HESI practice questions

During labor the nurse determines that a full term client is demonstrating late decels. In which sequence should the nurse implement these nursing action

1. reposition the client 2. increase IVF 3. provide O2 via face mask 4. call the HCP

The nurse is providing care to a primipara whose most recent cervical exam at 0700 was 6/+1/100. Assuming an expected progression of labor, approx what time will the client enter into the second stage of labor

1100

A 25 year old client has a positive pregnancy test. One year ago she had a spontaneous aobrtion at 3 months gestation. What will the nurse document the client's chart regarding her GTPAL

2-0-0-1-0

The PP nurse is providing instructions to a client after the birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function

3 days PP

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing hx, the client indicates that she has delivered premature twins, one full term baby and has had no aortions. Which GTPAL should the nurse document in this client's record

3-1-1-0-3

When assessing a client who is at 12 weeks gestation, the nurse recommends that she and her husband consider attending childbirth prep classes. When is the best time for the couple to attend these classes

30 weeks gestation

The nurse is using the Silverman-Anderson index to assess an infant with resp distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign

5

The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure

A 40 week primigravida who is at 6cm cervical dilation and the presenting part is not engaged

A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension and mag sulfate is prescribed to control the symptoms. Which assessment finding would indicate that therapeutic drug levels has been achieved

A decreased resp rate from 24 to 16

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate

A home pregnancy test can be used right after your first missed period

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage

A multiparous client who delivered a large baby after oxytocin induction

A nonstress test is performed on a client who is pregnant and the results of the test indicate nonreactive findings. The HCP prescribes a contraction stress test and the results are documented as negative. How should the nurse document this finding

A normal test result

A primigravida client who is 5cm dilated, 90% effaced and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the HCP

A platelet count of 67

The nurse notes hypotonic, irritability and a poor sicking reflex in a full term newborn on admission to the nursery. The nurse suspect fetal alcohol syndrome and is ware that which additional sign would be consistent with this syndrome

Abnormal palmar creases

A client in a PP unit ℅ sudden sharp CP and dyspnea. The nurse notes that the client is tachycardic and the resp rate is elevated. The nurse suspects a PE. which should be the initial nursing action

Administer oxygen 8-10L/min by facemask

Fetal distress is occurring with a laboring client. As the nurses prepares the client for a cesarean birth, what is the most important nursing action

Administer oxygen 8-10L/min via facemask

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late decel on the monitor strip. What is the most appropriate nursing action

Administer oxygen via facemask

Prior to d/c, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home

Allow the cord to air-dry as much as possible

The nurse is monitoring a client in the immediate PP period for signs of hemorrhage. Which sign, if noted would be an early sign of excessive blood loss

An increase in pulse rate from 88 to 102 bpm

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide

An informed consent needs to be signed before the procedure

The nurse caring for a laboring client encourages her to void at least q2h and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention

An over distended bladder could be traumatizing during labor as well as prolong the progress of labor

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the newborn infant, the

Anterior fontanel closes at 12-18 months and the posterior by the end of the second month

A woman who gave birth 48 hours ago is bottle feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm and tender upon palpation. What action should the nurse take

Apply cold compresses to both breasts for comfort

A 40 week gestation primigravida client is being induced with an oxytocin secondary infusion and ℅ pain in her lower back. Which intervention should the nurse implement d/c the oxytocin infusion

Apply firm pressure to the sacral area

The nurse is assessing a client who is having a non-stress test at 41 weeks gestation. The nurse determines that the client is not having contractions , the FHR baseline is 144bpm and no FHR accelerations are occurring. What action should the nurse take

Ask the client if she has felt any fetal movements

The nurse is providing care to a PP client with O negative blood who is antibody positive. The newborn is O negative. What is the best nursing action for this client

Ask the mother if she desires any more children

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she expected. Her partner is also becoming anxious. What is the nurse's best action

Asking the client and her partner if they would like the nurse to stay in the room

The nurse is admitting a pregnancy client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action

Assess the baseline FHR

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan

Avoid alcohol within two hours before the next feeding

Methylergonovine is prescribed for a woman to treat PP hemorrhage. Before administration of this med, what is the priority assessment

BP

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first

Bathe the infant with an antimicrobial soap

Rh (D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the med. The nurse determines that the woman understands the purpose if the woman states that i will protect her next baby from which condition

Being affect by Rh incompatibility

The nurse is teaching a woman how to use her basal body temp pattern as a tool to assist her in conceiving a child. Which temp pattern indicates the occurrence of ovulation and therefore the best time for intercourse to ensure conception

Between the temp falls and rises

A client who is 3 days PP and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide

Breastfeed the infant every 2 hours

A breastfeeding PP client is diagnosed with mastitis and abx therapy is prescribed. Which instruction should the nurse provide to this client

Breastfeed the infant, ensuring that both breasts are completely empty

The mother of a newborn calls the clinic and roots that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother

Bring the infant to the clinic

A client with gestational HTN is in active labor and receiving an infusion of mag sulfate. Which drug should the nurse have available for signs of potential toxicity

Calcium gluconate

1 hour after giving birth to an 8lbs infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's HR is 84bpm and BP is 156/96. The HCP prescribed Methergine 0.2mg IM x1. What action should the nurse take immediately

Call the HCP to question the rx

Which assessment finding should the nursery nurse report to the pediatric HCP

Central cyanosis when crying

24 hours after admission to the newborn nursery, a full term male develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as

Cephalhematoma, caused by forceps trauma and may last up to 8 weeks

A 4 week old premature infant has been receiving epoetin alfa (Epogen) for the last 3 weeks. Which assessment finding indicates to the nurse that the drug is effective

Changes in apical HR from 180s to 140s

What action should the nurse implement to decrease the client's risk for hemorrhage after a c-section

Check the firmness of the uterus every 15min

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first

Check the infants oxygen saturation rate

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have esophageal atresia. Which symptoms are this newborn likely to exhibit

Choking, coughing and cyanosis

The nurse is planning care for a PP client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client

Client pain level

A client at 28 weeks gestation calls the antepartal client and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide

Come to the clinic today for an ultrasound

A multigravida client arrives at the L&D unit and tells the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the FHR is between 14-150bpm. What action should the nurse implement next

Complete a sterile vaginal exam

A pregnant client with mitral stenosis Class III is prescribed complete bed rest. The client asks the nurse, "Why must I stay in bed all the time?" which response is best for the nurse to provide this client

Complete bed rest decreased oxygen needs and demands on the heart muscle tissue

The nurse in the NICU receives a phone call to prepare for the admission of a 43 week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority

Connect resuscitation bag to the oxygen outlet

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours PP and notes that the client has saturated a urinal pad in 15 min. How should the nurse respond to this finding initially

Contact the OB and inform him/her of the finding

The PP nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse should provide which instruction to the mother

Continue to breastfeed q2-4h

The nurse is evaluating a full term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7cm and is 100% effaced at 0 station with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. What action should the nurse take next

Continue to monitor labor progress

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple sores

Correctly place the infant on the breast

A client at 32 weeks gestation is dx with preE. Which assessment finding is most indicative of an impending convulsion

DTR 3+ and hyper clonus

A woman with type 2 DM becomes pregnant and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement

Describe diet changes that can improve the mgmt of her diabetes

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2-3 min with a duration of 60 sec. An internal FHR monitor is in place. The baseline FHR has been 120-122 bpm for the past hour. What is the priority nursing action

Discontinue the infusion of oxytocin

A client at 32 weeks gestation comes to the prenatal clinic with ℅ pedal edema, dyspnea, fatigue and a moist cough. Which question is important for the nurse to ask this client

Do you have a hx of rheumatic fever

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate

Do you plan to have any other children

A new mother who has been insulin dependent for 8 years just delivered spontaneously an 8lbs 4oz infant. The nurse obtains a BGL of 112 when the infant is 8 hours old. What is the best nursing action for this client

Document the finding in the client's chart

A 24 hour old newborn has a pink papular rash with a vesicle superimposed on the thorax, back and abdomen. What action should the nurse implement

Document the finding in the infants record

The nurse is caring for a client in labor and is monitoring the FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitoring tracing. Which action is most appropriate

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation

Drying the infant with a warm blanket

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information

Each pregnancy carries a 50% chance of inheriting the disorder

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern

Edema, basilar rales and an irregular pulse

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client

Encourage healthy lifestyles for families desiring pregnancy

Total bilirubin level of a 36 hour breastfeeding newborn is 14. Based on this finding, which intervention should the nurse implement

Encourage the mother to breastfeed frequently

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement

Encourage the mother to stop feeding for a few min and comfort the infant

A PP client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client

Encouraging fluid intake

The PP nurse is assessing a client who delivered a healthy infant by c-section for s.s of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present

Enlarged, hardened veins

The nurse is performing an assessment on a pregnant client in the last trimester with a dx of preE. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this dx

Evidence of bleeding such as in the gums, petechiae and purpura

A client who delivered a healthy infant 5 days ago calls the clinic and reports that her lochia is getting lighter in color. Which action should the nurse take

Explain this is a normal finding

A client in active labor ℅ cramps in her leg. What intervention should the nurse implement

Extend the leg and dorsiflex the foot

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks gestation. Which assessment finding indicates the need to contact the HCP

FHR of 180bpm

Which assessment finding after an amniotomy should be conducted first

FHR pattern

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class

Feed your baby every 2-3 hours or on demand whichever comes first

The nurse is reviewing fetal circulation with a nursing student. The nurse concludes the student understands the teaching when which statements are made SATA The umbilical cord contains two veins and one artery Umbilical arterial blood has the highest oxygenation Fetal oxygenation occurs through the placenta The foramen ovale is open in the fetal state Blood flows from the placenta to the fetal heart

Fetal oxygenation occurs through the placenta The foramen ovale is open in the fetal state Blood flows from the placenta to the fetal heart

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5 year old child who was delivered at 38 weeks and tells the nurse that she does not have a hx of any type of abortionor fetal demise. Using GTPAL, what should the nurse document in the clients chart

G2, T1, P0, A0, L1

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks gestation. What type of emotional response should the nurse anticipate

Grief r/t her perceptions about the loss of this child

A mother who is HIV + delivers a full term newborn and asks the nurse if her baby will become HIV infected. Which explanation should the nurse provide

HIV infection is determined at 18 months of age when maternal HIV antibodies are no longer present

The home care nurse is monitoring a pregnant client who is at risk for preE. At each home care visit, the nurse assesses the client for which sign of preE

HTN

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take

Have the client breathe into her cupped hands

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client

Have the client empty her bladder

The clinic nurse is performing an initial assessment. The client states to the nurse, "I must be pregnant. My breasts are tender; my last period was 5 weeks ago and I feel nauseous in the mornings." What is the nurse's best response

Have you done a home pregnancy test

A client at 34 weeks gestation reports to the clinic nurse that she has frequent indigestion. What should the nurse include in the teaching plan SATA I'll ask your HCP to prescribe ondansetron for you Have you tried taking tums for your indigestion The baby is getting big, which reduces the size of the stomach Try eating small meals, 6 times per day You have no cause to be worried

Have you tried taking tums for your indigestion The baby is getting big, which reduces the size of the stomach Try eating small meals, 6 times per day

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips

The nurse is providing care to a 1hour old neonate born to mother who took insulin throughout her pregnancy. What conditions will the nurse include in the infants assessment throughout its hospitalization SATA Hypoglycemia Resp distress syndrome Hypernatremia Congenital anomalies Absent moro reflex

Hypoglycemia Resp distress syndrome Congenital anomalies

The nurse is discussing the timing of the next prenatal visit for the client at 34 weeks gestation. If the current visit occurred on April 4th, which statement indicates the client understands the teaching

I can come in on April 18

The nurse is providing care to a laboring client at term. Which client statement indicates to the nurse that the client is entering stage 2 of labor

I feel like I have to push down

The clinic nurse takes a phone call from a client who reports she is 12 weeks gestation. Which statements indicate to the nurse the client may be having a spontaneous absorption SATA

I have having severe abdominal cramping I am passing blood clots from my vagina

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts". Which statement by the client indicates a need for further instruction

I need to lie flat on my back to perform the procedure

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational DM. which statement made by the client indicates a need for further teaching

I should avoid exercise because of the negative effects on insulin production

The nurse is providing instructions to a pregnant client with a hx of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client indicted and understanding of the information provided by the nurse

I should drink adequate fluids and increase my intake of high-fiber foods

The nurse is providing instructions about measures to prevent PP mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further instruction

I should wash my nipples daily with soap and water

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction

I will ask the nurse to attend to my infant if I am napping and my husband is not here

The nurse has provided d/c instructions to a client who delivered a healthy newborn by c-section. Which statement made by the client indicted a need for further instruction

I will begin abdominal exercises immediately

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicate that further teaching is needed about the administration of the eye med

I will flush the eyes after instilling the point

The clinic nurse is providing care to a client at 20 weeks gestation. They are reviewing literature about gestational DM. which statement indicates to the nurse the client understands the information

I will have to drink the sweet syrup at my next appointment

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected and the nruse instructs the client regarding mgmt of care. Which statement made by the client indicates a need for further instruction

I will maintain strict bedrest throughout the remainder of the pregnancy

The nurse is assessing a pregnant client with type 1 DM about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement

I will need to increase my insulin dosage during the first 3 months of pregnancy

Which client statement indicates to the nurse that she understands her pre-pregnancy instructions

I will take 400mcg of folic acid daily

When returning for the results of her maternal serum alpha-fetoprotein, a primigravida asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to best describe how the test is interpreted

If MSAFP and estriol levels are low and the Hcg level is high, results are positive for a possible chromosomal defect

The PP nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temp is 100.2 F. What is the priority nursing action

Increase hydration by encouraging oral fluids

At 14 weeks gestation, a client arrives at the ED complaining of a dull pain in the RUQ of her abdomen. The nurse obtains a blood sample and initiates an IV. 30 min after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a HR of 120bpm, and a BP of 86/48. Which action should the nurse implement next

Increase the rate of IVF

A 41 week multigravida is receiving oxytocin to augment labor. Contractions are firm and occuring every 5 min with a 30-40 sec duration. The FHR increases with each contraction and returns to baseline afterwards. What is the next nursing action

Increase the rate of the oxytocin infusion

Which findings are most critical for the nurse to report to the HCP when caring for the client during the last trimester of pregnancy SATA Increased heartburn that is not relieved with doses of antacids Increase of FHR from 126 to 156bpm form the last visit Shoes and rings that are too tight b/c of peripheral edema in extremities Decrease in ability for the client to sleep for more than 2 hours at a time Chronic h/a that has been lingering for a week behind the client's eyes

Increased heartburn that is not relieved with doses of antacids Chronic h/a that has been lingering for a week behind the client's eyes

A full term is transferred to the nursery from L&D. which information is most important for the nurse to receive when planning intermediate care for the newborn

Infant's condition at birth and treatment received

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate

Inform the client that these contractions are common and may occur throughout the pregnancy

The nurse is assessing a client who is 6 hours PP after delivering a full term healthy newborn. The client complains to the nurse of feeling faint and dizzy. Which nursing action is most appropriate

Instruct the client to request help when getting out of bed

A pregnant client reports to the health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, TB is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan

Isoniazid plus rifampin will be required for 9 months

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus

It connects the umbilical vein to the IVC

A client who is attending antepartum classes asks the nurse why her HCP has prescribed iron tablets. The nurse's response is based on what knowledge

It is difficult to consume 18mg of additional iron by diet alone

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide

It is important that you want to take part in your care

The laboring client requests an epidural placement for labor pain. The standing order is 1000mL of LR to infuse over 15 min prior to the placement of an epidural. The lenient asks, "How come I have so much fluid so fast?". What is the nurse's best response

It is to help prevent low BP

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response

It promotes the fertilized ovum's normal implantation in the top portion of the uterus

The nurse is counseling a woman who wants to become pregnant. When a woman tells the nurse that she has a 36 day menstrual cycle and the first day of her LMP was Jan 8. The nurse correctly calculates that the woman's next fertile period will be

Jan 30-31

An expectant father tells the nurse he fears that his wife "is losing her mind". He states that she is constantly rubbing her abdomen and talking to the baby and she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father

Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement

Which nursing intervention would be most helpful in relieving postpartum uterine contractions or "afterpains"

Lying prone with a pillow on the abdomen

A female client with insulin dependent diabetes arrives at the clinic seeking a plan to get pregnant in approx 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client

Maintain blood sugar levels in a constant range within normal limits during pregnancy

The nurse is planning care for a newborn of a mother with DM. what is the priority nursing consideration for this newborn

Maintaining safety b/c of low BGLs

The nurse creates a plan of care for a woman with HIV infection and her newborn. The nurse should include which intervention in the plan of care

Maintaining standard precautions at all times while caring for the newborn

The client at 20 weeks gestation states to the nurse, "I feel dizzy when I go from a sitting to a standing position." What is the nurse's best response

Make sure you change positions slowly

On assessment of a PP client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action

Massage the fundus until it is firm

A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is started on an IV solution of terbutaline. Which assessment is the highest priority for the nurse to monitor during the administration of this drug

Maternal and fetal HR

A 30 year old gravida 2, para 1 client is admitted to the hospital at t26 weeks gestation in preterm labor. She is given a dose of terbutaline 0.25mg SQ. which assessment is the highest priority for the nurse to monitor during administration of this drug

Maternal and fetal HR

A pregnant client tells the nurse that the first day of her LMP was august 2, 2006. Based on bagele's rule, what is the estimated date of delivery

May 9, 2007

A client who gave birth to a healthy 8lbs infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant

Meet the mother's physical needs and demonstrate warmth toward the infant

The nurse assesses a client admitted to the L&D unit and obtains the following data-dark red vaginal bleeding, uterus tense between contractions, BP 110/68, FHR 11bpm, cervix 1cmdialted and effaced. Based on these assessment findings, what intervention should the nurse implement

Monitor bleeding from IV sites

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care

Monitor the newborn's response to feedings and weight gain pattern

A 38 week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities

Move about every hour

The nurse is reviewing ture and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement

My contractions will increase in duration and intensity

The nurse is performing teaching for a pregnant client who has been insulin dependent diabetic since she was 13 years old. Which statement indicted to the nurse that the teaching was effective

My insulin requirements will likely increase around 24 weeks gestation

The nurse prepares to administer a phytonadione (vit K) injection to a newborn and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide

Newborns are deficient in vitamin K and this injection prevents your newborn from bleeding

on admission to the prenatal clinic, a 23 year old woman tells the nurse that her LMP began on February 15th and that previously her periods were regular. Her pregnancy test is positive. The client's expected date of delivery would be

Nov 22

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform

Observe for an asymmetrical moro (startle) reflex

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for d/c. Which nursing action should be included in this infant's d/x teaching plan

Observe the parents applying a pavlik harness

A client at 30 weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals her cervix is closed, thick and high. Based on these data, which intervention should the nurse implement first

Obtain a specimen for UA

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected dx of placenta previa. The nurse reviews the HCPs rx and should question which rx

Obtain equipment for a manual pelvic exam

A client is admitted with the dx of total placenta previa. Which finding is most important for the nurse to report to the HCP immediately

Onset of uterine contractions

The nurse calls a client who is 4 days PP to follow up about her transition with her newborn at home. The woman tells the nurse, "I don't know what is wrong. I love my baby, but I feel so let down. I seem to cry for no reason!". What adjustment phase should the nurse determine the client is experiencing

PP blues

A client who delivered an infant 1 hour ago tells the nurse that she feels wet underneath her buttock. The nurses note that both perineal pads are completely saturated and the client is lying in a 6inch diameter pool of blood. Which action should the nurse implement next

Palpate the firmness of the fundus

A multigravida steps to the nurse, "I have to push''. The client had a cervical exam less than 10 min prior and she was 5/+1/100%. What is the nurse's next action

Perform a cervical assessment

The nurse is reviewing the HCP's rx for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question

Perform a vaginal exam every shift

Methylergonovine is prescribed for a client with PP hemorrhage. Before administering the med, the nurse should contact the OB who prescribed this med if which condition is documented in the clients' med hx

Peripheral vascular disease

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise

Persistent nonreassuring FHR

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan

Place petroleum point around the glans with each diaper change and cleansing

6 hours after an oxytocin induction was begun and 2 hours after spontaneous ROM, the nurse notes several sudden decreases in the FHR with quick return to baseline, w/w/o contractions. Based on this FHR pattern, which intervention is best for the nurse to implement

Place the client in a slight trendelenburg position

The laboring client states to the nurse, "I think my water just broke". The nurse observes a shiny, gelatinous, rope-like structure protruding from the client's vaginal area. What is the next nursing action

Place the client in knee chest position

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding

Place the client in trendelenburg's position

20 min after a continuous epidural anesthetic is administered, a laboring client's BP drops from 120/80 to 90/60. Which action will the nurse take

Place the woman in a lateral position

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching

Places the infant prone in the bassinet

A 55 year old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response

Please share with me more about your concern

The nurse is creating a plan of care for a PP client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery

Prepare an ice pack for application to the area

The nurse administered erythromycin ointment to the eyes of the newborn and the mother asked the nurse why this was performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with untreated gonococcal infection

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child but I would like to try with this baby." Which intervention is best for the nurse to implement first

Provide assistance to the mother to begin breastfeeding ASAP after delivery

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration and intensity. What is the priority nursing action

Provide pain relief measures

An off duty nurse finds a woman in the supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority

Put the newborn to breast

The nurse is providing d/c teaching for a client who is 24 hours PP. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?". What should the nurse instruct the client to do

Reduce activity level and notify the HCP

A 30 year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond

Regression in behaviors in the older child is a typical reaction so he needs attn at this time

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time

Rest between contractions

The nurses reviewed the findings from a pregnant client's glucose tolerance challenge test. The results were 156. What is the best nursing action r/t this finding

Schedule the clent for a return appointment in 1 week

The nurse should explain to a 30 year old gravid client that alpha fetoprotein testing is recommended for which purpose

Screen for NTD

The nurse is preparing a newborn for d/c. There is an order for a hep B vaccination prior to d/c. When planning to administer the vaccine, what information must the nurse obtain from the infants chart

Site of the vitamin K injection

After each feeding, a 3 day old newborn is spitting up large amounts of cow's milk based formula. The pediatric HCP changes the neonate formula to a soy milk based formula. Which information should the nurse provide to the mother about the newly prescribed formula

Soy milk based formula contains sucrose

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position

Supine position with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the women process the delivery

Support the mother in her reaction to the newborn infant

A 26 year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate 0.25 SQ to stop her labor contractions. The nurse plans to monitor for which prmaru s/e of terbutaline sulfate

Tachycardia and a feeling of nervousness

A women who had a miscarriage 6 months ago becomes pregnancy. Which instruction is most important for the nurse to provide this client

Take prescribed multivitamins and mineral supplements

A client at 30 weeks gestation is on bed rest at home b/c of increased BP. The home health nurse has taught her how to take her own BP and gave her parameters to judge a significant increase in BP. when the client calls the clinic complaining of indigestion, which instruction should the nurse provide

Take your BP now and if it is seriously elevated, go to the hospital

A 23 year old client who is receiving medicaid benefits is pregnant with her first child. Based on knowledge of the statistics r/t infant mortality, which plan should the nurse implement with this client

Teach the client why keeping perinatal care appts is important

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best

That is normal, the head will return to a round shape within 7-10 days

A pregnancy client tells the nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 16 weeks gestation b/c of which factor

The appearance of the fetal external genitalia

The nurse should encourage the laboring client to begin pushing when

The cervix is completely dilated

The home care nurse visits a pregnant client who has a dx of PreE. which assessment finding indicates a worsening of the preE and the need to notify the HCP

The client complains of a headache and blurred vision

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor

The client has a hx of cardiac disease

The nurse is performing an assessment of a pregnant client who is at 28 weeks gestation. The nurse measures the fundal height in cm and notes that the fundal height is 30cm. How should the nurse interpret this finding

The client is measuring normal for gestational age

The nurse is caring for four 1 day PP clients. Which client assessment requires the need for follow up

The client with lochia that is red and has a foul-smelling odor

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client

The client's readiness to learn

The nurse is teaching a PP client about breastfeeding. Which instruction should the nurse include

The diet should include additional fluids

A full-term infant is transferred to the nursery from L&D. which information is most important for the nurse to receive when planning immediate care to the newborn

The infant's condition at birth and tx received

The nurse evaluates the ability of a hep B positive mother to provide safe bottle feeding to her newborn during PP hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn

The mother washes and dries her hands before and after self are of the perineum and asks for a pair of gloves before feeding

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother

The scalp edema will subside in a few days after birth

A pregnant client in the first trimester calls the nurse at a healthcare clinic and reports that she has noticed a thin, colorless vaginal discharge. The nurse should make which statement to the client

The vaginal discharge may be bothersome but is a normal occurrence

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot". Which explanation should the nurse give to this anxious client

There's a strong, tough membrane to protect the baby so you need not to be afraid to wash or comb his/her hair

A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child

They use lubricants with each sexual encounter to decrease friction

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding

Three vessels-two arteries and one vein

A 40 week gestational client is receiving an IV infusion of oxytocin to augment early labor. The nurse should discontinue the infusion for which pattern of contractions

Transition Labor with contractions q 2 min lasting 90 sec each

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs

Two weeks before menstruation

A 35 year old primigravida client with severe preE is receiving mag sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing mag sulfate toxicity

Urine output 90mL/4hr

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn at term gestation

Vernix is a white, cheesy substance, predominantly located in the skin folds

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process

We want to attend a support group

The nurse is providing care to a client who just delivered her 6th term infant. In addition to routine PP care, what additional priority nursing action will the nurse include in this client's plan of care

Weight the peri pads before and after placement to the peri area

A newly pregnant client is crying loudly and reports to the clinic nurse over the phone that she took a rx pain med 4 weeks ago. What is the nurse's next response

When did your last period begin

The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the HCP

Yellowish tinge to the skin

The nurse is providing instructions to a pregnant client with HIV infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client

You will need to bottle feed your newborn

A client at 39 weeks gestation overhears her HCP say to the nurse, "Her Bishop score is 10." the client asks the nurse, "what does that mean?". What is the nurse's best response

Your cervix is ready for labor

A new mother asks the nurse, "How do I Know that my daughter is getting enough breast milk?" Which explanation will the nurse provide

Your milk is sufficient if the baby is voiding pale-straw colored urine 6-10 times a day

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis

Your type of pelvis is the most favorable for labor and birth

A newborn, whose mother is HIV + is scheduled for follow up assessments. The nurse knows that the most likely presenting symptoms for a pediatric client with AIDS is

a persistent cold

The nurse is preparing to administer an IV pain med to a client in labor. What will the nurse include in this client's plan of care r/t the administration of the med SATA a) Administer the med only when the client is having a contraction b) Assess the FHR for 10 min prior to administering the pain med c) Stop the main IV fluid during the administration of the med d) Have the mother do slow, deep-chest breathing during the administration e) Use a 16 gauge needle to administer the med through the existing IV f) Inject the med into the existing mainline bag of D5LR

a, b

As the placenta is delivered during a c-section the HCP states, "It looks like at least a 25% abruption". Which concerning sign will the PP nurse include in the client's assessment SATA a) Bleeding gums b) Petechiae c) HTN d) Oozing blood from IV site(s) e) Bradycardia

a, b ,d

A client at term presents to L&D in spontaneous labor; contractions are occuring every 3-4 min and they are 60 sec in duration. The client states to the nurse, "I think I have a break out of my genitalherpes.: What action will the nurse take next SATA a) Observe the client's perineum b) Contact the HCP c) Assess ongoing acyclovir tx d) Open a vaginal delivery pack e) Assess her partner's penis of lesions

a, b, c

The client at 10 weeks gestation states to the clinic nurse, "I have to urinate all of the time!". What is the nurse's response to this clients concern SATA a) The weight of your uterus is pressing on your bladder b) This is an anticipated finding at this point in your pregnancy c) Do you have any enticing or burning when you urinate d) You are not the first pregnant woman who has said that to me e) Make sure you drink around 1000mL of fluid daily

a, b, c

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication SATA a) Age 54 years b) BMI of 28 c) Previous difficulty with fertility d) Administration of oxytocin for induction e) Potassium level of 3.6

a, b, c

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 identify to determine if the neonate is small for gestational age SATA a) Admission weight of 4lbs 15oz b) Head to heel length of 17 in c) Frontal occipital circumference 12.5 in 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

The nurse is providing care to an infant born 2 min ago with an Apgar of 8 at one min. What nursing actions must the nurse include in the newborn's plan of care over the next 30 min SATA a) Temp b) HR c) Apgar score d) BP e) Blood glucose

a, b, c

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy SATA a) Ballottement b) Chadwick's sign c) Uterine enlargement d) Positive pregnancy test e) FHR detected by an electronic device f) Outline of fetus via radiography or ultrasound

a, b, c, d

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid SATA a) Allows for fetal movement b) Surrounds, cushions, and protects the fetus c) Maintains the body temp of the fetus d) Can be used to measure fetal kidney function e) Prevents large particles such as bacteria from passing to the fetus f) Provides an exchange of nutrients and waste products between mother and fetus

a, b, c, d

The nurse is providing PP instructions to a client who will be breastfeeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements SATA a) I should wear a bra that provides support b) Drinking alcohol can affect my milk supply c) The use of caffeine can decrease my milk supply d) I will start my estrogen birth control pills again as soon as I et home e) I know if my breasts get engorged, I will limit my breastfeeding and supplement the baby f) I plan on having bottled water available in the fridge so I can get additional fluids easily

a, b, c, f

The PP client is preparing for d/c. She states to the nurse, "I have not had a bm yet." What are the nurse's recommendations for this client SATA a) Drink no less than five 8 ounce glasses of water or non caffeine beverages per day b) Make sure you eat 4-5 servings of high fiber foods a day, like broccoli and pears c) Increase the frequency of breastfeeding to no less than q2h d) Since it is nice outside, take a 15min walk 2-3 times a day e) Take your narcotic pain meds as prescribed, q3-4h

a, b, d

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan SATA a) The ductus arteriosus allows blood to bypass the fetal lungs b) One vein carries oxygenated blood from the placenta to the fetus c) The normal fetal heart beat range is 160-180 bpm in pregnancy d) Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta e) Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta

a, b, d

An insulin-dependent client with GDM is in the second stage of labor. What supplies will the delivery nurse gather for care of the newborn SATA Erythromycin point Scale Vacuum extractor Measuring tape Blood glucose testing kit

a, b, d, e

The L&D nurse is providing care to a mother who has experienced a fetal demise in utero at 36 weeks gestation. What will the nurse include in this client's plan of care SATA a) Contact the hospital chaplin b) Ask about the last fetal movements c) Apply the electronic fetal cardiac monitor d) Ask about plans for labor pain mgmt e) Ask the parents if they want to hold the baby after birth

a, b, d, e

The nurse in a newborn nursery is monitoring a preterm newborn for resp distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome SATA a) Cyanosis b) Tachypnea c) Hypotension d) Retractions e) Audible grunts f) Presence of a barrel chest

a, b, d, e

A client at 34 weeks gestation arrives at the clinic and says to the nurse that she thinks she is having contractions. What actions will the nurse include in this client's plan of care SATA a) State to her "Let me know if you have a contraction during your visit today" b) Ask the client, are the contractions painful c) Tell the client, you have nothing to worry about d) Ask her, do they come as frequently as every 5 min e) Tell the client, it is time for you to go directly to L&D f) Inform her, those could be braxton-hicks contractions

a, b, d, f

A client at 36 weeks gestation presents to L&D and states to the nurse, "I have been leaking fluid for the past two day. At first I thought it was urine, now I'm not so sure". Which nursing actions are most appropriate for this client SATA a) Assess maternal vital signs b) Place an electronic fetal monitor c) Place a peripad d) Assess the fluid for a foul odor e) Obtain a maternal BGL f) Obtain a CBC

a, b, d, f

The nurse is interviewing a newly pregnant client who is 16 years old. Which client statement indicates teaching is necessary for a safe pregnancy SATA a) I hate milk b) I only want to gain 10lbs c) I will never have sex again d) My sister is pregnant too e) I refuse to wear maternity clothes

a, b, e

When reviewing a prenatal record for a client at 32 weeks gestation the nurse notes that the client was recently diagnosed with chlamydia. What will the nurse include in the client's teaching plan SATA a) Call the clinic immediately if you feel any gush of fluid from your vagina b) Call the clinic immediately if you have contractions q5min for an hour c) Call the clinic immediately if you notice an increase in non-painful reddened areas d) Do not share needles with your sexual partners e) Do not have sex for 7 days after you take your abx

a, b, e

A mother who is breastfeeding her baby receives instructions from the nurse. Which instructions are most effective in preventing nipple soreness SATA a) Massage a small amount of medical grade lanolin into the nipple b) Increase nursing time gradually over several days c) Ensure that the baby is positioned correctly for latching on d) Manually express a small amount of milk before nursing e) Wear a cotton bra with non binding support

a, c

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings inculcate to the nurse that the client is at risk for contracting HIV SATA a) The client has a hx of IV drug use b) The client has a significant other who is heterosexual c) The client has a hx of STIs d) The client has had one sexual partner for the past 10 years e) The client has a previous hx of gestational DM

a, c

When explaining "postpartum blues" to a client who is 1 day PP, which symptoms should the nurse include in the teaching plan SATA a) Mood swings b) panic attacks c) Tearfulness d) Decreased need for sleep e) Disinterest in the infant

a, c

The nurse is preparing a memory box of items from the care of an infant who died in utero. What items will the nurse plan on including in the box SATA a) Measuring tape b) Erythromycin oint tube c) Infant hat d) Infant blanket e) Bottle of formula

a, c, d

The nurse is reviewing the prenatal record for a client scheduled for a glucose challenge test. Which maternal findings place this client at an increased risk for developing gestational DM SATA a) The client is 37 years old b) The client is pregnant for the second time c) The client is having twins d) The client's pre-pregnant weight was 190lbs (86kg) e) The client's BP is 132/88mmHg

a, c, d

A client is admitted to the hospital at 28 weeks of gestation in preterm labor. The nurse administers three doses of Turbeutalin 0.25 mg SQ. which s/e will the nurse anticipate for this client SATA a) Feeling of nervousness b) Depressed reflexes c) Tachycardia d) A flushed warm feeling e) Restlessness

a, c, e

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor SATA Pain in the lower back that radiates to the abdomen Contractions decreased in frequency with ambulation Progressive cervical dilation and effacement Discomfort localized in the abdomen Regular and rhythmic painful contractions

a, c, e

The nurse in a maternity unity is reviewing the client's records. Which clients should the nurse identify as being at the most risk for developing DIC SATA a) A primigravida with abruptio placenta b) A primigravida who delivered a 10 lbs infant 3 hours ago c) A gravida 2 who has just been diagnosed with dead fetus syndrome d) A gravida 4 who delivered 8 hours ago and has lost 500mL of blood d) A primigravida at 29 weeks of gestation who was recently diagnosed with gestational HTN

a, c, e

The nurse is teaching the pregnant client about fetal growth and development. Which client statements indicate understanding of the teaching SATA a) My baby gets oxygen through the placenta b) I can eat all I want the last 4 weeks of pregnancy c) The amniotic fluid helps with muscle development d) I need to stay under a blanket to keep by baby warm e) My baby will gain about a half pound per week after 36 weeks

a, c, e

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy SATA a) with bright red spotting b) Increased urination c) Lack of tenderness in the breast d) Increased amounts of discharge e) Increased right side flank pain

a, c, e

Which client statement indicates that she understands the instructions of breastfeeding her newborn SATA a) Breastfeeding my infant consistently every 3-4 hours decreases the likelihood of me ovulating b) Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk c) I should avoid foods that usually give me gas d) When I take a warm shower after I breastfeed, it relieved the pain from being engorged between breastfeedings e) When I feed my baby, I should start on the breast the baby stopped on last f) I should drink fluids when breastfeeding my baby especially at night

a, c, e, f

A pregnant teen says to the nurse, "I hope nothing changes to my breasts while I am pregnant!". What will the nurse include in the plan of care regarding breast changes in pregnancy SATA Areola darkening Retraction of the nipple Breasts become shiny Veins easier to see under the skin Pinkish nipple d/c

a, d

The HCP states to the nurse, the baby is in a left occiput anterior (LOA) position. The laboring client asks, "what does that mean?" what descriptions will the nurse use when teaching the client about the LOA fetal position SATA a) The baby's head is in your pelvis b) The baby's feet can be felt on your felt side c) The baby's back is on your right side d) That is the ideal fetal birthing position e) The baby is looking down towards the floor

a, d, e

The L&D nurse is admitting a client at 32 weeks gestation. She reports epigastric pain, weight gain of 10lbs in 1 week, and spots in front of her eyes. What nursing actions will the nurse include in this client's plan of care SATA a) Dipstick urine for protein b) Assess for a rigid and c) Briskly tap the costovertebral angle bilaterally d) Assess the patellar reflex bilaterally e) Determine the presence of clonus

a, d, e

The clinic nurse is reviewing signs of preterm labor with a client at 28 weeks gestation. Which client statements indicate to the nurse further teaching is necessary SATA a) I expect the discharge from vagina will change from thick to brown over the next two weeks b) I will call my HCP if I experience regular contractions that get stronger overtime c) I will call my HCP if I think I broke my bag of water d) The baby's movements will decrease and be almost still from here on out e) I should expect low back pain and diarrhea as the baby grows

a, d, e

The nurse is monitoring a client in preterm labor who is receiving IV mag sulfate. The nurse should monitor for which adverse effects of this med SATA a) Flushing b) Hypertension c) Increased urine output d) Depressed resp e) Extreme muscle weakness f) Hyperactive DTRs

a, d, e

The nurse is preparing a teaching session for a group of newly pregnant women and their significant other. When discussing fatigue early in pregnancy, which statements will the nurse include in the teaching plan SATA a) Fatigue is a result from the hormonal changes early in pregnancy b) You need to take 4-5, 60 min naps per day c) Make sure to keep your fluid intake to 1500mL/day d) Highly caffeinated drinks need to be avoided in pregnancy e) Keep up your regular 45 min of stationary cycling per day

a, d, e

A HCP informs the charge nurse of a L&D unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate SATA a) Dark, red vaginal bleeding b) Lower back pain c) Premature rupture of membranes d) Increased uterine irritability e) Bilateral pitting edema f) A rigid abdomen

a, d, f

The nurse is providing care to a 1 hour infant. An assessment of gestational age is performed and the estimates the age at 39-40 weeks. What findings will the nurse document in the infant's chart SATA Vernix in the creases of the neck Lanugo covering the entire back Creases over the anterior ⅓ of the foot Breast tissue less than 0.5cm in both breasts Labia majora covers the labia minora

a, e

The nurse is teaching a nursing student about the abbreviation GTPAL to note pregnancy outcomes. The nurse determines the teaching was successful when the students relates the abbreviation GTPAL to which terms SATA a) Gravidity b) Total c) Parity d) Born alive e) Living

a, e

The nurse is providing care for a laboring client with a GTPAL of 6-5-0-0-5 at term. Which assessments will the nurse include in this client's plan of care SATA a) Fundal assessment should be made every 5 min for 30 min after delivery of placenta b) Assess for lochia every 5 min for 30min after delivery of placenta c) Place the infant to breast immediately after delivery d) Encourage the mother to talk to her newborn e) Wrap the infant in a warm, sterile blanket immediately after delivery

a-c

The L&D nurse is admitting a client at 34 weeks gestation who reports contractions every 3-4 min for the past hour. What will the nurse include in the client's plan of care SATA Place an electronic fetal monitor Collect a urine sample Left lateral position Administer fluids Dim the lights

a-d

The nurse is preparing a list of self-care instructions for a PP client who was dx with mastitis. Which instructions should be included on the list SATA a) Wear a supportive bra b) Rest during the acute phase c) Maintain a fluid intake of at least 3000mL/day d) Continue to breastfeed if the breasts are not too sore e) Take the prescribed abx until the soreness subsides f) Avoid decompression of the breasts by breastfeeding or pumping

a-d

The nurse is teaching a prenatal class about the structure of the pelvis and is using a model of a pelvis in the presentation. Which statements will the nurse include in the teaching plan SATA a) The baby has to pass through the true pelvis b) The pelvis consists of three distinct features c) The true pelvis is below the pelvic brim d) The ischial spines determine how low the baby is located e) The shape of the pelvis does not impact the labor process

a-d

The nurse is just starting the shift and is providing care to a laboring woman at term. The FHR by internal monitor has been 120-122 bpm for the past 30min. What are the best nursing actions SATA a) Reposition the client b) Administer O2 by facemask c) Increase the rate of mainline IVF d) Assess the client's BP e) Assess for recent administered meds f) Ask the support person to leave the room

a-e

The nurse is providing care to a client at term undergoing an oxytocin induction. At last check she was 6/+1/100%. For the most recent 5 contractions, the FHR has fallen below the baseline after the onset of contraction and returns to baseline 20-30sec after the end of the contraction. What actions must the nurse take SATA a) Contact the HCP b) Stop the infusion of oxytocin c) Increase the infusion of the mainline IV fluid d) Apply oxygen by face mask e) Reposition the client

a-e

The nurse is teaching a group of teen girls about their reproductive system and pregnancy. What risk factors for an unplanned pregnancy will the nurse include in the teaching plan for these girls SATA Poverty Family problems Early onset of menarche Sexual exploration Group think

a-e

An 18 year old client states to the nurse that she wants to understand all of her options for birth control. What assessments will the nurse include in the client's intake interview SATA a) Sexual frequency b) Hx of blood clots c) Comforting in touching her genitalia d) Preferences for different methods e) Religious beliefs f) Allergies

a-f

During stage 2 of labor, what assessments must the labor nurse perform SATA FHR before the contraction FHR during the contraction FHR after the contraction Frequency of contractions Duration of contractions Uterine tone between contractions

all

The PP client has a rubella vaccine ordered prior to d/c. The nurse reviewed the student nurse's proper technique to use when administering this immunization. Which student statement indicates to the nurse the correct technique

at a 45 degree angle

The clinic nurse is performing an assessment on a client who is 20 weeks gestation which was confirmed by ultrasound. When performing the fundal height assessment, where will the nurse start palpating the abdomen

at the umbilicus

A client who delivered by c-section 24 hours ago is using a PCA pump for pain control. Her oral intake has been ince chips only since surgery. She is now complaining of bloating. Which nursing action takes the highest priority SATA a) Call the HCP to obtain an order to increase her diet b) Administer ordered mag hydroxide c) Encourage her to change position every 30 min d)Turn out the lights and discourage visitors e) Encourage her to breastfeed q2h

b, c

The clinic nurse is providing care to a client at 28 weeks gestation. The client asks, "What does my baby look like now?" How will the nurse respond SATA a) Your baby is about 14inches long b) Your baby weight about 2.5 lbs c) Your baby's arms are bent at the elbow d) Your baby can open and close its eyes now e) The baby has fat under its skin

b, c, d

A rubella titer result of a 1 day PP client is less than 1:8 and a rubella vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine SATA a) Breastfeeding needs to be stopped for 3 months b) Pregnancy need to be avoided for 1-3 months c) The vaccine is administered by the SQ route d) Exposure to immunosuppressed individuals needs to be avoided e) A hypersensitivity reaction can occur if the client has an allergy to eggs f) The area of the injection needs to be covered with a sterile gauze for 1 week

b, c, d, e

The clinic nurse is reviewing phone messages left from PP clients during the lunch break. Which calls will the nurse return before the others SATA A mother who reports her baby who is having trouble latching onto her breast while feeding The mother who reports her vaginal discharge went from bright to bright red The mother who reports her vaginal flow smells "like a chicken farm" The mother who reports she had sex before her 6 week hceck up The breastfeeding mother who reports redness and a painful right breast

b, c, e

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? SATA a) Bedrest as a necessary preventive measure may be prescribed b) Administration of SQ heparin post delivery as prescribed c) An over bed lift may be necessary if the client requires a cesarean section d) Less frequent cleansing of a cesarean incision, if present, may be prescribed e) Thromboembolism stockings or SCDs may be prescribed

b, c, e

A pregnant client is revving mag sulfate for the mgmt of preE. The nurse determines that the client is experiencing toxicity from the med if which findings are noted on assessment SATA a) Proteinuria of 3+ b) Resp rate of 10/min c) Presence of DTRs d) Urine output of 20mL/hr e) Serum mag level of 4

b, d

The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted client. The order reads, place 30 units of oxytocin in 500mL NS and start at 1mL/hr. Increase 1mL every 30 min until contracts are every 3-4 min. Oxytocin is packaged in glass vial that reads, 1 mL contains 10 units. What supplies will the nurse need to gather to start the infusion SATA a) A 1000mL bag of NS b) Three vials of oxytocin c) 22 gauge IV catheter d) Alcohol wipe e) IV start kit f) 1 or 3mL syringe

b, d-f

The clinic nurse is performing a fundal height assessment on a client in her third trimester. The client states to the nurse, "I am feeling dizzy when you press on my belly." What are the nurse's best actions to this comment SATA a) Encourage deep breathing b) Turn the client to her left side c) State, "I knew that would happen" d) Say, "This will only take a few more seconds" e) State, "That is from your baby pressing down on your blood vessels

b, e

The nurse is discussing many of the changes a pregnancy brings to a couple. Which of the father's statements concerns the nurse the most SATA a) I am not sure I know how to be a father b) I don't want to be a father c) I did not think pregnancy would happen so soon d) I am not sure I want to share my wife with a newborn e) I am sure I am not the father of this baby

b, e

The L&D nurse is providing care to a client at term with known cardiac disease. Which focused assessments will the nurse include in the client's plan of care SATA Elevated temp Cough Fetal tachycardia Uterine tenderness Dyspnea Chest pain

b, e, f

The nurse is performing an initial intake assessment for a newly pregnant client. Which questions will the nurse include in the assessment SATA a) Do you know the blood type of the baby's father b) Do you have proof of you immunizations c) Were your periods regular at every 28 days d) Are you having any nausea at anytime during the day e) Have you ever been told you have HPV

b-d

The nurse is providing care to a laboring client with a GTPAL of 7-5-0-1-5. The client reports contractions every 2-8min of moderate intensity for the past 6 hours. Her cervical exam upon admission is 4/0/75% and membranes are intact. In the next 20 min, what supplies will the nurse gather for this client SATA a) Erythromycin ophthalmic ointment b) Amnihook c) 1000mL of D5LR d) Oxytocin e) Blankets

b-d

The pregnant client at 28 weeks gestation complains to the nurse about hemorrhoid pain. What suggestions should the nurse offer the client SATA a) Place an ice pack to the hemorrhoids for 60 min three times a day b) Find a soft pillow when you are sitting at your desk at work c) Walk for 30 min at least twice a day d) Eat one cup of raspberries or a medium pear every day e) Increase your daily protein to 100g/day

b-d

A client presents to the ED with complaints of severe lower left abdominal pain and vaginal spotting. Her last menstrual period was 5 weeks ago. What are the nurse's next actions SATA Notify the OR staff Check the results of the hcg test Ask the client to describe the color of the vaginal bleeding Ask the client if she has ever been diagnosed with pelvic inflammatory disease Draw the client's blood for a type and crossmatch

b-e

A client in preterm labor (31 weeks gestation) is dilated to 4cm has been started on mag sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a rx for which med

betamethasone

A multigravida client at 41 weeks gestation presents in the L & D unit after a nonstress test indicates that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status

biophysical profile

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment finds should cause the nurse to immediately d/c oxytocin immediately SATA a) Fatigue b) drowsiness c) Uterine hyperstimulation d) Late decels of the FHR e) Early decels of the FHR

c, d

The nurse is providing care to a newborn just delivered from a mom who is positive for Hep B. what additional care will the nurse plan for this neonate SATA a) Place the baby next to the mother's face, eye to eye, immediately after delivery b) Delay the application of eye prophylaxis until 2-3 hours after birth c) Remove any maternal blood from the infant immediately after birth d) Bathe the neonate prior to administering the vit K injection e) Perform a gastric lavage prior to initiating breastfeeding

c, d

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn SATA a) Lethargy b) Sleepiness c) Irritability d) Constantly crying e) Difficult to comfort f) Cuddles when being held

c, d, e

The nurse is preparing a client with a term pregnancy who is inactive labor for an amniotomy. What equipment should the nurse have available at the client's bedside SATA a) Litmus paper b) Fetal scalp electrode c) A sterile glove d) An amnihook d) Sterile vaginal speculum f) Lubricant g) doppler

c, d, f, g

A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at -2 station. The HCP prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy SATA a) Less pressure on her cervix b) Decreased number of contractions c) Increased efficiency of contractions d) The need for increased maternal BP monitoring e) The need for frequent FHR monitoring to detect the presence of a prolapsed cord

c, e

The nurses teach care of the newborn to a childbirth prep class and describe the need for administration of abx ointment into the eyes of the newborn. An expectant father asks, "what type of disease causes infections in babies that can be prevented by using this point?". Which response by the nurse is accurate SATA a) Herpes b) Trichomonas c) Gonorrhea d) Syphilis e) Chlamydia f) Hep B

c, e

Which purposes of placental functioning, should the nurse include in a prenatal class SATA a) It cushions and protects the baby b) It maintains the temp of the baby c) It is the way the baby gets food and oxygen d) It prevents all antibodies and virus from passing to the baby e) It provides an exchange of nutrients and waste products between the mother and developing fetus

c, e

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the 2nd stage of labor SATA a) The contractions are regular b) The membranes have ruptured c) The cervix is dilated completely d) The client begins to expel clear vaginal fluid e) The ferguson reflex is initiated from perineal pressure

c, e,

The nurse is monitoring a PP client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma

change in VS

The nurse is performing an assessment on a client dx with placenta previa. Which assessment findings should the nurse expect to note SATA a) Uterine rigidity b) Uterine tenderness c) Severe abdominal pain d) Bright red vaginal bleeding e) Soft, relaxed nontender uterus f) Fundal height may be greater than expected for gestational age

d, e

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care SATA a) Avoid stimulation b) Decrease fluid intake c) Expose all of the newborn's skin d) Monitor skin temp closely e) Reposition the newborn q2h f) Cover the newborn's eyes with eye shields or patches

d, e, f

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!". The nurse performs a vaginal exam that reveals the cervix is 3cm dilated and 75% effaced. What additional information is most important for the nurse to obtain

date of LMP

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription

delivery of the fetus

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate

document the findings

The nurse is providing care to an infant at 24 hours old. Upon assessment, the nurse observes milia on the newborn's nose. What is the nurse's next action

document the findings in the newborn's chart

A client at 32 weeks gestation is diagnosed with PreE. which assessment finding is indicative of an impending convulsion

epigastric pain

The HCP prescribes terbutaline for a client in preterm labor. Before initiating this rx, it is most important for the nurse to assess the client for which condition

gestational DM

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering abx ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant

gonorrhea

The nurse in the PP unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse review the plan of care and prepares to monitor the client for which risk associated with placenta previa

hemorrhage

A primigravida at 40 weeks gestation is receiving oxytocin to augment labor. Which adverse effect should the nurse monitor for during the infusion of pitocin

hyperstimulation

Immediately after a newborn is suctioned, friend and placed under a radiant warmer. The infant has spontaneous resp and the nurse assesses an apical HR of 8bpm and resp of 20 breaths/min. What action should the nurse perform next

initiate pressure ventilation

The nurse is preparing to administer exogenous surfactant to a premature infant who has resp distress syndrome. The nurse prepares to administer the med by which route

intratracheal

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Ngele's rule, which expected date of delivery should the nurse document in the client's chart

july 26, 2021

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have

low birth weight

The nurse is providing care for a woman who just delivered. The umbilical cord extends from the vagina accompanied by a gush of blood. What is the next nursing action

massage the fundus

The nurse is preparing to assess the uterine fundus of a client in the immediate PP period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate

massage the fundus until firm

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action

monitor FHR

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which med is readily accessible should resp depression occur

naloxone

A prenatal client at 35 weeks gestation reports to the clinic for routine prenatal care. The nurse assesses the client and notices: constricted pupils, erratic behavior and multiple injection marks along the veins of both of the client's arms. What is the nurse's next action

noitify the physician

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 min that last 45 sec. The nurse notes that the FHR between contractions is 100bpm. Which nursing action is most appropriate

notify the HCP

The nurse observes that an antepartum client who is on bedrest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. What Is the best nursing action

notify the HCP

The nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the FHR is 174 bpm. On the basis of this finding, what is the priority nursing action

notify the OB

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate

notify the OB

The nurse is assessing a client in the 4th stage of labor and notes that the fundus is firm but that bleeding is excessive. Which should be the initial nursing action

notify the OR

1 hour following a normal vaginal delivery, a newborn's infant's axillary temp is 96 F, the lower lip is shaking and when the nurse assesses for a moro reflex, the baby's hands shake. What nursing action should the nurse take first

obtain a BGL

A client in active labor is admitted with PreE. which assessment finding is most significant in planning this client's care

patellar reflex 4+

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first

raise the HOB

The nurse is calculating the estimated date of confinement sign Ngele's rule for a client whose LMP started on December 1. Which date is most accurate

sept 8

A couple, concerned b/c the woman has not been able to conceive, is referred to a HCP for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent

shoulder pain

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected dx of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present

uterine tenderness

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction

variable decels

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief

what can I do for you