Maternal Newborn Dynamic Quizzing

A nurse is teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? A. "Apply ice packs to your breasts." B. "Hand express milk from your breasts 3 times each day." C. "Try to avoid wearing a bra as much as possible throughout the day." D. "Request a prescription for medication to suppress lactation."

A. "Apply ice packs to your breasts."

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

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

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine

A. 480 mL urine output in 24 hr

A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. Betamethasone B. Misoprostol C. Methylergonovine D. Poractant alfa

A. Betamethasone

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

A. Copper intrauterine device

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin

A. Small, pinpoint, reddish-purple spots on the chest

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

A. Stop the oxytocin infusion

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

A. The client reports a frequent cough

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

D. Instruct the client to apply cold compresses

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

D. Late decelerations with fetal bradycardia

A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements per hour

C. Vaginal bleeding

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizzinessafter lying on her back on the couch. Which of the following actions should the nurse take? A. Request a prescription for preeclampsia laboratory studies B. Advise the client to lie on her side C. Request an ultrasound to evaluate fetal wellbeing D. Advise the client to add a calcium supplement to her diet

B. Advise the client to lie on her side

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

B. Assess the newborn's blood glucose level

A nurse in a prental clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiological adaptation to pregnancy? A. Spotting with urination B. Breast tenderness C. Thick, white vaginal discharge D. Facial swelling

B. Breast tenderness

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

B. Expiratory grunting

A nurse is preparing to help with a vacuum-assisted birth. Which of the following actions should the nurse plan to take? A. Instruct the client to stop pushing during contractions B. Inform the client that caput succedaneum resolves in a few days C. Monitor the newborn for decreased levels of bilirubin after birth D. Identify that the newborn is at risk for facial palsy

B. Inform the client that caput succedaneum resolves in a few days

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

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

While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Administer methyl-prostaglandin IM B. Encourage the client to use the shower C. Place the client in a supine position D. Apply oxygen at 10 L/min via nonrebreather face mask

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

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take? A. Instruct the client to pant during contractions B. Position the client supine with leg elevated C. Encourage the client to soak in a warm bath D. Apply pressure to the client's sacral area during contractions

D. Apply pressure to the client's sacral area during contractions

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

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

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection

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

C. Persistent vomiting

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

D. Gonorrhea

A nurse is assessing an 18-hour-old newborn. Which of the following findings should be reported to the provider? A. Blood-tinged discharge from the vagina B. Overlapping sutures on the skull C. Subconjunctival hemorrhage D. Yellow-tinged skin

D. Yellow-tinged skin

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (SATA) - Magnesium sulfate infusion - Distended bladder - Oxytocin infusion - Prolonged labor - Small for gestational age newborn

- Magnesium sulfate infusion - Distended bladder - Prolonged labor

a nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? - Use slight downward pressure to compress the client's fundus - Place a hand just above the client's symphysis pubis - Rotate the upper hand to massage the client's uterus - Ask the client to lie on her back with her knees flexed - Position a hand around the top of the client's fundus

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

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

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

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

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

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

C. Autosomal recessive

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

A. "Try pelvic tilt exercises."

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

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

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Palpable fetal movement B. Chadwick's sign C. Positive pregnancy test D. Amenorrhea

A. Palpable fetal movement

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

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

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

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

A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? A. Place the client in a side-lying position B. Discontinue the oxytocin infusion C. Apply oxygen to the client via a face mask D. Check for umbilical cord prolapse

A. Place the client in a side-lying position

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

A. September 14

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A. Measure the newborn's length from the anterior fontanel to the heel B. Measure the newborn's weight while he is wearing a clean diaper C. Measure the circumference of the newborn's head with a tape measure just above the eye brows D. Measure the circumference of the newborn's chest with a tape measure 2 cm (0.79 in) below the nipple line

C. Measure the circumference of the newborn's head with a tape measure just above the eye brows

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

C. Swelling of the face and fingers

A postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. The nurse should recommend that the client use which of the following breastfeeding positions? A. Side-lying B. Clutch hold C. Across-the-lap D. Cross-cradle

A. Side-lying

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

B. Generalized petechiae

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

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

While assessing a client who is in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention? A. The fundus is at midline B. The fundus is below the umbilicus C. The bladder is resonant with percussion D. The bladder fluctuates with palpation

D. The bladder fluctuates with palpation

A nurse is caring for a client in labor whose cervix is dilated to 9 cm. She is experiencing strong contractions every 2 min lasting 75 sec. The nurse should recognize that the client is in which of the following phases or stages of labor? A. Latent phase of first stage B. Active phase of first stage C. Second stage D. Transition phase of first stage

D. Transition phase of first stage

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

D. Tremors

A nurse is reinforcing teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? A. "Apply ice packs to your breasts." B. "Hand express milk from your breasts 3 times each day." C. "Try to avoid wearing a bra as much as possible throughout the day." D. "Request a prescription for medication to suppress lactation."

A. "Apply ice packs to your breasts."

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

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

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

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

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will place my baby on his back when putting him to sleep." B. "I will keep my baby's crib close to the heat vents to keep him warm." C. "I will use an infant carrier when I drive to places close to my house." D. "I will tie my baby's pacifier around his neck with a piece of yarn."

A. "I will place my baby on his back when putting him to sleep."

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Screening f

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

A provider tells a client at 12 weeks gestation who practices Hinduism that she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? A. "Let's discuss other foods that are also high in protein that you could substitute for meat." B. "Eating meat during pregnancy provides necessary protein and does not c

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

A nurse is caring for a client who is scheduled to udergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an O-positive blood type. Which of the following interventions should the nurse perform? A. Apply an external fetal monitor to the client B. Instruct the client to drink fluids and not to void prior to the procedure C. Administer Rho(D) immunoglobulin after the procedure. D. Instruct the client to take a deep breath and hold it dur

A. Apply an external fetal monitor to the client

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

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

A nurse is teaching a client who is at 12 weeks gestation about manifestations of potential complications that she should report to her provider. Which of the following pieces of information should the nurse include in the teaching? A. Facial swelling B. Urinary frequency C. White vaginal discharge D. Intermittent nausea

A. Facial swelling

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

A. Fetal heart rate baseline of 90 bpm

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

A. Frequent headaches

A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take? A. Gather equipment for neonatal resuscitation B. Discontinue oxytocin infusion C. Prepare for emergency cesarean delivery D. Position the parent to facilitate the McRoberts maneuver

A. Gather equipment for neonatal resuscitation

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

A. Gestational diabetes

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

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

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

A. Intraventricular hemorrhage

A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? A. Maternal hypotension B. Fetal tachycardia C. Increased fetal heart rate variabiltiy D. Maternal hypothermia

A. Maternal hypotension

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

B. "Decrease your intake of spicy foods."

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

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

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

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

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

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

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

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

A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement? A. Encourage the client to use a hot pack on the perineum B. Administer ferrous sulfate orally C. Help the client apply a breast binder D. Administer Rh immune globulin

B. Administer ferrous sulfate orally

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

B. Administer the hepatitis B vaccine prior to discharge

A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmocological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation? A. Breathing techniques B. Counter-pressure C. Biofeedback D. Use of a focal point

B. Counter-pressure

A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A. Hypothermia B. Dark brown vaginal discharge C. Decreased urinary output D. Fetal heart tones

B. Dark brown vaginal discharge

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

B. Decreased blood glucose

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

B. Decreased blood pressure

A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can only be obtained from continuous electronic fetal monitoring? A. Determination of a baseline B. Determination of variability C. Presence of accelerations D. Presence of decelerations

B. Determination of variability

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure (CPAP) B. Initiate close observation of the newborn for indications of respiratory distress C. Consult a respirato

B. Initiate close observation of the newborn for indications of respiratory distress

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

B. Nails extending over fingers

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

B. Obtain a stat prescription for a bilirubin level

A nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include? A. Count the fetal heart rate for 15 seconds after contractions B. Palpate and count the maternal radial pulse while listening to the fetal heart rate C. Place the listening device over the fetal chest to hear the fetal heart rate D. Percuss the maternal abdomen to verify the position of the uteru

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

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

D. Presence of ketones in the urine

A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take? A. Have the client watch a video on fetal growth and development during pregnancy B. Supply pamphlets that discuss the importance of nutrition during pregnancy C. Explain how poor nutrition can prevent the baby from growing properly D. Provide examples of how eating well will help maintain a healthy weight

D. Provide examples of how eating well will help maintain a healthy weight during pregnancy

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

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

A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse provide? A. "Don't worry. Your baby is fine." B. "You will need to ask your provider about the monitor." C. "Your provider feels this step would be best." D. "We need to observe your baby more closely."

D. "We need to observe your baby more closely."

A nurse is caring for a client who is at 39 weeks gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep all 4 side rails up while the client is in bed B. Monitor the fetal heart rate every hour C. Insert an indwelling urinary catheter D. Check the cervix prior to analgesic administration

D. Check the cervix prior to analgesic administration

A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? A. Increased platelet count B. Fetal distress C. Decreased urinary output D. Dark red vaginal bleeding

D. Dark red vaginal bleeding

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

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

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

D. Exaggerated reflexes

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? A. Fundal height of 34 cm (13.4 in) B. Total pregnancy weight gain of 3.6 kg (8 lb) C. Gestational hypertension D. Fetal gastrointestinal anomaly

D. Fetal gastrointestinal anomaly

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

D. Fetal scalp electrode

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

D. Frequent stimulation

A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect? A. Legs that are shorter than the arms B. Temperature of one leg differing from that of the other C. Symmetrical gluteal fold D. Limited abduction of a hip

D. Limited abduction of a hip

A nurse is assessing a client who is at 30 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse identify as an indication that the client needs a biophysical profile? A. Fundal height 30 cm B. Fetal movements count 12 kicks in 12 hours C. Fetal heart rate 136/min D. Nonreactive non-stress test

D. Nonreactive non-stress test

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

D. November 9, 2018

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

D. Pelvic inflammatory disease (PID)

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

D. Prepare the client for an emergency cesarean delivery

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? A. "A fetal stethoscope can first detect your baby's heart rate at 22 weeks." B. "After week 16, we can see if your baby is a boy or a girl." C. "A Doppler device can detect your baby's heart rate at 12 weeks." D. "You will first feel the baby move at about 8 weeks."

C. "A Doppler device can detect your baby's heart rate at 12 weeks."

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

C. 1,000 mg

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

C. 3 cm below the umbilicus

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10

C. 9

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

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

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

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

A nurse is reviewing the laboratory report for a client with suspected HELLP syndrome. Which of the following findings should the nurse report to the provider as an indication of this disorder? A.Elevated hemoglobin B. Elevated creatinine levels C. Elevated liver enzymes D. Elevated platelet count

C. Elevated liver enzymes

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

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

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

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

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

C. Fetal heart rate decreased by 15/min

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

C. Fetal heart tones auscultated by Doppler

A nurs e is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? A. urinary output B. Blood pressure C. Fundal consistency D. Pulse rate

C. Fundal consistency

A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? A. Administer magnesium sulfate 4 g IV bolus B. Insert an indwelling urinary catheter C. Give oxygen at 10 L/min via face mask D. Keep the environment quiet and the lights dimmed

C. Give oxygen at 10 L/min via face mask

A nurse is caring for a client in the latent stage of labor who is reporting a pain level of 4 on a scale of 1 to 10. Which of the following actions should the nurse take? A. Encourage the client to use hydrotherapy B. Teach the client biofeedback to control labor pain C. Lead the client in relaxation breathing techniques D. Administer a benzodiazepine medication

C. Lead the client in relaxation breathing techniques

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

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

A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolpased umbilical cord. Which of the following actions should the nurse take first? A. Place the client in an extreme Trendelenburg position B. Increase the IV fluid infusion rate C. Manually apply upward pressure intravaginally on the presenting part D. Administer 8 to 10 L/min of oxygen via a nonrebreather face mask

C. Manually apply upward pressure intravaginally on the presenting part

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

D. Provide kangaroo care for the infant

A client who is pregnant tells the nurse that she is financially unstable to buy the food and vitamins recommended during pregnancy. Which of the following actions should the nurse take? A. Explain to the client that improper nutrition could lead to birth defects in her baby. B. Instruct the client to return to the clinic for weekly weigh-ins for the remainder of the pregnancy C. Provide the client with sample menus to promote nutritious meal preparations D. Refer the client to a community resou

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

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

D. Reposition the client from side to side

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement? A. Self-hypnosis B. Biofeedback C. Acupuncture D. Slow-paced breathing

D. Slow-paced breathing

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

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

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

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

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

C. Place the client in a lateral position

A nurse is assessing a 4-hour-old newborn prior to breastfeeding and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? A. Apply an oxygen hood over the newborn's head and neck B. Check the newborn's temperature using a temporal thermometer C. Place the naked newborn on the mother's bare chest and cover both with a blanket. D. Give the newborn glucose water between feedings

C. Place the naked newborn on the mother's bare chest and cover both with a blanket.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

B. Renal agenesis

A nurse is caring for a client who is pregnant with a male child and expresses concern to the nurse about the possibility of the child having hemophilia. The client is a carrier of the gene mutation for this condition. Which of the following percentages represents the chance that the child will have this disorder? A. 25% B. 50% C. 75% D. 100%

B. 50%

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

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

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

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

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

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

A nurse is caring for a client who is pregnant. The client asks, "Is it okay to have a few beers while I'm pregnant?" Which of the following responses should the nurse make? A. "Total abstinence from alcohol is recommended." B. "One occasional beer during pregnancy is okay." C. "High levels of alcohol consumption should be decreased." D. "A low-calorie liquor is safe to drink."

A. "Total abstinence from alcohol is recommended."

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

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

A nurse is caring for a client at 12 weeks gestation who has a BMI of 45. Which of the following pieces of information should the nurse provide for the client regarding the recommended weight gain during her pregnancy? A. "You should plan to gain no more than 20 pounds during your pregnancy." B. "You should plan to gain between 25 to 35 pounds during your pregnancy." C. "You should not plan to gain any weight during your pregnancy because you are already well-nourished." D. "Since you have highe

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

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

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

A nurse in the labor and delivery suite is planning care for a group of 4 clients. Which of the following clients should the nurse see first? A. A client who is in active labor and has late decelerations on the fetal heart monitor strip B. A client who is in transition and screaming and disturbing other clients C. A client who has epidural analgesia and is reporting breakthrough pain D. A client who has received an oxytocin infusion and is experiencing contractions every 2 min lasting 60 sec

A. A client who is in active labor and has late decelerations on the fetal heart monitor strip

A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome

A. A newborn who is large for gestational age

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

A. Accepting the pregnancy

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

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

A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take? A. Asssit the client to ambulate in the hallway B. Instruct the client to splint the incision with a pillow C. Have the client drink fluids through a straw D. Encourage the client to drink carbonated beverages

A. Asssit the client to ambulate in the hallway

A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? A. Check the fetal heart tones B. Assess the uterine contraction pattern C. Measure maternal vital signs D. Obtain a biophysical profile

A. Check the fetal heart tones

A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? A. Severe hypotension B. Proteinuria C. Elevated platelet count D. Seizures

B. Proteinuria

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

A. Report of fetal movement by the client

A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? A. The fundal height measures greater than gestational age B. A rigid abdomen is noted on palpation C. The client reports a pain level of 8 on a 0-to-10 pain scale D. A urine drug screen is positive for cocaine

A. The fundal height measures greater than gestational age

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? A. Uterine tone B. Fetal heart rate C. Blood pressure D. Amount of bleeding

A. Uterine tone

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression

A. Uteroplacental insufficiency

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

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

A nurse is teaching a prenatal class about nonpharmacological comfort measures during labor. Which of the following statements should the nurse identify as an indication that the instructions have been understood? A. "I can have my partner apply counterpressure to my upper abdomen." B. "My baby will be monitored with a Doppler device during hydrotherapy." C. "I can have the nurse apply acupressure to my lower abdomen." D. "My TENS unit will not help with lower back pain during early labor."

B. "My baby will be monitored with a Doppler device during hydrotherapy."

A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amounts of milk from your breasts frequently."

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

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? A. "Stand under a hot shower with your breasts exposed." B. "Place ice packs on your breasts." C. "Wear a loose-fitting, comfortable bra." D. "Limit fluid intake to 1 L per day."

B. "Place ice packs on your breasts."

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

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

A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I feel like I cannot breathe when I walk up the stairs."

B. "When my water broke, it was not clear."

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan? A. "Your partner needs to be cultured and be treated with metronidazole only if his cultures are positive." B. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." C. "If both you and your partner are treated simultaneously, you may continue to

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

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

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

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

B. Assess the newborn for respiratory depression

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

B. Citrus fruit

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

B. Document the findings and continue to monitor

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

B. Estrogen

A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include? A. Position the client on her hands and knees while in bed B. Flex the client's legs apart and raise her knees to her abdomen C. Apply gentle pressure on the client's fundus while she is lying supine D. Push the fetus's anterior shoulder under the symphysis pubis externally.

B. Flex the client's legs apart and raise her knees to her abdomen

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

B. Hypoglycemia

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

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

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

B. Menorrhagia

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

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

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? A. Administer the oxytocin with manual IV tubing B. Monitor the fetal heart rate every 15 minutes initially C. Begin the infusion at 10 milliunites/min D. Titrate the dosage until the client has 1 contraction every minute

B. Monitor the fetal heart rate every 15 minutes initially

A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 1422/90 mmHg. Which of the following actions should the nurse take? A. Repeat the measurement immediately using the opposite arm B. Repeat the measurement after allowing the client to sit for 5 to 10 minutes C. Repeat the measurement after repositioning the client so that her feet are off the floor D. Repeat the measurement while ensuring the client's arm is dangling at her side

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

A nurse is caring for a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min via nasal cannula D. Prepare the client for an amniocentesis

B. Place the client in a left lateral position

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? A. Perform a detailed physical assessment B. Place the newborn directly on the client's chest C. Give the newborn IM vitamin K D. Administer erythromycin ophthalmic ointment

B. Place the newborn directly on the client's chest

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

B. Platelet count 135,000/ mm^3

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? A. Rapidly advance oral feedings B. Position the naked newborn on the parent's bare chest C. Provide frequent periods of visual and auditory stimulation D. Discourage the use of pacifiers

B. Position the naked newborn on the parent's bare chest

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

B. Preterm labor

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

B. Prolonged labor

A nurse is assessing a client at 37 weeks gestation who has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect? A. Bradycardia B. Uterine contractions C. Seizures D. Bradypnea

B. Uterine contractions

A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? A. Bilirubin level 5 mg/dL B. Weight loss 12% of birth weight C. Loose, green stools D. Axillary temperature of 36.6°C (97.9°F)

B. Weight loss 12% of birth weight

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

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

A nurse is teaching a client at 13 weeks gestation about the treatment of incompetent cervix with cervical clerage. Which of the following statements by the client indicates an understanding of the teaching? A. "I am sad that I won't be able to get pregnant again." B. "I can resume having sex as soon as I feel up to it." C. "I should go to the hospital if I think I may be in labor." D. "I should expect bright red bleeding while the clerage is in place."

C. "I should go to the hospital if I think I may be in labor."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

C. Assist the client to the toilet

A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? A. Blood pressure B. Intake and output C. Daily weight D. Severity of edema

C. Daily weight

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

C. Avoid eye contact during feedings

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

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

A nurse is caring for a client who has a prescription for nalaxone. Which of the following is the intended action of the medication in relation to the central nervous system (CNS)? A. Accentuate the effects of narcotics on the CNS B. Depress activity of the CNS C. Block the effects of narcotics on the CNS D. Stimulate activity of the CNS

C. Block the effects of narcotics on the CNS

A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? A. Perform chest percussion B. Place the newborn in a prone position C. Continue routine monitoring D. Request a prescription for supplemental oxygen

C. Continue routine monitoring

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

C. Continue to monitor the newborn routinely

A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern? A. Pink, mucoid vaginal discharge B. Brownish vaginal discharge C. Contractions lasting 100 seconds D. Contractons occuring every 4 to 5 minutes

C. Contractions lasting 100 seconds

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

C. Giving the hepatitis B vaccine

A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? A. Nausea and vomiting B. Tachycardia C. Hypotension D. Respiratory depression

C. Hypotension

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

C. Impaired placental perfusion

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? A. Monitor the client's intake and output B. Initiate a high-fiber diet for the client C. Monitor the client's weight weekly D. Initiate bedrest with the head of the bed elevated

C. Monitor the client's weight weekly

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

C. Mottling

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

C. Notify the provider

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

C. October 27

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

C. Oxytocin

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

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

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

C. Progesterone

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

C. The newborn has urinated once since the circumcision

A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski

C. Tonic neck

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? A. Breast engorgement B. Hypothermia C. Urinary retention D. Rupture of membranes

C. Urinary retention

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

C. Weak and irregular pulse

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

D. "A weight gain of about 25 to 35 lb is good."

A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which of the following statements should the nurse make? A. "An epidural given too early during labor can cause maternal hypertension." B. "An epidural given too early during labor will not be effective in active labor." C. "An epidural given too early can cause fetal depression." D. "An epidural given too early can prolong labor."

D. "An epidural given too early can prolong labor."

A nurse is caring for a client who is in labor. The client asks the nurse, "Why are you pressing on my abdomen?" Which of the following responses should the nurse make? A. "I can determine your baby's heart rate." B. "I can confirm that you have sufficient fluid around your baby." C. "I can confirm that your baby moves with stimulation." D. "I can determine the position of your baby."

D. "I can determine the position of your baby."

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

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

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

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

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. "My baby's head will be cone-shaped for about 2 months." B. "My doctor performed this procedure because I didn't dilate past 6 centimeters." C. "My doctor performed this procedure because my hemoglobin was low." D. "My baby has a higher risk of developing jaundice."

D. "My baby has a higher risk of developing jaundice."

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

D. "My heart feels like it is racing."

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

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

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

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

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

D. "This medication can make you sleepy."

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

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

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

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

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

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

A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. "You will have to drink 3 to 5 8-oz glasses of water to fill your bladder." B. "This procedure will not rupture your membranes or cause premature labor." C. "You might feel light pressure during the collection of a blood sample from the baby." D. "You will feel some mild discomfort during the procedure."

D. "You will feel some mild discomfort during the procedure."

A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring interventions? A. A newborn who has acrocyanosis B. A newborn who has a macular, papular, vesicular rash on the torso C. A newborn who has a blood glucose level of 54 mg/dL D. A newborn whose axillary temperature is 36.1°C (96.9°F)

D. A newborn whose axillary temperature is 36.1°C (96.9°F)

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication? A. Prolonged rupture of membranes at 38 weeks gestation B. Intrauterine growth restriction C. Post-term pregnancy D. Active genital herpes

D. Active genital herpes

A nurse is caring for a client whose last menstrual period (LMP) began on July 8. Using Naegele's rule, what is the client's estimated date of birth (EDB)? A. October 1 B. April 1 C. October 15 D. April 15

D. April 15

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

D. Assist the client into a warm shower

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

D. At 28 weeks gestation

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

D. Barrel-shaped chest

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula if the newborn is gaining weight too quickly B. Prop the bottle with a blanket for the last feeding of the day C. Discard unused refrigerated formula after 72 hr D. Boil water for powdered formula for 1-2 min

D. Boil water for powdered formula for 1-2 min

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

D. HbA1c

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

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

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

D. Implement seizure precautions

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

D. January 15

A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority? A. The client reports a pain level of 8 on a scale from 0 to 10 during contractions B. The client's blood pressure is 148/92 mmHg C. The client's temperature is 38.3°C (101°F) D. The fetal heart rate is 90/min

D. The fetal heart rate is 90/min

A nurse at the clinic is preparing to teach the provess of involution to a group of antenatal clients. Which of the following information should the nurse provide? A. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum D. The fundus is not pa

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

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

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

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

D. There is decreased abdominal movement with breathing

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

D. Urine ketones

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

D. Use additional pillows to support extremities and abdomen

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

D. Vitamin C