Learning System 3.0 NCLEX Maternal

A nurse is collecting data from a newborn. Which of the following locations should the nurse palpate to check the anterior fontanel?

A

A nurse is assisting with care for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions? A. Palpating the firmness of the uterus during a contraction B. Calculating the time from the end of a contraction to the beginning of the next C. Measuring the time from the beginning of a contraction to the end of that same contraction D. Evaluating the amount of time from the beginning of a contraction to the beginning of the next contraction

D. Evaluating the amount of time from the beginning of a contraction to the beginning of the next contraction

A nurse is collecting data from a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider? A. Intermittent auscultation B. Biophysical profile C. Non-stress test (NST) D. Fetal scalp electrode

D. Fetal scalp electrode

A nurse is caring for a newborn who was born to a client with narcotic use disorder. Which of the following nursing actions is contraindicated for the care of the newborn? A. Promoting maternal-newborn bonding B. Tight swaddling of the newborn C. Small, frequent feedings D. Frequent stimulation

D. Frequent stimulation

A nurse is assisting with monitoring the fetal heart rate tracings of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Baseline fetal heart rate of 110 to 130/min B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia

D. Late decelerations with fetal bradycardia

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent urinary tract infections C. Previous cesarean birth D. Pelvic inflammatory disease

D. Pelvic inflammatory disease

A nurse is collecting data on a client who is at 8 weeks of gestation. Which of the following findings should the nurse report to the provider? A. WBC 14,000/mm^3 B. Hgb 11.5 g/dL C. Blood pressure variation of 10 mmHg between arms D. Small amount of brown vaginal discharge

D. Small amount of brown vaginal discharge

A nurse is assisting with the care of a client who is in active labor and notes early decelerations on the fetal monitor. The nurse should identify that which of the following circumstances can cause early decelerations? A. Cord compression B. Fetal hypoxemia C. Uteroplacental insufficiency D. Fetal head compression

D. Fetal head compression

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

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

A nurse in a prenatal clinic is reinforcing teaching with a client who has a new diagnosis of heartburn. Which of the following statements should the nurse include? A. "Go for a walk after eating." B. "Limit your food consumption to 2 meals a day." C. "Drink plenty of water with your meals." D. "Wear tight clothing to enhance digestion."

A. "Go for a walk after eating."

A nurse is caring for four newborns. Which of the following newborns is at the greatest risk for hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathological jaundice D. A newborn who has fetal alcohol syndrome

A. A newborn who is large for gestational age

A nurse is caring for a client who is postpartum and non-lactating. The client reports breast pain. Which of the following statements should the nurse make? A. "Try taking a warm shower." B. "Be sure to wear a well-fitted supportive bra." C. "Expel breast milk using your hand." D. "Avoid laying your newborn on your chest until the pain subsides."

B. "Be sure to wear a well-fitted supportive bra."

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

B. Hypoglycemia

A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions should the nurse take? A. Place the newborn in an infant carrier B. Initiate a latex-free environment C. Cover the sac with a large piece of dry gauze D. Obtain a rectal temperature every 4 hours

B. Initiate a latex-free environment

A nurse is collecting data from a newborn who has hypoglycemia. Which of the following findings should the nurse expect? A. Abdominal distention B. Decreased temperature C. Increased muscle tone D. Transient nystagmus

B. Decreased temperature

A nurse is reinforcing teaching about breastfeeding with a client. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."

C. "I may notice increased cramping when I am feeding my baby."

A nurse is reinforcing teaching about the rubella immunization with a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching A. "I should not breastfeed for at least 3 days after receiving this immunization." B. "I will need a second rubella booster when I see my midwife at 6 weeks postpartum." C. "I should be careful to avoid becoming pregnant within the next month." D. "This vaccine will be given into my arm muscle."

C. "I should be careful to avoid becoming pregnant within the next month."

A nurse is reinforcing teaching with a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. "I know not to eat anything after midnight." B. "I will have medication given to me to cause contractions." C. "I should press the button on the handheld marker when my baby moves." D. "I will have to stimulate my breast to cause contractions."

C. "I should press the button on the handheld marker when my baby moves."

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? A. "I should clean my diaphragm with alcohol each time I use it." B. "I should leave the diaphragm in place for 4 hours after intercourse." C. "I should replace my diaphragm every 2 years." D. "I should use a vaginal lubricant to insert my diaphragm."

C. "I should replace my diaphragm every 2 years."

A nurse is assisting with a prenatal class for a group of antepartum clients. Which of the following pieces of information should the nurse include about the hepatitis B immunization? A. "The first dose should be administered at 3 months of age." B. "Your baby will receive this immunization subcutaneously, which means under the skin." C. "We will need your consent prior to administering the vaccine." D. "Your baby will receive this vaccine in a series of 5 doses."

C. "We will need your consent prior to administering the vaccine."

A nurse is caring for a client who is at 28 weeks of gestation. The client asks, "Why do people say I should not lie on my back while I'm pregnant?" Which of the following responses should the nurse make? A. "When you lie on your back, your blood pressure increases." B. "When you lie on your back, your pulse increases." C. "When you lie on your back, your uterus compresses your vena cava." D. "When you lie on your back, you reduce your chance of developing hemorrhoids."

C. "When you lie on your back, your uterus compresses your vena cava."

A nurse is reinforcing teaching with a client who has come to the family-planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse reinforce with the client? A. "If you lose weight, you will need a refitting for your IUD." B. "An IUD provides protection from certain sexually transmitted infections." C. "Your risk for ectopic pregnancy increases with an IUD." D. "You shouldn't use an IUD if you want to have children later."

C. "Your risk for ectopic pregnancy increases with an IUD."

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

C. 1,000 mg

A nurse is reviewing laboratory findings for a newborn. Which of the following findings should the nurse report to the provider? A. Hgb 20 g/dL B. Hct 55% C. Glucose 29 mg/dL D. WBC count 7000/mm^3

C. Glucose 29 mg/dL

A nurse is collecting data from a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client how to perform a sitz bath

C. Notify the provider

A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. "You will need to wait 3 months before resuming sexual intercourse." B. "You don't need to use contraception until you are 4 months postpartum." C. "As long as you breastfeed, you will experience an overproduction of vaginal lubrication." D. "A reduction in sexual interest could indicate postpartum depression."

D. "A reduction in sexual interest could indicate postpartum depression."

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

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

A nurse is reinforcing teaching with a client who is pregnant and has been treated for a urinary tract infection (UTI) twice during this pregnancy. Which of the following statements should the nurse make? A. "Drink 5 ounces of cranberry juice daily." B. "Practice holding your urine to prevent pregnancy-related urge incontinence." C. "Avoid taking baths because warm water can irritate the urethra." D. "Empty your bladder before and after vaginal intercourse."

D. "Empty your bladder before and after vaginal intercourse."

A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make? A. "You're eating for 2, so you should double your caloric intake." B. "You'll lose weight easily after the birth of your baby." C. "Plan to gain a total of 15 to 20 pounds during pregnancy." D. "Gaining weight will promote a healthy pregnancy."

D. "Gaining weight will promote a healthy pregnancy."

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

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

A nurse is instructing a client about how to use a diaphragm. In what order should the client complete the insertion process? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Inspect the diaphragm 2. Hold the diaphragm between the thumb and fingers 3. Insert the diaphragm into the vagina 4. Place 2 tsp of contraceptive jelly on the side of the diaphragm 5. Assume a squatting position

1. Inspect the diaphragm 4. Place 2 tsp of contraceptive jelly on the side of the diaphragm 5. Assume a squatting position 2. Hold the diaphragm between the thumb and fingers 3. Insert the diaphragm into the vagina

A nurse is collecting data from a newborn who has a light skin tone and Rh isoimmunization. Which of the following findings should the nurse expect when inspecting the newborn's skin? A. Jaundice B. Cyanosis C. Pallor D. Dark red skin

A. Jaundice

A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? A. Lateral B. Lithotomy C. Trendelenburg D. Prone

A. Lateral

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

A. The client reports a frequent cough.

A nurse is assisting with the care of a client who is at 32 weeks of gestation and has preeclampsia. Which of the following provider prescriptions should the nurse expect? A. The client should take low-dose aspirin daily. B. The client should check fetal kick counts every other day. C. The client should have her blood pressure measured while standing. D. The client should maintain complete bed rest.

A. The client should take low-dose aspirin daily

A nurse is reinforcing teaching about newborn baths with a client who is 2 days postpartum. Which of the following pieces of information should the nurse include? A. Wash the newborn's face with plain warm water B. Wash the newborn's hair before the rest of the body C. Bathe the newborn once each day D. Bathe the newborn immediately after a feeding

A. Wash the newborn's face with plain warm water

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

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

An antepartum client asks the nurse about safety tips for riding in a motor vehicle. Which of the following responses should the nurse make? A. "Wear the lap belt snugly across your pelvic bones." B. "Disable the airbags in your vehicle as per manufacturer instructions." C. "Place your seat as close as possible to the steering wheel." D. "Place the shoulder harness underneath your arm when driving."

A. "Wear the lap belt snugly across your pelvic bones."

A nurse is caring for a 12-hour-old newborn who is asymptomatic and has a blood glucose level of 32 mg/dL. Which of the following actions should the nurse take? A. Advise the parent to feed the newborn B. Give the newborn 60 mL (2 oz.) of glucose water C. Recheck the newborn's glucose level in 4 hours D. Initiate phototherapy for the newborn

A. Advise the parent to feed the newborn

A nurse is collecting data on the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations

B. Expiratory grunting

A nurse is collecting data from a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Overlapping suture lines B. Generalized petechiae C. Acrocyanosis D. Transient strabismus

B. Generalized petechiae

A nurse is collecting data from a client who is in labor and has received epidural anesthesia for pain control. Which of the following manifestations should the nurse identify as an adverse effect of epidural anesthesia? A. Polyuria B. Pruritus C. Hypertension D. Dry mouth

B. Pruritus

A nurse is collecting data from a newborn who was born with meconium-stained amniotic fluid. Which of the following findings should the nurse report as an indication of meconium aspiration syndrome? A. High Apgar score B. Rapid respirations C. Flushed skin D. Elevated PO2

B. Rapid respirations

A nurse is caring for a client who reports cramping while trying to breastfeed her newborn. Which of the following instructions should the nurse provide to the client? A. "You might need to walk around to decrease gas." B. "Breastfeeding can cause uterine contractions." C. "We will need to check you for hemorrhaging." D. "You should lie on your side during breastfeeding."

B. "Breastfeeding can cause uterine contractions."

A nurse is assessing a newborn immediately after birth. The newborn is pink and crying and has a heart rate of 108/min. Which of the following actions should the nurse take? A. Initiate chest compressions B. Dry the newborn on the mother's chest C. Administer epinephrine to the newborn D. Apply an oxygen saturation monitor

B. Dry the newborn on the mother's chest

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

C. Extended extremities

A nurse is reinforcing teaching with a client who is at 32 weeks of gestation and reports regular alcohol use during her pregnancy. The nurse should inform the client that her child is at risk for which of the following characteristics? A. Large head size B. Increased weight C. Poor coordination D. Hypoactive reflexes

C. Poor coordination

A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is scheduled for a nonstress test. Which of the following instructions should the nurse provide the client? A. "You should press a button when you feel contractions." B. "You will be positioned in a semi-Fowler's position." C. "You must sign consent prior to the procedure." D. "The test will take approximately 10 minutes."

B. "You will be positioned in a semi-Fowler's position."

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

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

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

B. Assess the newborn for respiratory depression

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

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

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Wrap a cold compress around the newborn's foot B. Restrain the newborn's foot C. Make the puncture at the inner aspect of the heel D. Apply pressure to the big toe

B. Restrain the newborn's foot

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

B. Retinopathy

A nurse is caring for a client who had a cesarean birth 36 hours ago and is experiencing pain due to gas. Which of the following strategies should the nurse recommend? A. Sip a carbonated beverage throughout the day B. Rock in a rocking chair C. Lie flat in bed with the legs extended D. Use a straw when drinking fluids

B. Rock in a rocking chair

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

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

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

B. Sponge-bathe the newborn every other day

A nurse is collecting data from a pregnant client who is at 26 weeks of gestation. The client states, "I felt dizzy yesterday when I was lying on my back." Which of the following responses should the nurse make? A. "You will need a laboratory test to rule out preeclampsia." B. "You should lie on your side when resting." C. "You will need an ultrasound to ensure your baby is alright." D. "You should decrease your potassium intake."

B. "You should lie on your side when resting."

A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take? A. Monitor the client's contractions once every 30 minutes B. Encourage the client to use a rapid pant-blow breathing pattern C. Assist the client to void once every 3 to 4 hours D. Place the client in the lithotomy position

B. Encourage the client to use a rapid pant-blow breathing pattern

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

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

A nurse on an antepartum unit is assisting the charge nurse with an in-service session for newly licensed nurses. Which of the following descriptions should the nurse identify as referring to a pudendal block? A. Using low-voltage electric currents to decrease pain B. Eliminating sensation from the umbilicus to the thighs C. Providing local anesthesia to the perineum during delivery D. Removing sensation from the breasts to the feet

C. Providing local anesthesia to the perineum during delivery

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Blood pressure 139/89 mmHg B. Deep tendon reflexes 2+ C. Report of blurred vision D. Bilateral, dull headache

C. Report of blurred vision

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. "Clean the lesions twice a day with hydrogen peroxide." B. "Apply a hot compress to the affected areas." C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." D. "Expect to receive penicillin prior to delivery."

C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms."

A nurse is collecting data from a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus

C. 3 cm below the umbilicus

A nurse is assisting with the care of a newborn immediately following birth. Which of the following actions should the nurse take first? A. Weigh the newborn B. Instill erythromycin ophthalmic ointment in the newborn's eyes C. Administer vitamin K to the newborn D. Dry the newborn

D. Dry the newborn

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is caused by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."

D. "This is a source of your fluid loss after delivery."

A nurse is reinforcing teaching about breastfeeding with a client who is at 32 weeks of gestation. Which of the following responses should the nurse make? A. "You should place plastic-lined breast pads into your bra." B. "You should start pumping your breasts now." C. "You should apply lanolin ointment to your areolas." D. "You should use warm water to wash your nipples."

D. "You should use warm water to wash your nipples."

A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as a manifestation of a urinary tract infection? A. Hematuria B. Temperature 39°C (102.2°F) C. Diuresis D. 2 saturated perineal pads per hour

A. Hematuria

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

C. Progesterone

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

C. Re-evaluate the FHR tracing in 15 minutes

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

C. Respiratory distress syndrome

A nurse is reinforcing teaching with new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski

C. Rooting

The nurse is reviewing the laboratory results of a term newborn. For which of the following findings should the nurse notify the provider? A. Hematocrit 55% B. Platelet count 250,000/mm^3 C. Serum glucose 120 mg/dL D. Arterial blood gas pH 7.35

C. Serum glucose 120 mg/dL

A nurse is reinforcing teaching with a client who is postpartum and has a hearing impairment. Which of the following techniques should the nurse use? A. Raise voice volume B. Stand in front of a light or window C. Sit at the client's eye level D. Ask client to read educational material after the teaching

C. Sit at the client's eye level

A nurse is reinforcing teaching with a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? A. Urinary hesitancy B. Hematuria C. Stress incontinence D. Increased vaginal moisture

C. Stress incontinence

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

C. Swelling of the face and fingers

A nurse is reinforcing teaching about parental attachment with a client who is postpartum. Which of the following client behaviors indicates an understanding of the teaching? A. The client primarily touches the newborn with her fingertips. B. The client does not critique the newborn's features and body parts. C. The client has given the newborn a name. D. The client is quiet with a blank facial expression.

C. The client has given the newborn a name.

A nurse is collecting data from a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider? A. A scant amount of serosanguineous drainage is noted in the newborn's diaper. B. The newborn's circumcision site is covered with yellow exudate. C. The newborn has urinated once since the circumcision. D. The newborn fusses during each diaper change.

C. The newborn has urinated once since the circumcision.

A nurse is reinforcing discharge teaching with a client about breastfeeding her newborn. Which of the following pieces of information should the nurse include? A. Milk should replace the colostrum in 12 to 14 days. B. The newborn should have 3 to 4 wet diapers each day. C. The newborn should appear satisfied after each feeding. D. The client's breasts should feel firm after each feeding.

C. The newborn should appear satisfied after each feeding.

A nurse is caring for a client who is pregnant and whose last menstrual period (LMP) began on April 8. Using Naegele's rule, which of the following dates would be the client's estimated date of birth (EDB)? A. July 15 B. July 11 C. January 11 D. January 15

D. January 15

The nurse is collecting data from a newborn. Which of the following techniques should the nurse use? A. Count the newborn's respirations for 30 seconds B. Auscultate the heart rate when the newborn is crying and active C. Use a sphygmomanometer on the newborn's arm D. Measure the newborn's head at the widest part

D. Measure the newborn's head at the widest part

A nurse is contributing to the plan of care for a client who is pregnant and has a deep-vein thrombosis (DVT). Which of the following actions should the nurse include? A. Apply compression stockings each morning after assisting the client in the bathroom. B. Gently massage the affected extremity for 10 minutes twice daily. C. Apply cold compresses to the affected extremity for 20 minutes 4 times per day. D. Monitor the client for bleeding from intravenous insertion sites.

D. Monitor the client for bleeding from intravenous insertion sites.

A nurse is using Naegele's rule to determine the estimated date of birth (EDB) for a client whose first day of her last menstrual period was February 2, 2018. The nurse should identify which of the following as the client's EDB? A. November 16, 2018 B. October 19, 2018 C. October 26, 2018 D. November 9, 2018

D. November 9, 2018

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

D. Nutritional status

A nurse is caring for a client who is postpartum and has endometritis. Which of the following findings should the nurse report to the provider? A. Foul-smelling lochia B. Uterine pain with palpation C. Temperature 38.1°C (100.6°F) D. Oxygen saturation 93%

D. Oxygen saturation 93%

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

A. Gestational diabetes

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Fetal heart rate baseline of 90 bpm B. Maternal temperature of 37.8°C (100°F) C. Uterine relaxation of 1 min between contractions D. Uterine contractions increasing in intensity

A. Fetal heart rate baseline of 90 bpm

A nurse is collecting data from a client who is postpartum. The nurse should identify which of the following findings as a manifestation of endometritis? A. Foul-smelling lochia B. Fundus 2 cm above the umbilicus C. Decreased heart rate D. Dysuria

A. Foul-smelling lochia

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

A. Frequent headaches

A nurse is reviewing the medical record of a client who is pregnant prior to her first prenatal visit and notes that her pregnancy history is documented as 4, 1, 0, 2, 2. When the client arrives for the visit, which of the following questions should the nurse ask? A. "Were your twins born vaginally or by cesarean?" B. "Have you needed counseling to help you cope with the fact that you do not have any living children?" C. "What did your previous provider tell you about the reasons for your preterm births?" D. "Will you have someone to help you care for your 4 children after this baby is born?"

A. "Were your twins born vaginally or by cesarean?"

A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. Which of the following actions should the nurse plan to take when performing a fundal massage? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1. Rotate the upper hand to massage the client's uterus. 2. Use slight downward pressure to compress the client's fundus. 3. Place a hand just above the client's symphysis pubis. 4. Position a hand around the top of the client's fundus. 5. Ask the client to lie on her back with her knees flexed.

5. Ask the client to lie on her back with her knees flexed. 3. Place a hand just above the client's symphysis pubis. 4. Position a hand around the top of the client's fundus. 1. Rotate the upper hand to massage the client's uterus. 2. Use slight downward pressure to compress the client's fundus.

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

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

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

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

A nurse is reinforcing with teaching a postpartum client about how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. "I should stop swaddling my baby once she is able to roll over by herself." B. "My baby's legs should be extended straight out when I swaddle her." C. "I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."

A. "I should stop swaddling my baby once she is able to roll over by herself."

A nurse is reinforcing discharge teaching about circumcision care for the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."

A. "I will apply petroleum jelly to my baby's penis for the first few days."

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Screening for trisomy 13 syndrome and other chromosomal disorders is done automatically for clients at increased risk." D. "I can provide you with information about sterilization so that the disorder is not passed to your future children."

A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder."

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

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

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

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

A nurse is reinforcing teaching with a postpartum client about the proper technique for performing Kegel exercises. Which of the following statements should the nurse make? A. "Pretend you are urinating and stop your urine stream intermittently." B. "You should bear down as if you are passing gas during the exercises." C. "You should feel tightening in the buttocks during the exercises." D. "Each muscle contraction should be held for a minimum of 30 seconds."

A. "Pretend you are urinating and stop your urine stream intermittently."

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

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

A nurse is reinforcing teaching with new parents about safe sleeping recommendations to reduce the risk of sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? A. "Room sharing is recommended during infant sleep." B. "Bundle the infant snuggly in 2 blankets at bedtime." C. "Only use bumper pads that can be securely attached to the crib rails." D. "The side-lying position is safest for sleeping."

A. "Room sharing is recommended during infant sleep."

The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? A. "The blood-tinged mucus is a result of pseudomenstruation." B. "The blood-tinged mucus indicates a urinary tract infection." C. "The blood-tinged mucus is due to uric acid crystals." D. "The blood-tinged mucus is a result of the initial genital examination."

A. "The blood-tinged mucus is a result of pseudomenstruation."

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

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

A nurse is assisting with discussing a nonstress test with a client who is at 39 weeks of gestation. Which of the following statements indicates an understanding of the information? A. "This test will assist in determining if my baby is okay by monitoring the heart rate." B. "This test will determine if chromosomal disorders are present." C. "This test will require me to take a medication that will prompt contractions." D. "This test will use sonar to determine how my baby is doing."

A. "This test will assist in determining if my baby is okay by monitoring the heart rate."

A nurse working in a clinic is reinforcing antenatal education about alcohol consumption during pregnancy with a group of clients who are pregnant. Which of the following pieces of information should the nurse include? A. "Total abstinence from alcohol is recommended." B. "An occasional beer during pregnancy is okay." C. "High levels of alcohol consumption should be decreased." D. "A low-calorie liquor is safe to drink."

A. "Total abstinence from alcohol is recommended."

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

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

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

A. "Try pelvic tilt exercises."

A nurse at a family-planning clinic is preparing to give a presentation to clients about using a diaphragm. Which of the following pieces of information should the nurse plan to include in the session? A. "Use spermicidal jelly whenever you use your diaphragm." B. "Insert the diaphragm about 8 hr before sexual activity." C. "You should remove the diaphragm 30 min after intercourse." D. "A diaphragm comes in 1 size and does not require fitting."

A. "Use spermicidal jelly whenever you use your diaphragm."

A nurse is reinforcing teaching with a client who is breastfeeding and has pregestational diabetes controlled with insulin. Which of the following instructions should the nurse include? A. "You have a higher risk for hypoglycemia due to breastfeeding." B. "Reduce your overall carbohydrate intake until you achieve your prepregnancy weight." C. "You will need to take twice the amount of insulin while you breastfeed." D. "You should tailor your mealtimes depending on the needs of your baby."

A. "You have a higher risk for hypoglycemia due to breastfeeding."

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

A. "You should eat some crackers before rising from bed in the morning."

A nurse is reinforcing teaching about weight gain during pregnancy for a client who is a primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include? A. "You should plan to gain 25 to 35 pounds during your pregnancy." B. "You should plan to gain 11 to 20 pounds during your pregnancy." C. "Because you started pregnancy at a normal BMI and weight, your weight gain is not limited as long as you follow a healthy, balanced diet." D. "Because you are of normal weight prior to pregnancy, you are encouraged to gain 28 to 40 pounds during pregnancy."

A. "You should plan to gain 25 to 35 pounds during your pregnancy."

A nurse is contributing to the plan of care for a client who is at 12 weeks of gestation and has a BMI of 45. Which of the following recommendations should the nurse make for the client regarding weight gain during her pregnancy? A. "You should plan to gain no more than 20 lb during your pregnancy." B. "You should plan to gain between 25 and 35 lb during your pregnancy." C. "You should not plan to gain any weight during your pregnancy because you are already well-nourished." D. "Since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 lb."

A. "You should plan to gain no more than 20 lb during your pregnancy."

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

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

A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation." D. "You should schedule a cesarean birth after your water breaks."

A. "You will have a cesarean birth prior to the onset of labor."

A nurse is reinforcing teaching to a client who is postpartum and has been prescribed warfarin therapy for a deep vein thrombosis. Which of the following instructions should the nurse include? A. "You will need to use a reliable form of contraception while on warfarin therapy." B. "You will need to take a baby aspirin every day while on warfarin therapy." C. "You will need to use formula instead of breast milk while on warfarin therapy." D. "You will need to massage your affected leg 3 times a day while on warfarin therapy."

A. "You will need to use a reliable form of contraception while on warfarin therapy."

A nurse is reinforcing discharge teaching with the parent of a newborn. Which of the following statements should the nurse include in the teaching? A. "Your baby should be rear-facing in a car seat until 2 years of age." B. "Cover your baby with a light blanket during naps." C. "Set your hot water heater to no more than 140 degrees Fahrenheit." D. "Ensure your baby's crib has side rails that can be lowered."

A. "Your baby should be rear-facing in a car seat until 2 years of age."

A nurse is caring for a client at her first prenatal visit. The client is worried about the health of her fetus because she drank alcohol and smoked in the first week of pregnancy, before she knew she was pregnant. Which of the following responses should the nurse make? A. "Your baby wasn't susceptible to substances during the first 2 weeks of your pregnancy." B. "The first week is a very sensitive period for your baby, so we will increase the frequency of ultrasounds." C. "Your baby's palate was closing at that time, so your baby might be at increased risk for having a cleft palate." D. "Your baby's organs were formed in the first few days, so the baby should not be at risk for major malformations."

A. "Your baby wasn't susceptible to substances during the first 2 weeks of your pregnancy."

A nurse is collecting data on a newborn who was born at 43 weeks of gestation. Which of the following findings should the nurse expect? A. Absent vernix B. Abundant lanugo C. Increased subcutaneous fat D. Short, brittle nails

A. Absent vernix

A nurse is assisting with obtaining a New Ballard score for a newborn. Which of the following manifestations indicates prematurity? A. Abundant lanugo B. Plantar creases over the entire sole C. Formed and firm ear with instant recoil D. Skin with cracking and rare veins

A. Abundant lanugo

A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester? A. Accepting the pregnancy B. Preparing for the end of pregnancy C. Preparing for parenthood D. Accepting the baby

A. Accepting the pregnancy

A nurse is collecting data from a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider? A. Apical heart rate of 80/min while crying B. Apneic episode of 10 seconds while sleeping C. Positive Moro reflex D. Vernix caseosa in the skin folds

A. Apical heart rate of 80/min while crying

A nurse is reinforcing teaching about manifestations of postpartum depression with a client. Which of the following findings should the nurse include? A. Episodes of irritability without justification B. Sleeping more than 15 hours per day C. Desire to take care of the newborn without help D. Ability to verbalize negative feelings about the newborn

A. Episodes of irritability without justification

A nurse is assisting with the care of a client who is scheduled to have an amniocentesis to assess fetal lung maturity. The client is G2P1 at 36 weeks of gestation and has an O-positive blood type. Which of the following interventions should the nurse perform? A. Apply an external fetal monitor to the client B. Reinforce instructions with the client to drink fluids and not void prior to the procedure C. Administer Rho(D) immunoglobin after the procedure D. Ask the client to take a deep breath and hold it during the entry of the needle

A. Apply an external fetal monitor to the client

A nurse is reinforcing teaching with the parent of a newborn about care following circumcision using a Plastibell device. Which of the following pieces of information should the nurse include? A. Apply gentle pressure using sterile gauze if bleeding occurs at the circumcision site. B. The plastic rim of the bell will fall off in 2 to 3 days following circumcision. C. Use mild soap and water to wash the penis twice each day after circumcision. D. Apply petrolatum to the circumcision site after each diaper change.

A. Apply gentle pressure using sterile gauze if bleeding occurs at the circumcision site.

A nurse is preparing to administer erythromycin ophthalmic ointment 0.5% to a newborn. Which of the following actions should the nurse plan to take? A. Apply the ointment in the lower conjunctival sac of each eye B. Obtain a written consent from the guardian prior to administering the ointment C. Wipe the excess ointment immediately to prevent irritation D. Administer the ointment from the outer canthus of the eye to the inner canthus.

A. Apply the ointment in the lower conjunctival sac of each eye

A nurse is collecting data from a client who is 12 hours postpartum. Which of the following locations should the nurse expect to palpate the client's fundus? A. Approximately 1 cm above the umbilicus B. Approximately 2 cm below the level of the umbilicus C. At the symphysis pubis D. Directly between the symphysis pubis and umbilicus

A. Approximately 1 cm above the umbilicus

A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? A. Ask the client to drink a glass of orange juice B. Prepare the client for a vaginal examination C. Request a serum hemoglobin level D. Obtain a clean-catch urine specimen

A. Ask the client to drink a glass of orange juice

A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take? A. Assess the fetal heart rate before and after the procedure B. Monitor the client's temperature every 4 hours after the procedure C. Medicate the client for pain 30 minutes prior to the procedure D. Perform cervical assessments every 2 hours after the procedure

A. Assess the fetal heart rate before and after the procedure

A nurse is caring for a client who is postpartum and reports abdominal pain due to flatus. Which of the following actions should the nurse take? A. Assist the client to ambulate in the hallway B. Encourage the client to increase fiber intake C. Administer a dose of laxative medication to the client D. Increase the client's fluid intake

A. Assist the client to ambulate in the hallway

A nurse is checking the vital signs of a newborn. Which of the following routes should the nurse use when checking the newborn's temperature? A. Axillary B. Temporal artery C. Oral D. Tympanic

A. Axillary

A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use? A. Axillary B. Temporal C. Tympanic D. Rectal

A. Axillary

A nurse is assisting with the care of a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? A. Betamethasone B. Nifedipine C. Indomethacin D. Verapamil

A. Betamethason

A nurse is assisting with the assessment of a 1-day-old newborn. Which of the following findings indicates that the newborn has acrocyanosis? A. Bluish-colored skin B. Pursed lips C. Clenched fists D. Rounded nose

A. Bluish-colored skin

A nurse is assisting the respiratory therapist with obtaining an arterial blood gas (ABG) specimen from a newborn. Which of the following actions should the nurse take? A. Carefully restrain the newborn during the procedure B. Place a warm cloth on the newborn's heel prior to the procedure C. Prepare wet gauze for the newborn's puncture site D. Administer pancuronium to the newborn prior to the procedure

A. Carefully restrain the newborn during the procedure

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

A. Collard greens

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

A. Continue to monitor the fetal heart tracings

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

A. Copper intrauterine device

A nurse is caring for a client who has preeclampsia with severe features and is receiving a continuous infusion of magnesium sulfate. The nurse notes that the client is difficult to arouse and has absent deep tendon reflexes. Which of the following action should the nurse take? A. Discontinue the magnesium sulfate B. Reposition the client to a left lateral recumbent position C. Administer hydralazine intravenously D. Darken the room and avoid making loud noises

A. Discontinue the magnesium sulfate

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

A. Encourage the client to frequently change positions

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

A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL. Incorrect Answers: B. The expected reference range for this newborn's platelet count is 150,000 to 300,000/mm^3. C. The expected reference range for this newborn's total bilirubin level is 2 to 6 mg/dL. D. The expected serum glucose level for this newborn is 40 to 60 mg/dL.

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

A. Hyperbilirubinemia

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

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

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

A. Instruct the client about vena cava syndrome and measures to prevent it

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

A. Intraventricular hemorrhage

A nurse is reinforcing nutritional teaching with a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet? A. Iron B. Calcium C. Vitamin E D. Vitamin K

A. Iron

A nurse is reinforcing teaching about nutrition with a client who is at 6 weeks of gestation. The nurse should identify that which of the following foods contains the highest folate content per serving? A. Liver B. Avocado C. Egg D. Pasta

A. Liver

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

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

A nurse is assisting with the plan of care for a client who is postpartum and has a history of a pulmonary embolus. The provider has prescribed heparin therapy prophylactically. Which of the following interventions should the nurse recommend to include in the plan? A. Monitor aPTT and platelet count B. Perform fundal massage every 1 to 2 hours C. Assist the client with using a breast pump until therapy is discontinued D. Maintain strict bedrest

A. Monitor aPTT and platelet count

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

A. Nausea in the morning

A provider is assisting with the care of a client who is postpartum following a vaginal delivery. The nurse should identify that which of the following circumstances is a risk factor for postpartum hemorrhage? A. Oxytocin-induced labor B. Oligohydramnios C. Small fetus D. Gravida 1

A. Oxytocin-induced labor

A nurse is caring for a client following a forceps-assisted birth. The nurse should identify which of the following findings as a complication of this procedure? A. Pelvic hematoma B. Retained placenta C. Infertility D. Uterine inversion

A. Pelvic hematoma

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 minutes, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborn's glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for phenylketonuria (PKU)

A. Perform a heel stick to check the newborn's glucose level

A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is scheduled to receive phototherapy. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shirt D. Check the newborn's temperature twice daily

A. Place an opaque mask over the newborn's eyes

A nurse is measuring the body length of a newborn. Which of the following actions should the nurse take? A. Place the newborn on a flat surface B. Position the newborn with the knees bent C. Extend the newborn with the arms overhead D. Measure the newborn from the neck to the heel

A. Place the newborn on a flat surface

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take? A. Place the unwrapped newborn on the mother's bare chest B. Feed the infant 5 to 15 mL of 5% glucose water to assess the suck/swallow reflex C. Bathe the newborn under running warm water before feeding D. Administer vitamin K and eye prophylaxis prior to feeding

A. Place the unwrapped newborn on the mother's bare chest

A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy? A. Report of fetal movement by the client B. Auscultation of the fetal heart rate with Doppler ultrasound C. Presence of Chadwick's sign on pelvic examination D. Report of Braxton-Hicks contractions by the client

A. Report of fetal movement by the client

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan? A. Reposition the newborn every 3 hours B. Apply lotion to the newborn's exposed skin twice daily C. Feed the newborn 1 oz of glucose water every 2 hours D. Dress the newborn in a diaper and a thin cotton t-shirt

A. Reposition the newborn every 3 hours

A nurse in a clinic is caring for a client who is pregnant and reports a last menstrual period (LMP) that began on December 7. Which of the following dates would be the client's estimated date of birth (EDB)? A. September 14 B. September 7 C. March 14 D. March 7

A. September 14

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

A. Stop the oxytocin infusion

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment. B. The newborn's blanket should be removed so her movements will not be restricted. C. The newborn's hat should be removed to avoid overheating. D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding.

A. The newborn would benefit from skin-to-skin contact in a quiet environment.

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

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

A nurse is assisting with the care of a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? A. Turn the newborn every 2 hours B. Supplement with 5% glucose water between scheduled feedings C. Dress the infant lightly in a tee shirt and diaper D. Apply lotion to the skin every 4 hours

A. Turn the newborn every 2 hours

A nurse is preparing to elicit the fencing reflex from a newborn. Which of the following actions should the nurse take? A. Turn the newborn's head quickly to 1 side B. Clap loudly directly above the newborn C. Tap the bridge of the newborn's nose when his eyes are open D. Extend 1 of the newborn's legs and press down on the extended leg's knee

A. Turn the newborn's head quickly to 1 side

A nurse is collecting data from a pregnant client who is at 16 weeks of gestation. Which of the following manifestations should the nurse report to the provider? A. Urinary urgency B. Constipation C. Periodic tingling in fingers D. Pyrosis

A. Urinary urgency

A nurse is caring for a client who is at 16 weeks of gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? A. Use a 20-gauge needle and administer the medication using the Z-track method B. Use a 22-gauge needle and administer the medication deep into the thigh C. Use a 25-gauge needle and administer the medication into the deltoid muscle D. Use an 18-gauge needle and administer the medication into the rectus femoris muscle

A. Use a 20-gauge needle and administer the medication using the Z-track method

A nurse is reinforcing discharge teaching with the parents of a newborn. Which of the following instructions should the nurse include? A. Use a bulb syringe to help clear the newborn's nasal passages B. Position the newborn on the stomach to sleep C. Apply talcum powder to the newborn's skin after a bath D. Dress the newborn in several layers when going outside

A. Use a bulb syringe to help clear the newborn's nasal passages

A nurse is measuring the head circumference of a newborn. Which of the following actions should the nurse take? A. Use a tape measure to obtain the greatest breadth and width of the head B. Expect the measurement to be approximately 27 cm (11 in) in diameter C. Collect neurological data if the head circumference has a diameter of 33 to 35 cm (13 to 14 in) D. Expect the head circumference to be a smaller value than the chest circumference

A. Use a tape measure to obtain the greatest breadth and width of the head

A nurse is assisting with the care of a client who is at 34 weeks of gestation and presents with vaginal bleeding. Which of the following data should the nurse collect to determine if the bleeding is caused by placenta previa versus abruptio placenta? A. Uterine tone B. Fetal heart rate C. Blood pressure D. Amount of bleeding

A. Uterine tone

A nurse is caring for a client who is in the first trimester of pregnancy and reports daily nausea that interferes with her ability to work. Which of the following dietary supplements should the nurse recommend to help alleviate the client's nausea? A. Vitamin B6 B. Vitamin C C. Vitamin B12 D. Vitamin D

A. Vitamin B6

A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following nutrients should the client increase her intake of while breastfeeding? A. Vitamin C B. Iron C. Folate D. Calcium

A. Vitamin C

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

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

The nurse is reinforcing teaching with a client who is pregnant about how to take a prescribed iron supplement for anemia. Which of the following statements should the nurse make? A. "Eating strawberries and oranges will help your body absorb the iron better." B. "Take your iron pills in the morning if you notice they upset your stomach." C. "Take your iron with a cup of tea." D. "If you forget an iron pill, it is okay to take 2 doses together."

A. "Eating strawberries and oranges will help your body absorb the iron better."

A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include? A. "Fill the perineal bottle with warm water prior to use." B. "Squeeze the perineal bottle while standing up in the bathroom to cleanse the perineum." C. "Only use half of the perineal bottle for cleansing." D. "Wipe the perineum with toilet paper from back to front after using the perineal bottle."

A. "Fill the perineal bottle with warm water prior to use"

A client at 12 weeks of gestation reports practicing Hinduism. The provider states that the client needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? A. "Let's discuss other foods that are high in protein that you could substitute for meat." B. "Eating meat during pregnancy provides necessary protein and does not cause miscarriage." C. "Why do you think that eating animal products will cause you to have a miscarriage?" D. "Your doctor is recommending what is best for you and your baby."

A. "Let's discuss other foods that are high in protein that you could substitute for meat."

A nurse is preparing a client who is pregnant for an ultrasound. Which of the following pieces of information is the most important for the nurse to collect? A. Time of the client's last void B. Who will accompany the client to the ultrasound C. Date of the client's last menstrual period D. Whether the client wants to know the sex of the fetus

A. Time of the client's last void

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

B. "A weight gain of about 25 to 35 pounds is good."

A nurse is reinforcing teaching with the guardian of a newborn who is scheduled to undergo a circumcision. Which of the following pieces of information should the nurse include in the teaching? A. "Wash your child's penis with soap starting on day 3 after the circumcision." B. "Apply the diaper loosely over the penis." C. "Your baby's glans penis will be bright red after the circumcision." D. "Remove the yellow exudate that will appear on the glans penis 24 hours following the circumcision."

B. "Apply the diaper loosely over the penis."

A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include? A. "Cover the cord with the edge of the diaper." B. "Clean the cord stump with tap water." C. "Apply a damp cloth over the cord stump once each day." D. "You should gently tug on the cord stump in 5 days if it has not yet fallen off."

B. "Clean the cord stump with tap water."

A nurse is reinforcing discharge teaching with the parents of a newborn about how to care for their child's uncircumcised penis. Which of the following statements should the nurse make? A. "Retract the foreskin until you feel resistance." B. "Clean the penis once per day with soap and water." C. "Use a cotton swab to clean under the foreskin." D. "Apply petroleum jelly to the foreskin every other day."

B. "Clean the penis once per day with soap and water."

A nurse is collecting data from a client who is at 20 weeks of gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse reinforce with the client? A. "Limit your intake of food to twice per day." B. "Decrease your intake of spicy foods." C. "Rest in a supine position for a few minutes after eating." D. "Increase your intake of water and carbonated beverages."

B. "Decrease your intake of spicy foods."

A nurse is reinforcing teaching with a parent about how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching? A. "I should clean the circumcision site with half-strength hydrogen peroxide twice a day." B. "I should apply the diaper loosely until the circumcision site is healed." C. "I should notify the doctor if a yellow discharge forms on the head of the penis." D. "Newborns typically do not experience any pain from this procedure."

B. "I should apply the diaper loosely until the circumcision site is healed."

A nurse is providing breastfeeding education to a client who delivered 12 hours ago. Which of the following client statements indicates an understanding of the teaching? A. "I should have less cramping while I'm breastfeeding." B. "I should breastfeed at least 8 to 12 times in a 24-hour period." C. "I should wait to breastfeed until my baby awakens from her nap." D. "I should switch breasts after 5 minutes of nursing."

B. "I should breastfeed at least 8 to 12 times in a 24-hour period."

A nurse is talking with a client at 20 weeks of gestation who is scheduled for a sonogram. The client states, "I am here to have my regular prenatal checkup, but I do not want any pictures taken of my baby." Which of the following responses should the nurse make? A. "Do not worry. We can do the sonogram without showing you the sex of the baby." B. "I would like to hear more about why you do not want the sonogram, including any cultural reasons." C. "I think you should reconsider because the sonogram is an important part of the baby's checkup." D. "You have the right to tell the doctor that you do not want the sonogram."

B. "I would like to hear more about why you do not want the sonogram, including any cultural reasons."

A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make? A. "I understand how you feel." B. "I'm here for you if you would like to talk." C. "It is better that the loss happened now, before you got to know your baby." D. "You are young and can have other children."

B. "I'm here for you if you would like to talk."

A nurse is reinforcing education with a client who is pregnant about symptoms that should immediately be reported to the provider. Which of the following client responses indicates an understanding of the teaching? A. "I should call my provider if I develop melasma." B. "If I notice that my eyes are puffy, I should call my provider." C. "I should call my provider if I notice that my feet and ankles are swollen." D. "If I notice periodic numbness and tingling in my fingers, I should call my provider."

B. "If I notice that my eyes are puffy, I should call my provider."

A nurse is reinforcing teaching about nonstress testing with a client who is pregnant. Which of the following pieces of information should the nurse include? A. "This test is an invasive procedure that presents minimal risk to the fetus." B. "If the test is reactive, that means your baby's heart rate is healthy." C. "When your baby moves, the test should record the baby's heart rate decreasing by about 15 beats per minute." D. "The results of the test will be recorded as positive if no fetal movement occurs during the 20-minute testing period."

B. "If the test is reactive, that means your baby's heart rate is healthy."

A nurse is reinforcing discharge teaching with a postpartum client regarding elimination. Which of the following statements should the nurse include in the teaching? A. "You should urinate at least twice daily." B. "Increase fluids to help prevent constipation." C. "Put your hand under running cold water if you experience hesitancy when trying to urinate." D. "You should use laxatives daily to keep your bowel movements regular."

B. "Increase fluids to help prevent constipation."

A nurse is reinforcing postpartum teachings with a client who is non-lactating about breast discomfort. Which of the following interventions should the nurse discuss with the client? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amounts of milk from the breasts frequently."

B. "Place fresh cabbage leaves on your breasts."

A nurse on a postpartum unit is reinforcing teaching with a client about postpartum blues. Which of the following instructions should the nurse include? A. "Seek immediate assistance for feelings of fatigue." B. "Plan opportunities to get out of the house frequently." C. "You will experience intense fears and anxiety if you have postpartum blues." D. "Most parents feel angry when the baby cries."

B. "Plan opportunities to get out of the house frequently."

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Tinnitus B. Numbness in the hand C. Headache D. Nasal stuffiness interfering with sleep

C. Headache

A nurse is caring for a client who is 48 hours postpartum. The client expresses distress about her older children's acceptance of the new baby. Which of the following statements should the nurse make? A. "It would be best if your children met the new baby at home in a familiar setting." B. "Present the older children with a small gift and say it is from the baby." C. "Make sure you are holding the baby when the older children come to visit." D. "Try not to split up the children so no one will feel left out."

B. "Present the older children with a small gift and say it is from the baby."

A nurse is reinforcing teaching with the parent of a newborn about preventing cold stress. Which of the following statements should the nurse include? A. "Cold stress decreases the newborn's need for oxygen." B. "Skin-to-skin contact with the parent helps provide warmth." C. "The newborn must be air dried to avoid lying in wet clothes." D. "Examinations will be done with the newborn in a room kept at 68° Fahrenheit."

B. "Skin-to-skin contact with the parent helps provide warmth."

A nurse is assisting with the care of a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue your IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."

B. "The bleeding is minimal until I discontinue your IV medication."

A nurse is caring for a client who is at 20 weeks of gestation. The client asks the nurse what the baby looks like now. Which of the following answers by the nurse provides an accurate response? A. "Lanugo has disappeared." B. "The fetus resembles a born human." C. "The arm and leg buds are noticeable." D. "Subcutaneous fat gives the body a wrinkled appearance."

B. "The fetus resembles a born human."

A client at a routine prenatal care visit asks the nurse if vaginal yeast infections are common during pregnancy. Which of the following responses should the nurse make? A. "Have you discussed this with your doctor yet?" B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." C. "Women who are already prone to vaginal yeast infections get them during pregnancy." D. "Why are you concerned about yeast infections during pregnancy?"

B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common."

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

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

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

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

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

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

A nurse is reinforcing teaching with a client about postpartum fatigue. Which of the following statements should the nurse include? A. "Strenuous exercise can help improve your sleep." B. "Try to take naps when your infant is napping." C. "Avoid consuming dairy products such as milk before bedtime." D. "You might want to ask family not to visit until you are more rested."

B. "Try to take naps when your infant is napping."

A nurse is reinforcing teaching with the parent of a breastfed newborn about bowel elimination. Which of the following statements should the nurse make? A. "You should expect the stools to be semi-formed." B. "You can expect the stools to be yellow and seedy." C. "You should switch to formula if the stools become pasty." D. "You can expect the stools to have a sour odor."

B. "You can expect the stools to be yellow and seedy."

A nurse is caring for a client who in the first trimester of a low-risk pregnancy. The client tells the nurse that she and her partner would like to continue their sexual relationship, but she is afraid it will cause a miscarriage. Which of the following responses should the nurse make? A. "I will talk to your provider about a referral to a sex therapist." B. "You can safely have intercourse as long as you don't feel discomfort." C. "You should try alternative positions for sexual intercourse." D. "You should abstain from intercourse until 6 weeks postpartum."

B. "You can safely have intercourse as long as you don't feel discomfort."

A nurse is reinforcing education with a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? A. "It will take about 10 minutes to complete the test." B. "You might have to drink orange juice during the test." C. "During the test, you will be asked to massage your nipples." D. "During the test, you will receive a medication to relax your uterus."

B. "You might have to drink orange juice during the test."

The nurse is reinforcing teaching with a client who is postpartum about the rubella vaccine. Which of the followings statements should the nurse include? A. "You must not take this immunization if you've had the chickenpox." B. "You must not become pregnant for 28 days after receiving this immunization." C. "You must not breastfeed because the virus is passed in breastmilk." D. "You must not receive other vaccines at the same time as the rubella vaccine."

B. "You must not become pregnant for 28 days after receiving this immunization."

A nurse is reinforcing teaching about toxoplasmosis with a client who is pregnant. Which of the following instructions should the nurse include? A. "To prevent toxoplasmosis, you will need to receive a measles, mumps, and rubella vaccination during your pregnancy." B. "You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis." C. "You will get a body rash if you are infected with toxoplasmosis." D. "Toxoplasmosis is transmitted through a bite from an infected mosquito." Check Answer

B. "You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis."

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

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

A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000 mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts

B. 3+ deep tendon reflexes

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

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

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

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

A nurse is contributing to the plan of care for a client who is at 34 weeks of gestation and has preeclampsia with severe features. Which of the following interventions should the nurse include as the priority action following a seizure? A. Provide a peaceful, relaxing environment for the client B. Administer oxygen to the client at 10 L/min via face mask C. Place blankets on the raised side rails of the client's bed D. Insert an indwelling urinary catheter for the client

B. Administer oxygen to the client at 10 L/min via face mask

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

B. Administer the hepatitis B vaccine prior to discharge

A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take? A. Review the medical record for a history of gastric bypass surgery B. Advise the client to start iron and vitamin C supplementation C. Review the medication list to determine if the client is taking an anticonvulsant D. Request an order for sickle cell anemia screening

B. Advise the client to start iron and vitamin C supplementation

A nurse is caring for a client who reports that her last menstrual period (LMP) began on July 8. Based on Naegele's rule, which of the following is the client's expected date of birth (EDB)? A. April 1 B. April 15 C. October 15 D. October 1

B. April 15

A nurse is caring for a client who is postpartum. After bringing the newborn back to the parent following an assessment, the parent immediately gives the infant to the grandparent. Which of the following actions should the nurse take? A. Make a referral to child protective services B. Ask the client about the family's cultural beliefs C. Take the newborn back to the nursery until the mother is ready to offer care D. Explain to the client the importance of caring for the newborn personally

B. Ask the client about the family's cultural beliefs

A nurse is assisting with the care of a recently delivered newborn whose mother had gestational diabetes. Which of the following actions should the nurse take within the first hour after birth? A. Administer the hepatitis B vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

B. Assess the newborn's blood glucose level

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

B. Assess the newborn's blood glucose level

A nurse in a prenatal clinic is collecting data from several clients. Which of the following client reports is an expected physiological adaptation to pregnancy? A. Spotting with urination B. Breast tenderness C. Thick, white vaginal discharge D. Facial swelling

B. Breast tenderness

A nurse is collecting data from a newborn following a vaginal birth with the assistance of a vacuum extractor device. The newborn has head swelling that crosses the suture line. The nurse should document this finding as which of the following conditions? A. Cephalohematoma B. Caput succedaneum C. Nevus flammeus D. Erythema toxicum

B. Caput succedaneum

A nurse is collecting data from a newborn. Which of the following findings should the nurse report to the provider? A. Anterior fontanel of 5 cm B. Central cyanosis C. Edematous scrotum D. Capillary refill of under 2 seconds

B. Central cyanosis

A nurse is assisting with the plan of care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus ß-hemolytic culture D. 1-hour glucose tolerance test

C. Group B streptococcus ß-hemolytic culture

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

B. Change the client's position

A nurse is reinforcing teaching with the parents of a newborn about the facility's safety measures. Which of the following pieces of information should the nurse include? A. Expect staff to identify the newborn by verifying the information on the bassinet card B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room C. Place the newborn in the bassinet when using the bathroom D. Hold the newborn securely when walking in the hallway

B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room

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

B. Citrus fruit

A nurse is reinforcing discharge teaching about bathing with the parent of a newborn. Which of the following instructions should the nurse include? A. Shake cornstarch inside the newborn's diaper after bathing B. Clean the newborn's face first using water C. Wash the newborn's umbilical cord with a mild soap D. Avoid massaging the newborn's scalp when washing the hair

B. Clean the newborn's face first using water

A nurse is reinforcing teaching with a client at 10 weeks of gestation about self-care management for common discomforts in pregnancy. Which of the following instructions should the nurse include? A. Douche every other day to minimize leukorrhea B. Consume frequent snacks to decrease episodes of nausea C. Refrain from scheduling dental procedures until the third trimester D. Decrease fluid intake to reduce urinary frequency

B. Consume frequent snacks to decrease episodes of nausea

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

B. Decreased blood pressure

A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings is a sign of a potential complication? A. Dark red lochia with small clots B. Deep tendon reflexes 4+ C. Urine output since birth of 3,000 mL D. Soft pink hemorrhoids

B. Deep tendon reflexes 4+

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

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

While assisting with the care of a client in labor, a nurse observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Notify the provider B. Document the findings and continue to monitor C. Administer oxygen to the client via face mask D. Assist with sterile speculum examination

B. Document the findings and continue to monitor

A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence

B. Double vision

A nurse is assisting with the care of a newborn immediately after birth. The newborn is pink and crying and has a heart rate of 108/min. Which of the following actions should the nurse take? A. Initiate chest compressions B. Dry the newborn on the mother's chest C. Administer epinephrine to the newborn D. Apply an oxygen saturation monitor

B. Dry the newborn on the mother's chest

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

B. Estrogen

A nurse is contributing to the plan of care for a client who plans to formula-feed her newborn. Which of the following actions should the nurse include in the plan? A. Suggest the client stand under a hot shower with her breasts exposed 2 times per day B. Have the client place ice packs on her breasts 4 times per day C. Have the client avoid wearing a bra for 14 days D. Encourage the client to stimulate her nipples daily

B. Have the client place ice packs on her breasts 4 times per day

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

B. Ketones 2+

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

B. Massage the fundus

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

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

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

B. Menorrhagia

A nurse is reinforcing teaching about formula feeding with the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Boil bottles and nipples for 20 minutes after each use B. Mix 1 scoop of powdered formula with 2 oz of water C. Store prepared bottles in the refrigerator for up to 4 days D. Warm formula by heating bottles in the microwave on the lowest setting

B. Mix 1 scoop of powdered formula with 2 oz of water

A nurse is collecting data from a newborn. Which of the following findings suggests the newborn is post-mature? A. Pale, translucent skin B. Nails extending over the fingers C. Weak gag reflex D. Thin covering of fine hair on the shoulders and back

B. Nails extending over the fingers

A nurse is collecting data for a newborn who is 12 hours old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. Administer phytonadione IM B. Obtain a stat prescription for a bilirubin level C. Obtain a bagged urine specimen D. Perform a gestational age assessment

B. Obtain a stat prescription for a bilirubin level

A nurse in a clinic is preparing to auscultate fetal heart tones using a Doppler for a client who is pregnant. Which of the following actions should the nurse prepare to take? A. Apply petroleum jelly on the client's abdomen B. Palpate and count the maternal radial pulse while listening to the fetal heart rate. C. Place the wand over the fetal chest to hear the fetal heart rate D. Percuss the maternal abdomen to verify the position of the fetus

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

A nurse is collecting data from a client who is 48 hours postpartum. Which of the following findings should the nurse report to the provider? A. The fundus is firm after palpation with moderate lochia noted. B. Pelvic and uterine pain is present while at rest. C. Urination is documented every 2 to 4 hours. D. The client reports difficulty sleeping the previous night.

B. Pelvic and uterine pain is present while at rest.

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%

B. Platelet count 135,000/mm^3

A nurse is assisting with the care of a client who is in labor and has received epidural analgesia. The nurse observes that the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Position the client on her side C. Assist with an examination for cord prolapse D. Provide glucose via oral hydration or IV

B. Position the client on her side

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

B. Preterm labor

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

B. Prolonged labor

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

B. Provide a sitz bath with warm water

A nurse in a provider's office is reviewing the medical record of a client who is at 28 weeks of gestation. The nurse should identify that prophylactic administration of Rh immune globulin is contraindicated for which of the following findings? A. The client is a Jehovah's Witness. B. The client has Rh-positive blood. C. The client had an external cephalic version. D. The client is currently pregnant with fraternal twins.

B. The client has Rh-positive blood.

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord. B. They can cause delayed cord separation. C. They can cause swelling of the surrounding tissue. D. They can cause skin discoloration.

B. They can cause delayed cord separation

A nurse is caring for a client who is 6 hours postpartum following a dysfunctional labor. Which of the following statements by the client indicates a possible complication? A. "Suddenly, I seem to be urinating all the time." B. "I am really thirsty and hungry this morning." C. "I think I have changed my pad every 15 minutes." D. "Honestly, I'm so tired I don't want to hold the baby."

C. "I think I have changed my pad every 15 minutes."

A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I can store my pumped milk in the door of the refrigerator." B. "I can use the microwave to thaw my frozen breast milk." C. "I will discard any unused breastmilk that is left in the bottle." D. "I can refreeze any breastmilk after it has been thawed."

C. "I will discard any unused breastmilk that is left in the bottle."

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

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

A nurse is assisting with the care of a client who has been experiencing mild contractions for a few days. The nurse places an external fetal monitor on the client. The client asks, "What will the monitor show you?" Which of the following responses should the nurse make? A. "It will indicate if you are in active labor." B. "It will measure your heart rate." C. "It indicates if your baby is receiving an adequate amount of oxygen." D. "It indicates the intensity of the contractions you are currently having."

C. "It indicates if your baby is receiving an adequate amount of oxygen."

A nurse is reinforcing teaching with a client who is at 38 weeks of gestation. The client asks, "When will I know I am in the first stages of labor?" Which of the following responses should the nurse make? A. "Labor starts when you feel pelvic pressure." B. "This stage begins with the expulsion of the placenta." C. "Labor begins with consistent regular contractions." D. "Labor starts when the fetal head is delivered."

C. "Labor begins with consistent regular contractions."

A nurse is reinforcing teaching with a client about using a disposable sitz bath. Which of the following instructions should the nurse include? A. "Tighten your gluteal muscles during the bath." B. "You should use the sitz bath about 4 times each day." C. "Loosen the tube clamp to regulate the rate of flow." D. "Place the bath in a bowl with the overflow toward the front of the toilet."

C. "Loosen the tube clamp to regulate the rate of flow."

A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make? A. "The light helps your baby maintain his body temperature." B. "The light helps your baby establish a regular sleeping pattern." C. "The light will help lower your baby's bilirubin level." D. "The light will help regulate your baby's blood sugar."

C. "The light will help lower your baby's bilirubin level."

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

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

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

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

A nurse is reinforcing teaching with a client who is at 28 weeks of gestation. The client asks, "Is it safe for me to take a 12-hour drive to visit my family?" Which of the following responses should the nurse make? A. "Yes, but avoid using rest-stop bathrooms to reduce your exposure to infection." B. "Yes, but stop and lie down in the back seat if you feel dizzy. Sitting for long periods can put pressure on major blood vessels and make you faint." C. "Yes, but be sure to get out of the car and walk around regularly so you don't develop blood clots in your legs." D. "Yes, but monitor your blood pressure. Remaining in a sitting position during a long car trip can lower your blood pressure."

C. "Yes, but be sure to get out of the car and walk around regularly so you don't develop blood clots in your legs."

A nurse is collecting data from a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands

C. Grunting with expiration

A nurse is providing counseling for a couple who is experiencing infertility issues. Which of the following statements by the nurse is appropriate? A. "Even though you can't have children biologically, you can always adopt a child." B. "You need to take a break from these attempts to conceive." C. "You might want to join our support group for couples who are experiencing similar problems." D. "Why didn't you get your immunizations when you were a child?"

C. "You might want to join our support group for couples who are experiencing similar problems."

A nurse is reinforcing teaching with a client who has hemorrhoids following a vaginal birth. Which of the following statements should the nurse include in the teaching? A. "You should apply the peripad from back to front." B. "You should wipe the perineum dry after using the squeeze bottle." C. "You should apply witch hazel after voiding or defecating." D. "You should use anesthetic cream once daily in the morning."

C. "You should apply witch hazel after voiding or defecating."

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

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

A nurse is reinforcing discharge teaching with a client who is postpartum. Which of the following statements should the nurse make? A. "You should notify the provider if your breasts feel full 5 days following delivery." B. "You should contact the provider if you do not have a bowel movement within 2 days." C. "You should notify the provider immediately if either of your legs becomes swollen." D. "You should contact the provider if you experience vaginal discharge lasting longer than a week."

C. "You should notify the provider immediately if either of your legs becomes swollen."

A nurse in an outpatient setting is reinforcing education with a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. "During the last trimester, you should sleep mainly on your back." B. "During the second trimester of pregnancy, you will notice increased urinary frequency and urgency." C. "You will probably first notice your baby moving when you are around 20 weeks of gestation." D. "You should plan to gain 40 to 45 lb during your pregnancy."

C. "You will probably first notice your baby moving when you are around 20 weeks of gestation."

A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following pieces of information should the nurse include? A. "You should allow your baby to nurse for a total of 20 min per feeding." B. "Your baby should have 5 wet diapers per day." C. "Your baby should have bursts of 15 sucks or swallows at a time." D. "You can expect your baby to have dark black stools for the first week of life."

C. "Your baby should have bursts of 15 sucks or swallows at a time."

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

C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery."

A nurse is reinforcing teaching about oxytocin with a client who is in the third trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for use of this medication? A. Prolonged rupture of membranes at 38 weeks of gestation B. Intrauterine growth restriction C. Active genital herpes D. Post-term pregnancy

C. Active genital herpes

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection

C. Administer immune globulin to the client to prevent fetal isoimmunization

A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water sitz bath for the client's perineum B. Encourage the client to sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Administer an acetaminophen suppository rectally

C. Apply cold ice packs to the client's perineum

A nurse is collecting data from a client on the first postpartum day. Findings include a fundus that is firm and 1 fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? A. Report the vital signs to the provider B. Massage the fundus C. Ask the client when she last voided D. Obtain a prescription for an oxytocic agent

C. Ask the client when she last voided

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

C. Assist the client to the toilet

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

C. Autosomal recessive

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

C. Head circumference 28 cm (11 in)

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

C. Avoid eye contact during feedings

A nurse is reinforcing teaching about circumcision care with a parent of a newborn. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes D. Apply the diaper tightly to apply pressure to the site

C. Avoid using diaper wipes on the site during diaper changes

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. Which of the following laboratory findings should the nurse report to the provider? A. Hematocrit 34% B. White blood cell count 12,000/mm^3 C. Blood glucose 50 mg/dL D. Erythrocyte sedimentation rate 33 mm/hr

C. Blood glucose 50 mg/dL

A nurse is reinforcing safety teaching with the parents of a newborn. Which of the following instructions should the nurse include? A. Position the newborn on the stomach when sleeping B. Cleanse the newborn's ears with a cotton-tipped swab C. Burp the newborn frequently during feedings D. Allow the newborn to air dry after bathing

C. Burp the newborn frequently during feedings

A nurse is assisting with the care of a newborn who is large for gestational age, appears restless, and has tremors. Which of the following actions should the nurse take first? A. Place the newborn under a radiant warmer B. Provide nonnutritive sucking for the newborn C. Check the newborn's blood glucose level D. Swaddle the newborn

C. Check the newborn's blood glucose level

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

C. Continue to monitor the newborn routinely

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

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

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

C. Decreased blood glucose

A nurse is collecting data from a client who has placenta previa and is at 27 weeks of gestation. Which of the following manifestations should the nurse expect? A. Severe abdominal pain B. Increased blood pressure C. Decreased urinary output D. Cool, clammy skin

C. Decreased urinary output

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

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

A nurse is assisting with the plan of care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? A. Swaddle the newborn in a receiving blanket during the treatment B. Maintain NPO status until the newborn's bilirubin is within the expected reference range C. Ensure the newborn's eyes are closed before applying the eye shield D. Apply lotion to the newborn's skin twice per day

C. Ensure the newborn's eyes are closed before applying the eye shield

A nurse is reinforcing teaching about breastfeeding with a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast B. Newborns are expected to lose up to 15% of their birth weight C. Ensure the newborn's mouth covers the nipple and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth

C. Ensure the newborn's mouth covers the nipple and areola

A nurse is assisting with the care of a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? A. Diarrhea B. Thromboembolism C. Fetal asphyxia D. Oliguria

C. Fetal asphyxia

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

C. Fetal heart rate decreased by 15/min

A nurse is caring for a client who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Positive serum pregnancy test B. Amenorrhea C. Fetal heart tones auscultated by Doppler D. Chadwick sign

C. Fetal heart tones auscultated by Doppler

A nurse is assisting with the care of a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ophthalmic ointment B. Conducting a newborn hearing screening C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease

C. Giving the hepatitis B vaccine

A nurse in an antepartum clinic is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Leg cramps B. Insomnia C. Glycosuria D. Leukorrhea

C. Glycosuria

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

C. Impaired placental perfusion

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal findings is a potential risk factor for pathological hyperbilirubinemia? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection

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

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

A nurse is assisting with the care of a client in the latent stage of labor who is reporting a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Encourage the client to use hydrotherapy B. Teach the client biofeedback to control labor pain C. Instruct the client about relaxation breathing techniques D. Administer a benzodiazepine medication

C. Instruct the client about relaxation breathing techniques

A nurse is reinforcing teaching with a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. Altered carbohydrate metabolism B. Hyperbilirubinemia C. Intracranial hemorrhage D. Hypoglycemia

C. Intracranial hemorrhage

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

C. Lightening

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

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

A nurse is collecting data from a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/min

C. Mottling

A nurse is collecting data from a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools

C. Nasal flaring

A nurse is collecting data from a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia

C. Neurological disorder

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

C. Nonreactive nonstress test

A nurse is caring for a client who is postpartum. The client suddenly appears restless and reports an inability to catch her breath. Which of the following actions should the nurse take? A. Evaluate vital sign trends, focusing on blood pressure history B. Review admission laboratory values, specifically hematocrit C. Notify the unit charge nurse and the rapid response team D. Ask the client about pain, urination, and lochia characteristics

C. Notify the unit charge nurse and the rapid response team

A nurse is calculating a client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? A. October 13 B. November 13 C. October 27 D. November 27

C. October 27

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

C. Oxytocin

A nurse is assisting with the care of a client who had a precipitous delivery. Which of the following items of data is the nurse's priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids

C. Palpating the client's fundus

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

C. Persistent vomiting

A nurse is assisting with the care of a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? A. Decrease IV fluids B. Give oxygen at 2 L/min via nasal cannula C. Place the client in a lateral position D. Administer indomethacin

C. Place the client in a lateral position

A nurse is reinforcing teaching with the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include? A. Position the child's car seat forward-facing at 1 year of age B. Place the retainer clip 2 inches above the newborn's umbilicus C. Place the shoulder harness in the slots that are level with the newborn's shoulders D. Position the newborn's car seat at a 20° angle in the vehicle

C. Place the shoulder harness in the slots that are level with the newborn's shoulders

A nurse enters the hospital room of client who has preeclampsia. The client is out of bed, falls, and begins having tonic-clonic convulsions. Which of the following actions should the nurse take? A. Go to the nurse's station to summon help B. Apply oxygen via non-rebreather mask C. Turn the client's head to the side D. Monitor the fetal heart rate

C. Turn the client's head to the side

A nurse is preparing to apply an external uterine activity monitor for a client who is at 36 weeks of gestation. Which of the following actions should the nurse plan to take? A. Place the client in a supine position with her knees bent for the test B. Place the tocotransducer just below the level of the client's umbilicus C. Validate the monitor tracing by palpating for contraction frequency D. Ask the client to press the sensor each time she feels a contraction

C. Validate the monitor tracing by palpating for contraction frequency

A nurse is assisting with the care of a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect? A. Urinary output of 40 mL/hr B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hands with prompt capillary refill

C. Weak and irregular pulse

A nurse in an antepartum clinic is collecting data from a client who is 2 weeks postpartum and reports vaginal discharge. Which of the following discharge characteristics should the nurse expect? A. Dark red uterine discharge B. Pinkish-brown vaginal discharge C. Yellowish-white uterine discharge D. Bright red vaginal discharge

C. Yellowish-white uterine discharge

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

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

A nurse is reinforcing teaching with the guardian of a newborn about formula preparation and feeding. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should use a quick-flow nipple for the first few weeks." B. "I should warm the formula before feeding my newborn." C. "I should use soft bottle nipples to encourage sucking." D. "I should discard any formula left in the bottle after a feeding."

D. "I should discard any formula left in the bottle after a feeding."

A nurse is reinforcing teaching with a client at 7 weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates to the nurse an understanding of the teaching? A. "I should eat fatty foods to increase my caloric intake." B. "I should brush my teeth right after eating." C. "Acupressure bands on my elbows might help me feel better." D. "I should have a small snack before bedtime."

D. "I should have a small snack before bedtime."

A nurse in an antepartum clinic is reinforcing teaching about recommended weight gain with a client who is at 12 weeks of gestation. The client has a documented prepregnancy BMI of 32. Which of the following client statements indicates an understanding of the teaching? A. "I should limit my weight gain to 40 pounds during pregnancy." B. "I should limit my weight gain to 35 pounds during pregnancy." C. "I should limit my weight gain to 25 pounds during pregnancy." D. "I should limit my weight gain to 20 pounds during pregnancy."

D. "I should limit my weight gain to 20 pounds during pregnancy."

A nurse is reinforcing teaching about dietary recommendations to prevent neural tube defects. Which of the following recommendations should the nurse include? A. Take a multivitamin every day B. Decrease consumption of mercury-containing fish C. Increase consumption of dairy products D. Begin taking a folic-acid supplement

D. Begin taking a folic-acid supplement

A nurse is reinforcing teaching about home care with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. "I should make sure the baby's bath water is between 115 and 120 degrees Fahrenheit." B. "I should let my baby sleep on the sofa until he is old enough to roll over." C. "I should ensure the airbag is functional when my baby is riding in the front seat of a car." D. "I should remove the bumper pad and stuffed toys from my baby's crib."

D. "I should remove the bumper pad and stuffed toys from my baby's crib."

A nurse is reinforcing discharge teaching with the parents of a newborn about home safety. Which of the following parent responses indicates an understanding of the instructions? A. "I should attach a soft bumper pad to the rails on the inside of my baby's crib." B. "I should place my baby in an infant carrier on the sofa for daytime napping." C. "I should change the smoke detector batteries in my baby's room once a year." D. "I should use my elbow to check the temperature of my baby's bath water."

D. "I should use my elbow to check the temperature of my baby's bath water."

A nurse is reinforcing teaching about lactation suppression with a client whose newborn will be bottle-fed. Which of the following client statements indicates understanding of the teaching? A. "I should lightly massage my breasts when I feel discomfort." B. "I should express a small amount of milk if my breasts feel tight." C. "I should take a warm shower twice a day." D. "I should wear a support bra for a few days."

D. "I should wear a support bra for a few days."

A nurse is reinforcing teaching about mastitis with a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."

D. "I will avoid any of my family members who are ill."

A nurse is reinforcing teaching with a client who has an intrauterine device (IUD). Which of the following client statements indicates an understanding of the instructions? A. "I will tell my doctor when I have my regular menstrual period." B. "I should let my doctor know if I can feel the strings of the device." C. "I should call my doctor if I experience a headache." D. "I will notify my doctor If I have pain during vaginal intercourse."

D. "I will notify my doctor If I have pain during vaginal intercourse."

A nurse is reinforcing teaching about newborn care with the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time." C. "I will use a cotton-tipped swab to clean my baby's ear canals." D. "I will place a hat on my baby's head prior to going outside."

D. "I will place a hat on my baby's head prior to going outside."

A nurse is reinforcing teaching about newborn safety with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm my baby's formula in the microwave on a low setting." C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."

D. "I will purchase a firm mattress for the crib."

A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "After boiling the water, I should allow it to cool for 45 min prior to mixing it with the formula." B. "I should add 2 scoops of powdered formula to an 8 oz bottle of water." C. "I can store prepared bottles in my refrigerator for 72 hr." D. "I will warm the bottle of formula by placing it in a pan of hot water."

D. "I will warm the bottle of formula by placing it in a pan of hot water."

A nurse is assisting with planning a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation? A. "Move the siblings out of their cribs and into beds 2 weeks prior to the baby's delivery." B. "Consider having siblings play in another room when feeding your newborn." C. "Have the sibling present during the discharge of your newborn from the hospital." D. "Involve the siblings in decorating your newborn's room."

D. "Involve the siblings in decorating your newborn's room."

A nurse is reinforcing teaching with the guardian of a newborn who has physiological jaundice. The guardian asks, "Why does my baby have this condition?" Which of the following responses should the nurse make? A. "Jaundice is associated with hypoglycemia." B. "Jaundice means that your child's iron levels are insufficient." C. "Jaundice occurs when there is an electrolyte imbalance." D. "Jaundice is related to increased levels of bilirubin."

D. "Jaundice is related to increased levels of bilirubin."

A nurse is reinforcing teaching with a group of clients about pregnancy prevention during the postpartum period. Which of the following statements should the nurse include? A. "Non-lactating clients can ovulate immediately after giving birth." B. "Non-lactating clients ovulate in their third month postpartum on average." C. "Lactating clients can ovulate as early as their first month postpartum." D. "Lactating clients ovulate in their sixth month postpartum on average."

D. "Lactating clients ovulate in their sixth month postpartum on average."

A nurse is reinforcing discharge teaching with the parent of a newborn regarding the immunization schedule. Which of the following parent statements indicates an understanding of the teaching? A. "My baby should not have a hepatitis B vaccine if I test negative." B. "My baby will receive the first varicella vaccine at 6 months." C. "My baby will start getting immunizations once daycare begins." D. "My baby will receive the next immunization at 2 months old."

D. "My baby will receive the next immunization at 2 months old."

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

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

A nurse is reinforcing teaching with a client who asks about using essential oils for her labor and delivery expected to occur next month. Which of the following responses should the nurse make? A. "Studies show that jasmine has an antidepressant effect during labor." B. "Studies show that the use of lavender is effective for strengthening contractions." C. "Studies do not promote diffusing essential oils during labor due to the possibility of respiratory compromise." D. "Studies show no evidence that essential oils improve labor outcomes."

D. "Studies show no evidence that essential oils improve labor outcomes."

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

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

A nurse is collecting data from a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling the blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking, causing the milk to flow, also makes the uterus contract."

D. "The same hormone that is released in response to the baby's sucking, causing the milk to flow, also makes the uterus contract."

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

D. "This medication can make you sleepy."

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

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

A nurse is assisting with the care of a client who is in labor. The client asks the nurse, "Why is the other nurse pressing on my abdomen?" Which of the following responses should the nurse make? A. "To determine your baby's heart rate" B. "To determine if you have sufficient fluid around your baby" C. "To make sure your baby moves with stimulation" D. "To determine the position of your baby"

D. "To determine the position of your baby"

A nurse is reinforcing teaching with a client who is breastfeeding about strategies to prevent mastitis. Which of the following instructions should the nurse include? A. "Take an herbal galactogogue." B. "Gradually increase the time between feedings." C. "Wear an underwire bra." D. "Use your finger to release suction after feeding."

D. "Use your finger to release suction after feeding."

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

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

A nurse is reinforcing teaching about air travel with a client who is at 35 weeks of gestation. Which of the following statements should the nurse make? A. "Security will allow you to avoid the metal detectors prior to your flight." B. "Limit your water intake before and during your flight." C. "You should plan to travel by car or train to avoid exposure to radiation." D. "Wear compression stockings and walk around often during your flight."

D. "Wear compression stockings and walk around often during your flight."

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan? A. "Your partner needs to be cultured and treated with metronidazole only if his cultures are positive." B. "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative." C. "If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse." D. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative."

D. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative."

A nurse is reinforcing nutritional teaching with a pregnant client who has a BMI of 32. Which of the following statements should the nurse make? A. "You should have considered losing weight before getting pregnant." B. "Your baby has a higher chance of low birth weight due to your BMI." C. "You might want to consider a weight-reduction diet." D. "You might be at risk for a longer hospital stay than planned."

D. "You might be at risk for a longer hospital stay than planned."

A nurse is reinforcing teaching about exercise during pregnancy with a client who is in her third trimester. Which of the following statements should the nurse include? A. "Soak in a hot tub to soothe sore muscles." B. "Relax in a supine position for 10 minutes after your exercise session." C. "It is common to experience dizziness when you exercise during pregnancy." D. "You should be able to carry on a conversation easily during exercise."

D. "You should be able to carry on a conversation easily during exercise."

A nurse is collecting data from a client with suspected hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first? A. Complete blood count B. Liver enzymes C. Bilirubin level D. Urine ketones

D. Urine ketones

A nurse is reinforcing teaching with a client who is at 10 weeks of gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse make? A. "You should eat foods served at warm temperatures." B. "You should brush your teeth right after you eat." C. "You should try to eat sweet foods when you feel nauseated." D. "You should eat dry foods that are high in carbohydrates when you wake up."

D. "You should eat dry foods that are high in carbohydrates when you wake up."

A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include? A. "Take 600 milligrams of ibuprofen as needed for discomfort." B. "You should eat soft cheeses to increase your calcium intake." C. "You should roll your nipples daily to ensure they are everted." D. "You should use fluoride-based toothpaste to prevent dental caries."

D. "You should use fluoride-based toothpaste to prevent dental caries."

A nurse is caring for 4 newborns. Which of the following findings should the nurse report to the provider? A. A 1-hour-old newborn who has a blood glucose of 55 mg/dL B. An 8-hour-old newborn who has a respiratory rate of 50/min C. A 24-hour-old newborn whose chest circumference is 32 cm D. A 12-hour-old newborn who has a heart rate of 70/min while sleeping

D. A 12-hour-old newborn who has a heart rate of 70/min while sleeping

A nurse is caring for a client who is pregnant and states she would like to find a midwife with the highest possible level of education. Which of the following should the nurse recommend? A. A community-based midwife B. A certified professional midwife C. A doula D. A certified nurse midwife

D. A certified nurse midwife

A nurse is assisting with the plan of care for a newborn. Which of the following prescriptions requires informed consent? A. Perform a universal newborn screening B. Conduct a newborn hearing screening C. Instill erythromycin ophthalmic ointment D. Administer the hepatitis B vaccine

D. Administer the hepatitis B vaccine

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously B. Administer erythromycin eye ointment within 12 hours C. Administer erythromycin eye ointment from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh

D. Administer vitamin K in the newborn's thigh

A nurse is assisting with the care of a client who delivered a stillborn child. Which of the following actions should the nurse take? A. Tell the parents that they should hold their child while they have the chance B. Stay with the parents as long as the child is still in the mother's room C. Discourage the parents from viewing any congenital anomalies the child has D. Allow the parents to keep the child in their room for as long as they wish

D. Allow the parents to keep the child in their room for as long as they wish

A nurse is collecting data from a client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? A. Administer a tocolytic medication B. Apply a heating pad to the mid abdominal area C. Reassess the fundus in 2 hr D. Ambulate the client to the bathroom

D. Ambulate the client to the bathroom

A nurse is assisting with the care of a client in active labor and notes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Administer methylprostaglandin IM B. Encourage the client to use the shower C. Place the client in a supine position D. Apply oxygen at 10 L/min via nonrebreather face mask

D. Apply oxygen at 10 L/min via nonrebreather face mask

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

D. Assist the client in breathing into a paper bag

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

D. Assist the client into a side-lying position and continue to monitor

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

D. Assist the client into a warm shower

A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? A. Place the client's hands in warm water B. Administer an analgesic to the client C. Pour water from a squeeze bottle over the client's perineum D. Assist the client to the bathroom

D. Assist the client to the bathroom

A nurse is assisting with the plan of care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks of gestation

D. At 28 weeks of gestation

A nurse is collecting data from a client who missed 2 menstrual cycles and states that she might be pregnant. Which of the following findings is a positive sign of pregnancy? A. Quickening B. Breast tenderness C. Uterine enlargement D. Auscultation of a fetal heart rate.

D. Auscultation of a fetal heart rate.

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

D. Barrel-shaped chest

A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicates the newborn's mother is HIV-positive and plans to breastfeed. Which of the following findings should the nurse address with the newborn's interdisciplinary team? A. Hepatitis B vaccine B. Antiretroviral regimen C. Vitamin K D. Breastfeeding

D. Breastfeeding

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse recommend? A. Discontinue therapy if a fine rash appears B. Place moisturizing lotion on the newborn's skin C. Supplement feedings with 1 oz of glucose water every 4 hours D. Change the newborn's position every 2 to 3 hours

D. Change the newborn's position every 2 to 3 hours

A nurse is collecting data from a client who is at 39 weeks of gestation and shows manifestations of labor. Which of the following findings should alert the nurse to notify the provider that the client is in true labor? A. Contractions felt in the upper abdomen B. Small amount of bloody discharge C. Contractions occurring every 2 to 10 min D. Changes in cervical dilation or effacement

D. Changes in cervical dilation or effacement

A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp

D. Check the integrity of the cord clamp

A nurse is assisting with the care of a client in the third stage of labor who is receiving IV oxytocin. Which of the following actions should the nurse take? A. Discontinue the client's infusion of IV oxytocin B. Check the client's vital signs once every 30 minutes C. Massage the client's fundus once every 90 minutes D. Clean the client's perineum with warm sterile water

D. Clean the client's perineum with warm sterile water

A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. Which of the following is an example of a teratogen? A. Consuming caffeine during pregnancy B. Family history of a genetic disorder C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy

D. Drinking alcohol during pregnancy

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

D. Encourage the client to interact with the newborn

A nurse is preparing to perform a blood draw on a client during her first prenatal visit. The client reports an extreme fear of needles causing anxiety during blood draws or injections. Which of the following actions should the nurse take? A. Keep the room quiet during the blood draw B. Ask the client if she currently takes lithium C. Request a prescription for pre-procedure lorazepam D. Encourage the client to practice deep breathing exercises

D. Encourage the client to practice deep breathing exercises

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. Extended periods of sleep B. Poor muscle tone C. Respiratory rate 50/min D. Exaggerated reflexes

D. Exaggerated reflexes

A nurse is providing care for a pregnant adolescent at 12 weeks of gestation who verbalizes a fear of gaining weight during her pregnancy. Which of the following actions should the nurse perform? A. Have the client watch a video on fetal growth and development during pregnancy B. Supply pamphlets that discuss the importance of nutrition during pregnancy C. Reinforce how poor nutrition can cause her baby not to grow properly D. Give examples of how eating well will help her to maintain a healthy weight during pregnancy

D. Give examples of how eating well will help her to maintain a healthy weight during pregnancy

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea

D. Gonorrhea

A nurse is reinforcing education with a client who is of childbearing age. The nurse should state that which of the following structures expels the mature ovum? A. Blastocyst B. Fallopian tube C. Corpus luteum D. Graafian follicle

D. Graafian follicle

A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect? A. Maternal serum alpha-fetoprotein B. Pregnancy-associated plasma protein A C. Chorionic villus sampling D. HbA1c

D. HbA1c

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

D. Ibuprofen

A nurse is assisting with the care of a client who is in the early stage of labor and has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions

D. Implement seizure precautions

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

D. Instruct the client to apply cold compresses.

A nurse is assisting with the care of a newborn who has a positive Ortolani sign. Which of the following manifestations should the nurse expect? A. Decreased tongue mobility B. Decreased bone growth C. Irregular indentation of the lower sternum D. Irregular development of the hip socket

D. Irregular development of the hip socket

A nurse is assisting with the care of a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate D. Prepare the client for an emergency cesarean delivery

D. Prepare the client for an emergency cesarean delivery

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

D. Prepare the client for delivery

A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? A. Elevated serum potassium level B. Rapid weight gain C. Peripheral edema D. Presence of ketones in the urine

D. Presence of ketones in the urine

A nurse is assisting with care for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development? A. Avoid swaddling B. Place the infant in the supine position C. Provide physical care at short, frequent intervals D. Reduce ambient noise and lighting

D. Reduce ambient noise and lighting

A client who is pregnant tells the nurse that she is financially unable to buy the food and vitamins recommended during pregnancy. Which of the following actions should the nurse suggest when contributing to the plan of care for the client? A. Teach the client that improper nutrition could lead to birth defects in her baby B. Instruct the client to return to the clinic for a weekly weigh-in for the remainder of the pregnancy C. Provide the client with sample menus to aid in nutritious meal preparation D. Refer the client to a community resource that could assist with providing nutrition

D. Refer the client to a community resource that could assist with providing nutrition

A nurse is reviewing the fetal heart tracings for a client in labor and notes variable decelerations. Which of the following actions should the nurse take? A. Request a prescription for oxytocin B. Administer oxygen at 2 L/min via nasal cannula C. Prepare for the insertion of an intrauterine balloon D. Reposition the client from side to side

D. Reposition the client from side to side

A nurse in a prenatal clinic is preparing to check a client's blood pressure. Which of the following actions should the nurse plan to take? A. Ensure the client's feet are dangling B. Place the client's arm across her abdomen with her hand in her lap C. Allow the client to sit quietly for 2 to 3 minutes before checking her blood pressure D. Select a cuff that covers about 80% of the client's upper arm

D. Select a cuff that covers about 80% of the client's upper arm

A nurse is reinforcing teaching with the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to take? A. Maintain bright lighting to enable close observation of the infant at all times B. Place the infant in the prone position with arms and legs extended C. Rouse the infant every 1 to 2 hr to provide auditory and visual stimulation D. Teach the parent to provide kangaroo care for the infant

D. Teach the parent to provide kangaroo care for the infant

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. The client's temperature measures 101.9°F (38.8°C) 3 hours following delivery. B. Lochia is red with small clots and mucus 2 days after delivery. C. Client reports abdominal pain 48 hours after delivery when the newborn is breastfeeding. D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery

D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery

A nurse is reinforcing teaching about the process of involution with a client who is postpartum. Which of the following pieces of information should the nurse provide? A. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor. B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery. C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum. D. The fundus is not palpable abdominally at 2 weeks postpartum.

D. The fundus is not palpable abdominally at 2 weeks postpartum.

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

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

A nurse is preparing to provide care for a newborn with a light skin tone who was recently assigned an Apgar score of 2 for color. Which of the following findings should the nurse expect to observe in the newborn? A. The newborn's skin will appear blue. B. The newborn's skin will appear pale. C. The newborn's skin will appear mostly pink with blue extremities. D. The newborn's skin will appear completely pink all over.

D. The newborn's skin will appear completely pink all over.

A nurse is collecting data from a male newborn. Which of the following findings should the nurse report to the provider? A. Superficial cracking and peeling are evident on the skin of the hands and feet. B. The palmar grasp occurs spontaneously when the newborn is sucking. C. The bulge of the testes is palpable in the inguinal canal. D. There is decreased abdominal movement with breathing.

D. There is decreased abdominal movement with breathing.

A nurse is assisting with the care of a client in labor. Her cervix is dilated to 9 cm, and she has strong contractions every 2 min that last 75 sec. The nurse should recognize that this client is in which of the following phases or stages of labor? A. Latent phase of first stage B. Active phase of first stage C. Second stage D. Transition phase of first stage

D. Transition phase of first stage

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? A. Weak cry B. Absent Moro reflex C. Constipation D. Tremors

D. Tremors

A nurse is collecting data from a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider? A. Respiratory rate 14/min B. Temperature 37.8°C (100°F) C. Dizziness upon rising D. Urine output 20 mL/hr

D. Urine output 20 mL/hr

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

D. Use additional pillows to support extremities and abdomen

A nurse is caring for a client who has preeclampsia and is postpartum. Which of the following actions should the nurse implement when measuring the client's blood pressure? A. Encourage the client to take a walk in the halls prior to measuring blood pressure B. Hold the client's arm above heart level during the measurement C. Choose a cuff that covers 50% of the client's upper arm D. Use the Korotkoff phase V to record the diastolic value

D. Use the Korotkoff phase V to record the diastolic value

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

D. Vitamin C

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Don sterile gloves prior to puncturing the newborn's heel B. Puncture the center aspect of the newborn's heel C. Elevate the newborn's heel prior to the procedure D. Warm the heel with a warm washcloth prior to the procedure

D. Warm the heel with a warm washcloth prior to the procedure

A nurse is preparing to administer vitamin K IM to a newborn. Which of the following actions should the nurse plan to take? A. Identify the injection site on the dorsogluteal muscle B. Apply sterile gloves prior to administration C. Insert the needle at a 30° angle D. Withdraw the needle quickly after administration

D. Withdraw the needle quickly after administration

A nurse is collecting data from a newborn who is 18 hours old. Which of the following findings should be reported to the provider? A. Blood-tinged discharge from the vagina B. Overlapping sutures on the skull C. Subconjunctival hemorrhage D. Yellow tinge to the skin

D. Yellow tinge to the skin