm/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? a) Hgb 12.5 gm/dL; Hct 37%. b) Hgb 11.0 gm/dL; Hct 33%. c) Hgb 10.5 gm/dL; Hct 31%. d) Hgb 9.0 gm/dL; Hct 27%.
c
A 34-week gestation woman calls the obstetric office stating, "Since last night I have had three nosebleeds." Which of the following responses by the nurse is appropriate? a) "You should see the doctor to make sure you are not becoming severely anemic." b) "Do you have a temperature?" c) "One of the hormones of pregnancy makes the nasal passages prone to bleeds." d) "Do you use any inhaled drugs?"
c
A man has inherited the gene for familial adenomatous polyposis (FAP), an autosomal dominant disease. He and his wife wish to have a baby. Which of the following would provide the couple with the highest probability of conceiving a healthy child? a) Amniocentesis. b) Chorionic villus sampling. c) Pre-implantation genetic diagnosis. d) Gamete intrafallopian transfer.
c
A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? a) Skim milk. b) Ginger ale. c) Orange juice. d) Chamomile tea.
c
A woman is 36-weeks' gestation. Which of the following tests will be done during her prenatal visit? a) Glucose challenge test. b) Amniotic fluid volume assessment. c) Vaginal and rectal cultures. d) Karyotype analysis.
c
A woman who is a carrier for sickle cell anemia is advised that if her baby has two recessive genes, the penetrance of the disease is 100%, but the expressivity is variable. Which of the following explanations will clarify this communication for the mother? All babies with 2 recessive sickle cell genes will: a) Develop painful vaso-occlusive crises during their first year of life. b) Exhibit at least some signs of the disease while in the neonatal nursery. c) Show some symptoms of the disease but the severity of the symptoms will be individual. d) Be diagnosed with sickle cell trait but will be healthy and disease-free throughout their lives.
c
One week after missing her menstrual period, a woman performs an OTC pregnancy test and it is positive. What hormone is responsible for producing the positive result? A. Human placental lactogen. B. Gonadotrophin-releasing hormone. C. Human chorionic gonadotrophin D. prostaglandin E2 alpha
c
The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? a) The woman performs the procedure twice a day. b) The woman sits in warm tap water for ten minutes. c) The woman sprays her perineum from front to back. d) The woman mixes tap water with hydrogen peroxide.
c
A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
fluid volume deficit
The nurse is counseling a pregnant couple who are both carriers for phenylketonuria (PKU), an autosomal recessive disease. Which of the following comments by the nurse is appropriate? a) "I wish I could give you good news, but because this is your first pregnancy, your child will definitely have PKU." b) "Congratulations, you must feel relieved that the odds of having a sick child are so small." c) "There is a 2 out of 4 chance that your child will be a carrier like both of you." d) "There is a 2 out of 4 chance that your child will have PKU."
c
The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? a) Assist with stitch removal on third postpartum day. b) Administer analgesics every four hours per doctor orders. c) Teach client to contract her buttocks before sitting.
c
The nurse is examining a 2-day postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? a) Abnormal involution, lochia rubra heavy. b) Abnormal involution, lochia serosa scant. c) Normal involution, lochia rubra moderate. d) Normal involution, lochia serosa heavy.
c
To obtain the obstetric conjugate measurement, the nurse would do which of the following? a) Add 1.5 cm to the transverse diameter. b) First measure the angle of the pubic arch. c) Subtract 1.5 to 2 cm from the diagonal conjugate. d) Measure the diameter of the pelvic inlet.
c
Which of the following is the priority nursing action during the immediate postpartum period? a) Palpate fundus. b) Check pain level. c) Perform pericare. d) Assess breasts.
c
The nurse is developing a teaching plan for a client entering the third trimester of her pregnancy. The nurse should include which of the following in the plan? Select all that apply. a) Differentiating the fetus from the self. b) Ambivalence concerning pregnancy. c) Experimenting with mothering roles. d) Realignment of roles and tasks. e) Trying various caregiver roles. f) Concern about labor and delivery.
c d e f
A breastfeeding client calls her obstetrician stating that her baby was diagnosed with thrush and that her breasts have become infected as well. Which of the following organisms has caused the baby's and mother's infection?
candida albicans
A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? a) "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." b) "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." c) "It is not unusual to bleed heavily every once in a while, after a baby is born. It should subside shortly." d) "It is important for you to be examined by the doctor today. Let me check to see when you can come in."
d
A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? a) "That is very concerning. I will request that your physician order an enema for you." b) "Two days is not that bad. Some patients go four days or longer without a movement." c) "You have been taking antibiotics through your intravenous. That is probably why you are constipated." d) "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."
d
A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? a) "You must wait to begin to perform exercises until after your six-week postpartum checkup." b) "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." c) "By next week you will be able to return to the exercise schedule you had during your prepregnancy." d) "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."
d
A client, G1P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? a) "You'll feel better later after you have had a chance to rest and to eat." b) "Don't say that. There are many women who would be ecstatic to have that baby." c) "I am sure that you will have another baby. I bet that it will be a natural delivery." d) "To have things work out differently than you had planned is disappointing."
d
A client, G1P1001, 1-hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? a) Provide the woman with a bedpan. b) Advise the woman that the feeling is likely related to the trauma of delivery. c) Remind the woman that she still has a catheter in place from the delivery. d) Assist the woman to the bathroom.
d
A new antenatal G 6, P 4, Ab 1 client attends her fi rst prenatal visit with her husband. The nurse is assessing this couple's psychological response to their pregnancy. Which of the following requires the most immediate follow up? a) The couple are concerned with fi nancial changes this pregnancy causes. b) The couple expresses ambivalence about the current pregnancy. c) The father of the baby states that the pregnancy has changed the mother's focus. d) The father of the baby is irritated that the mother is not like she was before pregnancy.
d
A nurse is assessing a 1-day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? a) Fundus at the umbilicus. b) Nodular breasts. c) Pulse rate 60 bpm. d) Pad saturation every 30 minutes.
d
It is 4 p.m. A client, G1P0000, 3 cm dilated, asks the nurse when the dinner tray will be served. The nurse replies a) "Laboring clients are never allowed to eat." b) "Believe me, you will not want to eat by the time it is the dinner hour. Most women throw up, you know." c) "The dinner tray should arrive in an hour or two." d) "A heavy meal is discouraged. I can get clear fluids for you whenever you would like them, though."
d