Maternal and Newborn Exam 2/Final
Which situation should concern the nurse treating a postpartum client within a few days of birth?
The client feels empty since she gave birth to the neonate
The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)?
The client has a history of IV drug use, client has a history of STIs
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?
The client has a history of cardiac disease.
The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment?
The client has a history of hypertension
The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?
The client is measuring normal for gestational age.
A nurse is caring for a postpartum client with a platelet count of 15,000/ml and has been diagnosed with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?
administration of platelet transfusions as prescribed
A woman comes to the clinic because she has been unable to conceive. When reviewing the woman's history, the nurse would least likely identify which factor as a possible risk?
age of 25 years
The nurse is assessing a client for amenorrhea. During the assessment, the nurse notes facial hair and acne. The nurse knows this could be related to:
an androgen excess secondary to a tumor
The nurse should carefully monitor which neonate for hyperbilirubinemia?
neonate with ABO incompatibility
After the nurse teaches a client about ways to reduce the symptoms of premenstrual syndrome, which client statement indicates a need for additional teaching?
"I will make sure to take my estrogen supplements a week before my period."
When developing a teaching plan for a couple who are considering contraception options, the nurse would include which statement?
"The best contraceptive is one that you will use correctly and consistently."
A nurse is assessing the perineum of a postpartum woman using the REEDA scale. The woman is one day postpartum. The nurse notes that the woman has serous discharge. Which score would the nurse assign this finding?
1
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?
1 cm below the umbilicus
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum
The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Naegele's rule, what date later that same year will the nurse relay as the client's due date?
11/16
A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2021, and ended the menses on March 14, 2021. Using Naegele's rule, the nurse should tell the client that the estimated date of delivery is what date?
12/14/21
A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn?
24 oz
How long is the neonatal period for a newborn?
28 days
A nurse is reviewing the medical records of several newborns who are about to be discharged. The nurse notes the birth weight of each newborn, classifying the newborn with which birth weight as term?
3,500 grams
A nurse is assessing a newborn and obtains the newborn's head circumference. The head circumference is 35 cm. The nurse then measures the newborn's chest circumference. Which chest circumference measurement would the nurse document as expected and within normal parameters?
33 cm
A client with severe preeclampsia is receiving intravenous magnesium sulfate. The nurse is reviewing the laboratory results and determines that which magnesium level is within the therapeutic range?
5 mEq/L (2.5 mmol/L)
When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids?
6 to 8
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:
7 to 10
A nurse is assessing the perineum of several postpartum clients using the REEDA score. The nurse initiates interventions to minimize the risk for postpartum infection for the client with which score?
9
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider (PHCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the PHCP has documented the results as negative. How should the nurse interpret this finding?
A normal test result
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?
A normal test result
The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?
Ambulate the client as soon as her vital signs are stable
A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?
A private room 2 doors away from the nurses' station
A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond?
A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen
A postmenopausal woman presents to the clinic with painless vaginal bleeding. The health care provider wants to assess for endometrial cancer. The nurse would anticipate the health care provider ordering which procedure first?
A transvaginal ultrasound
A client diagnosed with severe preeclampsia is receiving magnesium sulfate by continuous intravenous infusion. Which assessment finding would indicate that the medication should be discontinued?
Absence of deep tendon reflexes
A nurse is caring for a pregnant client and discovers signs of bruises near her neck. On questioning, the nurse learns that the bruises were caused by her husband. The client tells the nurse that her husband had stopped abusing her some time ago, but this was the first time during the pregnancy that she was assaulted. She blames herself because she admits to not paying enough attention to her husband. Which facts about abuse during pregnancy should the nurse tell the client to convince her that the abuse was not her fault?
Abuse is a result of resentment toward the interference of the growing fetus and changes in the woman's shape, abuse is a result of the perception of the partner that the baby will be a competitor after he or she is born, abuse is a result of insecurity and jealousy of the pregnancy and the responsibilities it brings
A client who reported changes in her normal voiding patterns and altered bowel habits is diagnosed with polycystic ovarian syndrome. Which instruction is most appropriate for the nurse to provide the client to help alleviate her condition?
Adhere to follow-up care
A client has undergone an abdominal hysterectomy to remove uterine fibroids. Which interventions should a nurse perform as part of the postoperative care for the client?
Administer analgesics promptly and use a patient-controlled analgesia pump, frequent ambulation, administer antiemetics to control nausea and vomiting
A pregnant client is diagnosed with AIDS. Which of the following interventions should the nurse undertake to minimize the risk of transmission of AIDS to the infant?
Administer antiretroviral syrup to the infant within 12 hours after birth
A nurse is caring for a rape victim who was just brought to the local emergency care facility. Which interventions should the nurse perform to minimize risk of pregnancy in this client?
Administer prescribed double dose of emergency contraceptive pills
Which risk factors are associated with vaginal cancer?
Advancing age, HIV infection, Smoking
A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required?
After this surgery is done tomorrow, my baby will be able to eat and drink
A nurse is assessing a 45-year-old client for uterine fibroids. Which are the predisposing factors for uterine fibroids?
Age, nulliparity, obesity
A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement?
All congenital disorders can be diagnosed at birth
The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid?
Allows for fetal movement, Surrounds, cushions, and protects the fetus, Maintains the body temperature of the fetus, Can be used to measure fetal kidney function
A client is receiving treatment for injuries sustained during a fight with her partner. The nurse observes that the partner visits her daily in the hospital and appears very solicitous and contrite. When questioned, the client tries to convince the nurse that her partner always apologizes and brings gifts after a fight. Which information should the nurse provide this client?
Although your partner seems sorry, often they will repeat this behavior in the future
A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse include in the teaching?
An external monitor is attached in order to view fetal heart rate response to an established contraction pattern, The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation
The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement?
An increase in pulse rate occurs
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?
An informed consent needs to be signed before the procedure
The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?
Anesthetic may not be effective during the procedure
A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?
Apply ice
A nurse is interviewing a rape victim who was assaulted 6 months ago. Which questions should the nurse ask the client to know the extent of physical symptoms of PTSD?
Are you having trouble sleeping, have you felt irritable or experienced outbursts of anger, do you have heart palpitations or sweating, do you ever feel as if you are reliving the event
A client arrives at the health care facility reporting a lump that she felt during her breast self-examination. Upon diagnosis, the physician suspects fibroadenomas. Which question should the nurse ask when assessing the client?
Are you lactating?
A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?
Ask to see the woman's hospital identification badge
The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client?
Assess blood pressure, check urine for protein, assess deep tendon reflexes, teach the importance of keeping track of daily weight
A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?
Assess for pedal edema
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema
A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take?
Assess the bilirubin level
A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment?
Assess the client's uterine tone, Monitor the client's vital signs, Get a pad count
The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature?
Assure the newborn has a cap on the head and is kept covered
A woman comes to a local community health care facility with her partner. She has a broken arm and bruises on her face that she reports were caused by a fall. The nature of the injuries, however, causes the nurse to be convinced that this is a case of physical abuse. Which intervention should the nurse perform?
Attempt to interview the woman in private
A female client is prescribed metronidazole for treatment of trichomoniasis. Which of the following instructions should the nurse give the client undergoing treatment?
Avoid alcohol
A 33-year-old female client reports yellow nipple discharge and pain in her breasts a week before menses that dissipates on the onset of menses. Diagnosis reveals that the client is experiencing fibrocystic breast changes. Which instructions should the nurse offer the client to help alleviate the condition?
Avoid caffeine, maintain a low-fat diet, take diuretics as recommended
A 19-year-old female client has been diagnosed with pelvic inflammatory disease due to untreated gonorrhea. Which of the following instructions should the nurse offer when caring for the client?
Avoid douching vaginal area, complete the antibiotic therapy, limit the number of sexual partners
A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching?
Avoid over-the-counter (OTC) salicylates
A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?
BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min.
The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy?
Ballottement,Chadwick's sign,Uterine enlargement,Positive pregnancy test
Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?
Bathe the baby under a radiant warmer.
Rho(D) immune globulin is prescribed for a client after delivery, and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?
Being affected by Rh incompatibility
A nurse is caring for a client who is being hospitalized for physical injuries. She later confides to the nurse that the injuries are a result of a physical assault by her partner when he was drunk. The client feels degraded and ashamed but realizes that her partner was under the influence of alcohol. How should the nurse respond to this client?
Being drunk is not an excuse for physically assaulting an intimate partner
A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication?
Betamethasone
A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?
Bilirubin level went from 15 to 11
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
Bladder distention
A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?
Blood Pressure
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority assessment?
Blood pressure
Methylergonovine is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter?
Blood pressure
The nurse is reviewing the record of a pregnant woman and notes that the primary health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign?
Bluish discoloration of cervix and vagina
A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client?
Body secreting the excess fluids from pregnancy
The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain?
Calcium gluconate injection
A nurse caring for a 16-year-old female immigrant. The nurse wishes to assess if the client is a victim of human trafficking. Which questions should the nurse ask?
Can you leave your job or situation if you wish, can you come and go as you please, is there a lock on your door at home so you cannot get out
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition?
Caput succedaneum
The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?
Caregivers can demonstrate competency in caring for the infant and ask questions
A client needs additional information about the cervical mucus ovulation method after having read about it in a magazine. She asks the nurse about cervical changes during ovulation. About which should the nurse inform the client?
Cervix is high or deep in the vagina
A nurse is required to assess a client complaining of unusual vaginal discharge for bacterial vaginosis. Which of the following is a classic manifestation of this condition that the nurse should assess for?
Characteristic "stale fish" odor
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?
Check blood glucose
The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next?
Check for bladder distention, while encouraging the client to void
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?
Check the identification badge of any health care worker before releasing baby from room
A 40-year-old client reports low back pain after standing for a long time. The primary care provider has diagnosed the client with pelvic organ prolapse. The nurse correctly recognizes which clients are likely not candidates for corrective surgery.
Client at high risk of recurrent prolapse after surgery, client who is morbidly obese before surgery, client who has chronic obstructive pulmonary disease
Mammography is recommended for a client diagnosed with intraductal papilloma. Which factor should the nurse ensure when preparing the client for a mammography?
Client has not applied deodorant on the day of testing
Lumpectomy is a treatment option for clients diagnosed with breast cancer with tumors smaller than 5 cm. For which clients is lumpectomy contraindicated?
Client who has had previous radiation to the affected breast, client whose connective tissue is reported to be sensitive to radiation, client whose surgery will not result in a clean margin of tissue
It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?
Client's temperature remains below 100.4°F (38.8°C) orally
A healthy 28-year-old female client who has a sedentary lifestyle and is a chain smoker is seeking information about contraception. The nurse informs this client of the various risks of each. Which should the nurse recognize as contraindicated in the case of this client?
Combination oral contraceptives
The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement, the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness?
Compression of the vena cava
A nurse manager in a family planning clinic is conducting an in-service presentation for the nursing staff on contraception. After teaching the group about the different methods for contraception, the manager determines that the teaching was successful when the group identifies which contraceptive methods as mechanical barrier methods?
Condom, cervical cap, diaphragm, cervical sponge
A client reports that she has multiple sex partners and has a lengthy history of various pelvic infections. She would like to know if there is any temporary contraceptive method that would suit her condition. Which should the nurse suggest for this client?
Condoms
After discussing various methods of contraception with a client and her partner, the nurse determines that the teaching was successful when they identify which contraceptive method as providing protection against sexually transmitted infections (STIs)?
Condoms
A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?
Conduction
The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?
Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh
What two elements play the biggest role in becoming a mother after delivery of her newborn?
Love and attachment to the child and engagement with the child
A female client with a malignant tumor of the breast has to undergo chemotherapy for a period of 6 months. For which side effect should the nurse monitor when caring for this client?
Constipation
A nurse is caring for a client who has just had her intraductal papilloma removed through a surgical procedure. What instructions should the nurse give this client as part of her care?
Continue monthly breast self-examinations
A nurse is caring for a female client with urinary incontinence. Which instructions should the nurse include in the client's teaching plan to reduce the incidence or severity of incontinence?
Continue pelvic floor exercises, increase fiber in diet, control blood glucose levels
A nurse is caring for a female client undergoing radiation therapy after her breast surgery. The client is refusing to eat and states she does not have a desire to eat at this time. Which action should the nurse take first?
Continue to monitor the client
Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?
Convection
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?
Convection
A 41-year-old female client arrives at a health care setting reporting dull nipple pain with a burning sensation, accompanied by pruritus around the nipple. The physician suspects mammary duct ectasia. Which order should the nurse question?
Cool compresses to the affected area
The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?
Cover the glans generously with petroleum jelly
The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?
Creases on two-thirds of the foot
The nurse is caring for a client at the ambulatory care clinic who questions the nurse for information about contraception. The client reports that she is not comfortable about using any barrier methods and would like the option of regaining fertility after a couple of years. Which method should the nurse suggest to this client?
CycleBeads or medroxyprogesterone injection
A client states that she is to have a test to measure bone mass to help diagnose osteoporosis. The nurse would most likely plan to prepare the client for:
DEXA scan.
The nurse in the postpartum unit notes that a new mother was given methylergonovine intramuscularly following delivery. What assessment finding indicates that the medication was effective?
Decreased uterine bleeding
A couple is being assessed for infertility. The male partner is required to collect a semen sample for analysis. What instruction should the nurse give him?
Deliver sample for analysis within 1 to 2 hours after ejaculation
A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?
Demonstrating how to do cord care on the newborn
A nurse is caring for a client who has been admitted with an ear infection. While discussing her partner with the nurse, the client says that her lover's behavior is "threatening" and "intimidating" at times, even though he has not physically harmed her. She wants to know what emotional abuse is. Which statement best describes an example of emotional abuse?
Destroying valued possessions or attacking pets
The nurse discusses various contraceptive methods with a client and her partner. Which method would the nurse explain as being available only by prescription?
Diaphragm
During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement?
Diet and insulin needs change during pregnancy
A nurse working in a community health education program is assigned to educate community members about STIs. Which of the following nursing strategies should be adopted to prevent the spread of STIs in the community?
Discuss limiting the number of sex partners
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?
Diuresis
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?
Do you plan to have any other children?
During a woman's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What should be the nurse's next intervention?
Document findings in the electronic health record
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?
Document normal findings
A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take?
Document the data
A 52-year-old female client with an estrogen receptors positive (ER+) breast cancer is undergoing hormonal therapy. While taking a selective estrogen receptor modulator (SERM), the client begins to experience hot flashes. What should the nurse do next?
Document the hot flash in the client's chart
The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?
Document the lochia as scant
The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food?
Dried fruits
The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid?
Dried peas
The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure?
Drink 8 glasses of water per day
The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction?
During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection
Which finding would the nurse expect to find in a client with endometriosis?
Dyspareunia
A client presents for her annual Pap test. She wants to know about the risk factors that are associated with cervical cancer. Which should the nurse inform the client is a risk factor for cervical cancer?
Early age at first intercourse
A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms?
Eating dry crackers before arising
A client has undergone a mastectomy for breast cancer. Which instruction should the nurse include in the postsurgery client teaching plan?
Elevate the affected arm on a pillow
A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client?
Encourage an oral intake of 2 to 3 liters per day
When working in a local community health care center, a nurse is frequently asked about cervical cancer and ways to prevent it. Which information should be provided by the nurse?
Encourage cessation of smoking and drinking, encourage prevention of sexually transmitted infections to reduce risk factors, counsel teenagers to avoid early sexual activity
The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention?
Encourage fluid intake
On assessment, a newborn is exhibiting cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the primary health care provider (PHCP) prescribes surfactant replacement therapy. Through which route should the nurse prepare to administer this medication?
Endotracheally through the endotracheal tube
A pregnant woman of 30 weeks' gestation is admitted to the maternity unit in preterm labor. The woman asks the nurse about the purpose of betamethasone, which has been prescribed by the primary health care provider (PHCP). The nurse should tell the client that the medication will promote which action?
Enhance fetal lung maturity
A nurse is developing a plan of care for a postpartum woman, newborn, and partner to facilitate the attachment process. Which intervention would be appropriate for the nurse to include in the plan?
Ensure early and frequent parent-newborn interactions
A nurse is working in a community hospital situated in an area with a history of grievous assaults on women, including rape. The nurse discovers that most rape victims come to the hospital but leave without seeking medical treatment. Which intervention should the nurse perform to ensure that rape victims get legal and medical aid?
Ensure that the appropriate law enforcement agencies are apprised of the incident
The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?
Escherichia coli
A nurse is caring for a client for whom estrogen replacement therapy has been recommended for pelvic organ prolapse. Which nursing intervention is the most appropriate for the nurse to implement before the start of therapy?
Evaluate the client to validate her risk for complications
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?
Evaporative
A client complaining of genital warts has been diagnosed with HPV. The genital warts have been treated, and have disappeared. Which of the following should the nurse include in the teaching plan when educating the client about the condition?
Even after warts are removed, HPV still remains
The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?
Evidence of bleeding, such as in the gums, petechiae, and purpura
The nurse is caring for a newborn who was delivered via a planned cesarean birth. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?
Excessive fluid in the infant's lungs, making respiratory adaptation more challenging
The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?
Expose the newborn's bottom to air several times a day
A nurse is assigned to educate a group of women on cancer awareness. Which risk factors for breast cancer are modifiable?
Failing to breastfeed for up to a year after pregnancy, postmenopausal use of estrogen and progestins, not having children until after age 30
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours
A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother?
Feeding the infant more formula whenever she begins to fuss
Myomectomy is recommended to a client for removal of uterine fibroids. The client is concerned about the surgery and wants to know if there are any associated disadvantages. Which is a disadvantage of myomectomy?
Fibroids may grow back
A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?
Finish all antibiotics to decrease a genital tract infection
The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication?
Flushing, depressed respirations, extreme muscle weakness
The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding?
Fundus is at the appropriate level
The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?
G = 2, T = 1, P = 0, A = 0, L = 1
A nurse is caring for a client who has been diagnosed with genital warts due to HPV. The nurse explains to the client that HPV increases the risk of vulvar cancer. Which preventative measure to reduce the risk of vulvar cancer should the nurse explain to the client?
Genital examination should be done by the client
A nurse needs to assess a female client for primary stage herpes simplex virus infection. Which of the following symptoms related to this condition should the nurse assess for?
Genital vasicular lesions
The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex?
Gently stroke the newborn's cheek
A nurse is conducting an AIDS awareness program for women. Which of the following instructions should the nurse include in the teaching plan to empower women to develop control over their lives in a practical manner so that they can prevent becoming infected with HIV?
Give opportunities to practice negotiation techniques, encourage women to develop refusal skills, encourage women to use female condoms
A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information?
HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test
A nurse is educating a client on the technique for performing breast self-examination. Which instruction should the nurse include in the teaching plan with regard to the different degrees of pressure that need to be applied to the breast?
Hard pressure applied down to the ribs
The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?
Harm to self
An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur?
Naloxone
A client complaining of genital ulcers has been diagnosed with syphilis. Which of the following nursing interventions should the nurse implement when caring for the client?
Have the client urinate in water if urination is painful, instruct the client to wear nonconstricting, comfortable clothing
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?
Have the client void, and then massage the fundus until it is firm
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions?
Help the mother initiate breastfeeding within 30 minutes of birth, Encourage breastfeeding of the newborn infant on demand, Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother
Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution?
Her uterus is at the level of the umbilicus
When developing a teaching plan for a community group about HIV infection, which group would the nurse identify being most vulnerable for HIV infection?
Heterosexual women
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion?
History of syphilis
A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?
Hold the baby frequently
New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents?
Holding and comforting the newborn will not cause the infant to become spoiled
In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?
How much blood was on the two pads?
A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant?
Hydrocephalus
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
Hyperbilirubinemia
The nurse is examining the morning laboratory results of the newborns of mothers with diabetes. Which report finding should the nurse prioritize?
Hypocalcemia
A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement?
I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?
I didn't realize all that went into being a dad. I wasn't prepared for this.
The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation?
I don't like my face anymore. I always look like I have been crying
The nurse has a routine prescription to administer an injection of phytonadione (vitamin K) to the newborn. Which statement made by the new mother indicates that teaching on this medication was effective?
I know that this medication is used to prevent clotting abnormalities in the newborn
The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?
I need to lie flat on my back to perform the procedure.
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?
I should avoid exercise because of the negative effects on insulin production.
A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs?
I should avoid stressful situations
A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction?
I should do more exercises to strengthen my back muscles.
A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement?
I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water
A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction?
I should drink unpasteurized milk only
A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures?
I should wear underwear with a cotton panel liner
The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem?
I want to gain only 10 pounds because I want to have a small, petite baby
The nurse is teaching a woman in her first trimester measures to alleviate nausea and vomiting. Which statement by the woman indicates that further teaching is required?
I will eat dry crackers for breakfast after I get up
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?
I will eat fresh fruits and vegetables for snacks and for dessert each day
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutritional measures to minimize this problem?
I will eat fresh fruits and vegetables for snacks and for dessert each day.
The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed about administration of the eye medication?
I will flush the eyes after instilling the ointment
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?
I will maintain strict bed rest throughout the remainder of the pregnancy.
The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?
I will need to increase my insulin dosage during the first 3 months of pregnancy.
A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly?
I will need to prepare myself and my family for the loss of this pregnancy
Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma?
Impaired urinary elimination
A nurse is caring for a female client with symptoms of first-degree pelvic organ prolapse. Which instruction related to dietary and lifestyle modifications should the nurse provide to the client to help prevent pelvic relaxation and chronic problems later in life?
Increase dietary fiber
A female client who has a 2-month-old infant arrives at a health care facility reporting flu-like symptoms with fever and chills. When examining the breast, the nurse observes an increase in warmth. Which instruction should the nurse provide the client to help her cope with the condition?
Increase fluid intake
The nurse is instructing a client with dysmenorrhea on how to manage her symptoms. Which should the nurse include in the teaching plan?
Increase water consumption, use heating pads or take warm baths, increase exercise and physical activity
The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment?
Increased insulin
A 62-year-old female client arrives at a health care facility reporting skin redness in the breast area, along with skin edema. The physician suspects inflammatory breast cancer. For which symptom of inflammatory breast cancer should the nurse assess?
Increased warmth to the breast
A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority?
Ineffective thermoregulation related to decreased amount of subcutaneous fat
The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2F (38.4C), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?
Infection
A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?
Inform the client that these contractions are common and may occur throughout the pregnancy.
A client would like some information about the use of a cervical cap. Which information should the nurse include in the teaching plan of this client?
Inspect the cervical cap before insertion, wait for 30 minutes after insertion before engaging in intercourse, do not use the cervical cap during meses
A pregnant client has been diagnosed with gonorrhea. Which of the following nursing interventions should be performed to prevent gonococcal ophthalmia neonatorum in the baby?
Instill a prophylactic agent in the eyes of the newborn
A nurse who is conducting sessions on preventing the spread of STIs in a particular community discovers that there is a very high incidence of hepatitis B in the community. Which of the following measures should she take to ensure the prevention of the disease?
Instruct people to get vaccinated for hepatitis B
The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority?
Insufficient fluid volume
When teaching a postpartum client about possible complications following the birth, which would be the best information to include?
Interference with the maternal-newborn attachment process
A client diagnosed with fibroadenoma is worried about the chance of developing breast cancer. She also asks the nurse about various breast disorders and their risks. Which benign breast disorder should the nurse include as having the greatest risk for the development of breast cancer?
Intraductal papilloma
The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route?
Intratracheal
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
Involution
The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions?
Iron supplements may give me constipation
A nurse is conducting a session on education about cancers of the reproductive tract and is explaining the importance of visiting a health care professional if certain unusual symptoms appear. Which should the nurse include in her list of symptoms that merit a visit to a health care professional for further evaluation?
Irregular vaginal bleeding, persistent low backache not related to standing, elevated or discolored vulvar lesions
A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?
Isoniazid plus rifampin will be required for 9 months.
A client has been following the conventional 28-day regimen for contraception. She is now considering switching to an extended oral contraceptive (OC) regimen. She is seeking information about specific safety precautions. Which is true for the extended OC regimen?
It carries the same safety profile as the 28-day regimen
The senior nursing student is assigned to care for a client with severe preeclampsia who is receiving an intravenous infusion of magnesium sulfate. The co-assigned registered nurse asks the student to describe the actions and effects of this medication. Which statement, if made by the student, indicates the need for further teaching?
It increases acetylcholine, blocking neuromuscular transmission
A nurse is assessing the congenital reflexes of a newborn. The newborn's parent is watching the nurse and asks, "Why are you testing these things?" Which response by the nurse is appropriate?
It is a way for us to check your newborn's brain and nerve function
The nursing instructor asks a nursing student who is preparing to assist with the assessment of an 18 weeks' gestation gravida 2, para 1 (G2P1) pregnant woman to describe expectations related to the process of quickening. Which statements, if made by the student, indicate an understanding of this process?
It is the fetal movement felt by the mother, it is typically felt by the multigravida client between 16 to 18 weeks gestation
Which purposes of placental functioning should the nurse include in a prenatal class?
It is the way the baby gets food and oxygen, It provides an exchange of nutrients and waste products between the mother and developing fetus
The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?
It keeps alveoli from collapsing with breaths
The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?
It promotes the fertilized ovum's normal implantation in the top portion of the uterus.
It is recommended that a 48-year-old female client with breast cancer undergo a sentinel lymph node biopsy before a lumpectomy. The client asks the nurse the reason for removing the sentinel lymph node. Which statement will the nurse make?
It will prevent lymphedema, which is a common side effect
A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?
It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness
The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be sure to include in the presentation?
Jitteriness, Lethargy, Seizures
A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Naegele's rule, which expected date of delivery should the nurse document in the client's chart?
July 26, 2021
A client comes to the clinic with abdominal pain. Based on her history the nurse suspects endometriosis. The nurse expects to prepare the client for which evaluatory method to confirm this suspicion?
Laparoscopy
A client is to be examined for the presence and extent of endometriosis. For which test should the nurse prepare the client?
Laparoscopy
The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet?
Leafy green vegetables
A 52-year-old client is seeking treatment for menopause. She is not very active and has a history of cardiac problems. Which therapy option should the nurse recognize as contraindicated for this client?
Long-term hormone replacement therapy
The endometrial biopsy of a client reveals cancerous cells, and the primary health care provider has diagnosed it as endometrial cancer. Which responsibilities of the nurse are part of the treatment of the client?
Make sure the client understands all the available treatment options, inform the client about the possible advantages of a support group, off the family explanations and emotional support throughout the treatment
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?
Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure
The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action?
Massaging the abdomen during contractions, using both hands in a circular motion
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?
Mastitis
During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia?
Maternal infection
A nurse is working in a local community health care facility where she frequently encounters victims of abuse. For which signs should the nurse assess to find out if a client is a victim of abuse?
Mental health problems such as depression, anxiety, or substance abuse, injuries on the face, head, and neck, reported history of the injury is inconsistent with the presenting problem
The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents?
Monitor for appropriate weight gain patterns
A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit?
Monitor for fetal movement
The nurse is assisting with the circumcision of a male infant. Which nursing intervention is priority immediately after the procedure?
Monitor the site for bleeding
The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority?
Monitoring the apical pulse
A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension?
My vision for the past 2 days has been really fuzzy
A client who has come to the clinic is diagnosed with endometriosis. What would the nurse expect the primary care provider to prescribe as a first-line treatment?
NSAIDs
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?
Neglects to engage or provide care or show interest in infant
Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents?
Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss.
A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?
Newborns have the ability to focus only on objects in close proximity
A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client?
No action is need; this is normal
The primipara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?
No, it is the Moro reflex. This reflex simulates the action of warding off an attacker.
The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record?
Normal
A female client with metastatic breast disease is receiving trastuzumab as part of her immunotherapy. The client has nausea, fatigue, and diarrhea, appears jaundiced, and has a distended abdomen. What would the nurse do next?
Notify the health care provider
The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action?
Notify the primary health care provider (PHCP).
The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client?
Obtain nutritional counseling with a dietician, plan weekly nonstress tests starting at 32 weeks
A nurse is caring for a female client who is undergoing treatment for genital warts due to HPV. Which of the following information should the nurse include when educating the client about the risk of cervical cancer?
Obtaining Pap smears regularly helps early detection of cervical cancer, recurrence of genital warts increases the risk of cervical cancer, use of latex condoms is associated with a lower rate of cervical cancer
The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?
Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably
A nurse observes telltale signs of injuries from physical abuse on the face and neck of a female client. When questioned, the client tells the nurse that the injuries are the result of a physical attack by her partner and that she has developed palpitations thereafter. Which action should the nurse take to gain the trust of the client and enhance the nurse-client relationship?
Offer referrals so the client can get help that will allow her to heal
The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item?
Orange juice
A nurse is observing the interaction between a new mother and the neonate. The nurse notes that the neonate moves the head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?
Orientation
A woman has opted to use the basal body temperature method for contraception. The nurse instructs the client that a rise in basal body temperature indicates which event?
Ovulation
The nurse is caring for a neonate. Which is the most important step the nurse can take to prevent and control infection?
Practice meticulous handwashing
The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process?
Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?
Ovulation may return as soon as 3 weeks after birth
A nurse is explaining to new parents about the numerous changes that occur shortly after birth to the newborn. When describing how the ductus arteriosus closes, the nurse explains that which factor is most important to assist in its closure?
Oxygen
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?
Oxytocin
The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?
Pad count
A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client?
Pain, itching, and vaginal discharge
A nurse is educating a 25 year old client with a family history of cervical cancer. Which test should the nurse inform the client about to detect cervical cancer at an early stage?
Papanicolaou test
A 40-year-old client arrives at the community health canter experiencing a strange dragging feeling in the vagina. She stated that "at times it feels as if there is a lump" there as well. Which condition may be an indication of these symptoms?
Pelvic organ prolapse
A client reports lumpy, tender breasts, particularly during the week before menses. She reports pain that often dissipates after the onset of menses. The nurse suspects the client has fibrocystic breast changes. Which should the nurse do next?
Perform a breast examination
A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis?
Perform handwashing before and after breastfeeding
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?
Perform handwashing before breastfeeding
A client has opted to use an IUD for contraception. About which effect of the device on monthly periods should the nurse inform the client?
Periods become lighter
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the obstetrician who prescribed the medication if which condition is documented in the client's medical history?
Peripheral vascular disease
A nurse is describing the criteria needed for the diagnosis of premenstrual dysphoric disorder (PMDD). Which would the nurse include as a mandatory requirement for the diagnosis?
Persistent anger
Which oral medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate?
Phenytoin
The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response?
Pierced nipple
A nurse is caring for a client undergoing treatment for bacterial vaginosis. Which of the following instructions should the nurse give the client to prevent recurrence of bacterial vaginosis?
Practice monogamy
A 55-year-old client presents to the clinic with persistent vulvar pruritus, burning, and a lump. She states she has had the symptoms for 5 months and has been trying to treat them with over-the-counter creams. She has a history of multiple sexual partners and HPV and is a smoker. What should the nurse do next?
Prepare the client for a biopsy of the lesion
A nurse is giving discharge education to a group of new parents before they are discharged home with their infants. What information will the nurse include in the teaching?
Place the newborn on the back to sleep and stomach to play
The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes?
Places the client at risk for dystocia, has an increased risk of c-section, has a flat shape that may impede fetal descent
After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?
Postpartum depression develops gradually, appearing within the first 6 weeks
The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?
Postpartum psychosis
A client in preterm labor is being started on intravenous magnesium sulfate to stop the contractions. Several hours later, when the nurse is performing an assessment, the following data are obtained: blood pressure, 110/66 mm Hg; pulse, 66 beats per minute; respirations, 10 breaths per minute; and deep tendon reflexes absent. What should the nurse do next?
Prepare to administer calcium gluconate as an antidote for magnesium toxicity
The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?
Pressure changes occur and result in closure of the ductus arteriosus
A nurse is preparing a class for a group of women at a family planning clinic about contraceptives. When describing the health benefits of oral contraceptives, which benefits would the nurse include?
Protection against pelvic inflammatory disease, reduced risk for endometrial cancer, improvement in acne
The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia?
Proteinuria, hypertension
The nurse is preparing to administer phytonadione to the client. Which laboratory value should the nurse monitor in order to evaluate the effectiveness of the medication?
Prothrombin time
A client presents for a routine checkup at a local health care center. One of the clients distant relatives died of ovarian cancer, and the client wants to know about measures that can reduce the risk of ovarian cancer. The nurse informs the client about which measures to reduce the risk of ovarian cancer?
Provide genetic counseling and thorough assessment
Under which circumstances should gloves be worn in the newborn nursery?
Providing the first bath, Changing a diaper, Performing a heel stick Accucheck
The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources for which primary reason?
Reduce excessive maternal stress and fatigue
A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan?
Reduce external stimuli
A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function?
Reflex
The results of a Pap smear test have been classified as atypical squamous cells with possible HSIL (ASC-H) as per the 2001 Bethesda system. Which interpretation of the results is correct?
Reger for a colposcopy without HPV testing
A nurse is caring for a 45-year-old client using a pessary to help decrease leakage of urine and support a prolapsed vagina. Which recommendation is most commonly provided to a client regarding pessary care?
Remove the pessary twice weekly, and clean it with soap and water
A nurse is caring for a 32-year-old client for whom pessary usage is recommended for uterine prolapse. Which instructions should the nurse include in the teaching plan for the client concerning the pessary?
Report any discomfort with urination and defecation
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment?
Respirations of 10 breaths per minute, urine output of 20 mL in an hour
A client experiencing preterm labor at the 29th week of gestation has been admitted to the hospital. The client has a prescription to receive betamethasone but delivers too quickly for medication administration. As a result of not receiving this medication, which condition is most likely to develop in the preterm newborn?
Respiratory depression
A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse?
Respiratory rate of 10 breaths/minute
The nurse is assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider?
Restless and agitated, concerned with self and not the infant
A nurse is educating a 43-year-old female client about required lifestyle changes to help avoid breast cancer. Which instructions regarding diet and food habits should the nurse include in the teaching plan?
Restrict intake of salted foods, limit intake of processed foods, consume seven or more portions of complex carbohydrates daily
The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction?
Restrict visitors who may have an active infection
A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?
Resume intercourse if bright red bleeding stops
Which action will the nurse avoid when performing basic care for a newborn male?
Retracting the foreskin over the glans to assess for secretions
The nurse is caring for several clients after they successfully gave birth to their newborns. Which client(s) should the nurse anticipate will be given Rho(D) immune globulin?
Rh-negative client who had a spontaneous abortion (miscarriage) yesterday, Rh-negative client following an ectopic pregnancy, Rh-negative client who gives birth at 32 weeks' gestation to a newborn with type A+ blood
A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client?
Risk for fatigue related to chronic bleeding due to subinvolution
The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate?
Routine administration of heparin may be prescribed, an overbed lift may be necessary if the client requires a c-section, thromboembolism stockings or sequential compression stockings may be prescribed
A pregnant client arrives at the community clinic complaining of fever blisters and cold sores on the lips, eyes, and face. The primary health care provider has diagnosed it as the primary episode of genital herpes simplex, for which antiviral therapy is recommended. Which of the following information should the nurse offer the client when educating her about managing the infection?
Safety of antiviral therapy during pregnancy has not been established
A client with abnormal uterine bleeding is diagnosed with small ovarian cysts. The nurse has to educate the client on the importance of routine checkups. Which assessment is most appropriate for this client's condition?
Schedule ultrasound every 3 to 6 months
A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the nurse that the magnesium sulfate therapy is effective?
Seizures do not occur
A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching?
Some women just can't breastfeed. Maybe I'm one of these women
Which nursing actions limit overstimulation of the preterm infant?
Speak softly to the infant, Keep lights low in the nursery, Coordinate nursing care
The nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid?
Spinach
The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?
Staphylococcus aureus
A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?
Stools should be yellow-gold, loose, and stringy to pasty
A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and should tell the client that which change may persist after she gives birth?
Striae gravidarum
A client is waiting for the results of an endometrial biopsy for suspected endometrial cancer. She wants to know more about endometrial cancer and asks the nurse about the available treatment options. Which treatment information should the nurse give the client?
Surgery involves removal of the uterus, fallopian tubes, and ovaries; adjuvant therapy is used if relevant
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?
Symptoms include fever, chills, malaise, and localized breast tenderness
An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?
Tachypnea
A 30-year-old client would like to try using basal body temperature (BBT) as a fertility awareness method. Which instruction should the nurse provide the client?
Take temperature before rising and record it on a chart
When caring for a client with reproductive issues, the nurse is required to clear up misconceptions. This enables new learning to take hold and a better client response to whichever methods are explored and ultimately selected. Which misconceptions will the nurse need to clear up?
Taking birth control pills protects against STIs, douching after sex will prevent pregnancy, irregular menstruation prevents pregnancy
A client with large uterine fibroids is scheduled to undergo a hysterectomy. Which intervention should the nurse perform as part of the preoperative care for this client?
Teach turning, deep breathing, and coughing
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby
A nurse is teaching a female client about fertility awareness as a method of contraception. Which should the nurse mention as an assumption for this method?
The "unsafe" period is approximately 6 days
Which statement is false regarding bathing the newborn?
The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.
The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?
The bladder is distended
A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts?
The breast changes occur because of the secretion of estrogen and progesterone, Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida
The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?
The client complains of a headache and blurred vision
A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicate a need for further teaching?
The client is wearing knee high nylon stockings, the client is wearing sweatpants with snug elastic ankle bands
The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?
The client's last baby weighed 10 pounds at birth
A 65-year-old client presents at a local community health care center for a routine checkup. While obtaining her medical history, the nurse learned that the client had her menarche when she was 13 years old. She experienced menopause at 51. She is between 5 to 10 lbs underweight but is otherwise in good physical condition. The nurse should inform the client of which factor increases the client's risk of getting ovarian cancer?
The client's present age
A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client?
The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential
The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time?
The fetus is approximately 42 to 48 cm long, The lecithin-sphingomyelin (L/S) ratio is greater than 2:1
The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?
The iron is best absorbed if taken on an empty stomach.
Butorphanol tartrate is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which appropriate response?
The medication provides pain relief during labor
The client delivered a newborn baby 3 hours ago. The assigned nurse is reviewing the electronic health record to determine if the new mother is a candidate for Rh immune globulin administration. Which criteria must be present to determine that the client needs the medication?
The mother must be Rh negative, the newborn must be Rh positive, the indirect Coombs' test must be negative
The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis?
The newborn is not really mine emotionally, since I was never pregnant and do not have children, When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts, I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider
The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care?
The newborn will experience no bleeding episodes lasting more than 5 minutes
A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure?
The procedure is performed using artificial insemination of sperm instilled through the vagina
Which statement is true regarding fetal and newborn senses?
The rooting reflex is an example that the newborn has a sense of touch
A woman gave birth to a healthy term newborn about 2 hours ago. She asks the nurse about the appearance of her newborn's head. Assessment reveals swelling of the head that extends across the midline. Which response by the nurse would be appropriate?
The swelling in your newborn's head is due to the head pressing against your cervix during labor and birth. It will go away on its own in a few days
A client has been referred for a colposcopy by the physician. The client wants to know more about the examination. Which information regarding a colposcopy should the nurse give to the client?
The test is conducted because of abnormal results in Pap smears
A nurse is caring for a client who has just delivered a baby. Which of the following information should the nurse give the client regarding hepatitis B vaccination for the baby?
The vaccine consists of a series of three injections given within 6 months
A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?
The vaginal discharge may be bothersome but is a normal occurrence
The nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation?
The woman is experiencing magnesium excess
What should the nurse expect for a full-term newborn's weight during the first few days of life?
There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.
Kegel exercises are recommended for a client with pelvic organ prolapse. Which should the nurse inform the client about the exercises?
They alleviate mild prolapse symptoms
A client in her second trimester of pregnancy asks the nurse for information regarding certain oral medications to induce a miscarriage. What information should this client be given about such medications?
They can be taken only in the first trimester
A nurse is conducting an awareness session on sexual abuse, and she is explaining the psychological profile of an average abuser. Which trait is often displayed by abusers?
They exhibit antisocial behaviors
A client comes to a local community health care facility for a routine checkup. While talking to the nurse, the client happens to mention that every time she has a serious fight with her husband, he forces her to have intercourse with him. The client seems to be very disturbed when revealing this to the nurse. Which is an appropriate response by the nurse?
This behavior is considered sexual abuse
The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the primary health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client?
This is necessary to assist in identifying potential infections that may need to be treated
A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements?
This test can screen for spina bifida, if the test results are abnormal I may need further testing, this test can indicate the risks for of having a child with downs syndrome
A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response?
This test measures amniotic fluid volume and fetal activity. The test assesses 5 parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume
Butorphanol tartrate by intravenous push is prescribed for a client in labor. The nurse recognizes which assessment findings to be side or adverse effects of this medication?
Tinnitus, syncope, palpitations, nausea and vomiting
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn?
Toes fan out when sole of foot is stroked
A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?
Touching
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?
Touching
A nurse is caring for an HIV-positive client who is on triple-combination highly active antiretroviral therapy (HAART). Which of the following should the nurse include in the teaching plan when educating the client about the treatment?
Unpleasant side effects such as nausea and diarrhea are common, provide written materials describing diet, exercise, and medications, and ensure that the client understands the dosing regimen and schedule
Which body system is most vulnerable to infection during the postpartum period?
Urinary
A nurse is caring for a client who was raped at gunpoint. The client does not want any photos taken of her injuries. The client also does not want the police to be informed about the incident, even though state laws require reporting life-threatening injuries. Which intervention should the nurse perform to document and report the findings of the case?
Use direct quotes and specific language
An HIV-positive client who is on antiretroviral therapy complains of anorexia, nausea, and vomiting. Which of the following suggestions should the nurse offer the client to cope with this condition?
Use high-protein supplements
The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy?
Use of fertility drugs, History of chlamydia, use of an IUD, history of PID
A 13-year-old immigrant from Asia is admitted to the health care facility with vaginal bleeding. A genital examination reveals unhealed circumcision wounds. The client can understand limited English but cannot speak the language fluently. The service of an interpreter is employed. What are the points the nurse should keep in mind when interacting with this client?
Use pictures and diagrams to supplement the questions and answers of the client's understanding
A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider?
Weak and rapid pulse
A 38-year-old female client has to undergo lymph node surgery in conjunction with mastectomy. The client is likely to experience lymphedema due to the surgery. Post-surgery, which factors will make the client more susceptible to lymphedema?
Using the affected arm for drawing blood or measuring blood pressure, engaging in activities like gardening without using gloves, not wearing a well-fitted compression sleeve
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?
Uterine atony
The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion?
Uterine hyperstimulation, late decelerations of the fetal heart rate
The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition?
Vaginal bleeding, excessive nausea and vomiting, larger than normal uterus for gestational age, elevated hCG levels
A nurse is caring for a client who has been prescribed gonadotropin-releasing hormone (GnRH) medication for uterine fibroids. For which side effect of GnRH medications should the nurse monitor the client?
Vaginal dryness
The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier?
Viruses, nutrients, antibodies, medications
The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn?
Warmer bed, identification bands, suction equipment
What supplies would the nursery nurse collect in preparation for bathing a newborn infant?
Washcloth, warm tub of water, thermometer
A 30-year-old client tells the nurse that she would like to use a contraceptive sponge but does not know enough about its use and whether it will protect her against STIs. Which information should the nurse provide the client about using a contraceptive sponge?
We the sponge with water before inserting it, insert the sponge 24 hours before intercourse, leave the sponge in place for at least 6 hours following intercourse
A nurse is caring for a female client who has a history of recurring vulvovaginal candidiasis. Which of the following instructions should the nurse include in the teaching session with the client?
Wear white, 100% cotton underwear
After teaching a group of students about premenstrual syndrome, the instructor determines that additional teaching is needed when the group identifies which finding as a prominent assessment finding?
Weight loss
The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron?
Whole-grain cereal
A newborn has a 5-minute Apgar score of 9. What intervention should the nurse take for this client?
Wrap the infant in a blanket and hand to the mother for bonding
The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?
Wrap the infant in a warm, dry blanket
A client presents at a community health care center for a routine checkup. The client wants to know about any tests that can effectively detect ovarian cancer early. About which test that can aid in the detection of ovarian cancer should the nurse inform the client?
Yearly bimanual pelvic examinations
A 49-year-old client who is in the perimenopausal phase of life reports to the nurse a loss of lubrication during intercourse, which she feels is hampering her sex life. Which response by the nurse is appropriate?
You can manage the condition by using OTC moisturizers or lubricants
A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?
You might try using a water-soluble lubricant to ease the discomfort
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?
You should not lift anything heavier than your infant in its carrier
A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the woman?
You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Rubella immune, Positive Goodell and Chadwick, Rh positive, Type O
You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk
A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client?
You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed.
A client who has just been told that she is pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the primary health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response?
Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine
A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?
Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid
The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response?
Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time
The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?
Your type of pelvis is the most favorable for labor and birth
A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately?
a sudden drop in hematocrit
As the nurse examines the birth records, which newborn would the nurse expect to monitor closely for respiratory distress syndrome (RDS)?
a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus
The nurse is reviewing the medical records of several clients. Which client would the nurse expect to have an increased risk for developing osteoporosis?
a thin woman with small bones
A newborn with high serum bilirubin is receiving phototherapy. Which nursing intervention is the most appropriate for this client?
application of eye dressings to the infant
Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?
asymmetrical chest movement
A neonate born at 35 weeks' gestation is being screened for hypoglycemia. During the first 24 hours of life, when will the nurse screen this neonate?
before feedings
A young adult woman who is HIV-positive is receiving anti-retroviral therapy (ART) and is having difficulty with adherence. To promote adherence, which area would be most important for the nurse to assess?
beliefs and education
Which measurement best describes postpartum hemorrhage?
blood loss of 1,000 ml, occurring at least 24 hours after birth
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?
blood sugar
A nurse is assessing a neonate during the first 24 hours after birth. Which finding would the nurse recognize as normal?
body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?
bright red, raised bumpy area noted above the right eye
A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage?
by frequently assessing uterine involution
While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?
concentration of immature blood vessels
A Black couple are spending time with their newborn after the nurse brings the newborn back from the transition nursery. The parents note that their newborn's buttocks appear bruised and ask what happened. The nurse should explain this is related to which factor?
congenital dermal melanocytosis (slate gray nevi)
The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?
deep venous thrombosis
The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action?
delayed umbilical cord clamping
When teaching a group of postmenopausal women about hot flashes and night sweats, the nurse would address which primary cause?
estrogen deficiency
The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition?
expiratory grunting
The nurse is assessing the infants in the newborn nursery. For which common risk factor(s) for developing newborn jaundice should the nurse assess?
fetal-gestational parent blood group incompatibility, prematurity, breastfeeding, certain drugs, gestational diabetes in gestational parent
A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which periods?
first period of reactivity, period of decreased responsiveness, second period of reactivity
A nurse is preparing to conduct a neurological physical assessment of a neonate, including an evaluation of the major congenital reflexes. Which reflexes would the nurse assess?
gag, Babinski, Moro, Galant
The Apgar score is based on which 5 parameters?
heart rate, muscle tone, reflex irritability, respiratory effort, and color
A nursing student will pick which value as a correct laboratory value for a newborn?
hemoglobin (Hbg) 17 g/dL (170 g/L)
A nurse is conducting a refresher in-service program for a group of neonatal nurses. The nurse determines the session is successful after the participating nurses correctly choose which factor is responsible for the appearance of jaundice in the newborn?
hemolysis of erythrocytes
The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?
hemolytic disease
The nurse is administering methylergonovine 0.2 mg to a postpartum client with uterine subinvolution. Which assessment will the nurse need to make prior to administering the medication?
if blood pressure is lower than 140/90 mm Hg
The nurse is developing a plan of care for a client who is receiving aggressive drug therapy for treatment of HIV. The goal of this therapy is to:
improve survival rates
A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression?
inability to concentrate, loss of confidence, decreased interest in life
The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor?
increased vaginal acidity leading to growth of bacteria
When discussing contraceptive options, the nurse would recommend which option as being the most reliable?
intrauterine system
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence?
lack of thoracic compressions during birth
An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?
length of labor
A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?
lethargy and hypotonia
Which factors could increase the risk of overheating in a newborn?
limited ability of diaphoresis, isolette that is too warm
When reviewing the medical record of a client diagnosed with endometriosis, the nurse would identify which finding as a risk factor for this woman?
menstrual cycles of 24 days
When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate?
over the liver
Which measure would the nurse include in the teaching plan for a woman to reduce the risk of osteoporosis after menopause?
participating in regular daily exercise
Two weeks after giving birth, a birth parent is feeling sad, hopeless, and guilty because they cannot take care of the infant and their partner. The birth parent is tired but cannot sleep and has isolated themselves from family and friends. Which should the nurse prioritize for assessment?
postpartum depression
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and the client frequently indulges in obsessive concerns. The nurse notes that the client has difficulty relaxing and sleeping. The nurse interprets these findings as suggesting which condition?
postpartum psychosis
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?
radiation, convection, and conduction
After teaching a group of adolescents about HIV, the nurse asks them to identify the primary means by which adolescents are exposed to the virus. The nurse determines that the teaching was successful when the group identifies which means of exposure?
sexual intercourse
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?
showing increased confidence when caring for the newborn
A woman using the cervical mucus ovulation method of fertility awareness reports that her cervical mucus looks like egg whites. The nurse interprets this as which kind of mucus?
spinnbarkeit mucus
Which factor might result in a decreased supply of breast milk in a postpartum client?
supplemental feedings with formula
Which action would the nurse emphasize when teaching postmenopausal women about ways to reduce the risk of osteoporosis?
taking calcium supplements
A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported?
temperature of 38.3° C (101° F) or higher, refuse feeding, abdominal distention
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?
the taking-hold phase
When assessing the newborn's umbilical cord, what should the nurse expect to find?
two smaller arteries and one larger vein
During pregnancy, a client's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the client eliminates the additional fluid volume they have been carrying. What is one way the client does this?
urinary elimination
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
uterine atony
A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?
uterine atony
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify?
uterine infection, prolonged labor, hydramnios
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg
A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem?
white blood cell count 14,000/mm3 (14 ×109/L)
At what point should the nurse expect a healthy newborn to pass meconium?
within 24 hours after birth
The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?
yellowy mustard color with seedy appearance
