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A nurse is caring for a client who is 2 days postpartum and states "I want to continue breast feeding, but my nipples are sore." Which of the following responses should the nurse make?

"Allow expressed milk to air dry on the nipples after feeding your infant."

A nurse is providing discharge instructions to a client who is 24 hr postpartum and has decided not to breast feed. Which of the following instructions should the nurse include in the teaching?

"Apply ice packs to your breasts using a 15 minutes on, 45 minutes

A nurse is planning to teach a group of clients who are pregnant about breast feeding after returning to work. Which of the following information should the nurse include in the teaching?

"Breast milk can be stored in a deep freezer for 12 months."

A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching?

"Count your baby's movements daily."

A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching?

"Replace the diaphragm every 2 years."

A nurse is in a clinic caring for a client who is in her second trimester pregnancy. The client expresses concern about preparing her 2- year- old- child for a new sibling. Which of the following is an appropriate response by the nurse?

"Required scheduled interactions between toddler and the baby."

A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks of gestation and has preeclampsia. Which of the following responses by the nurse is appropriate?

"This medication prevents seizures."

A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse take?

"This procedure determines if your baby has genetic or congenital disorders."

A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?

"Transmission can occur via the saliva and urine of the newborn."

A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus B-hemolytic (GBS). The client ismultigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?

"We need to know if you are positive for GBS at the time of delivery."

A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include?

"You should anticipate nasal stiffness."

A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make?

"You should take 600 micrograms of folic acid per day."

A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching?

"You should take your temperature before getting up for the day."

A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching?

"You will lie on your side for 40 minutes after I administer the medication."

A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?

"Your contractions will become temporarily regular."

A nurse is providing vehicle safety education to parents of a premature newborn. Which of the following statements should the nurse include in the teaching?

"Your newborn will need to have a car seat test prior to discharge."

A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help retrieve this common discomfort of pregnancy?

Drink 2 to 3 L of water each day

A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks gestation. Which of the following actions should the nurse take? (Click in the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Administer ceftriaxone IM.

A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect?

Cool, clammy skin

A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction?

Cover the newborn's bladder with a sterile, non- adherent dressing.

A nurse is reviewing the laboratory report of a client who is 24 hr postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the following actions should the nurse take?

Administer an iron supplement to the client.

A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory disease. Available is metronidazole 500mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 tablets

A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first?

A client who as hyporeflexia while receiving IV magnesium sulfate

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference?

A client who is at 35 weeks of gestation and has a biophysical profile of 6

A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider?

A newborn who has a high-pitched cry with exaggerated Moro reflex

A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take?

Administer oxygen via a face mask.

A nurse is providing discharge instructions to a client who is breast feeding her newborn. Which of the following instructions should the nurse include?

Allow the baby to feed at least every 3 hours

A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

An urge to have a bowel movement during contractions

. A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching?

Apply cabbage leaves a^er feedings

A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain following the administration of oxycodone/acetaminophen. Which of the following actions should the nurse take first?

Assess the client's perineal area for swelling.

A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first?

Assist the client to the bathroom.

A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?

Blood pressure 142/92 mm Hg

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent deep-tendon reflexes. Which of the following medications should the nurse administer?

Calcium gluconate

A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect?

Chest circumference 2 cm (0.8) smaller than the head

A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor?

Chorioamnionitis

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider?

Deep tendon reflexes absent

A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, "No, the baby is too tired to be held." Which of the following actions

Demonstrate how to hold the newborn and allow client to practice.

A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding?

Encourage the client to void in the shower.

A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

Evaluate urinary output.

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?

Facial petechiae

A nurse is reviewing laboratory findings a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?

Fasting blood glucose 180 mg/dL

A nurse is caring for a client who is at 35 weeks of gestation and is on bed rest due to preeclampsia. Which of the following is an important action for the nurse to take?

Keep the lights dimmed in the room.

A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior positi7on. On which of the following sites should the nurse place the external fetal monitor to hear the point of maximum impulse of the fetal heart rate?

LLQ

A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heart beat. Which of the following terms should the nurse use to document this finding?

Funic souffle

A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

Heart rate 72/min

A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications?

Hemorrhage

A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicates a complication?

Hypotonic uterus

A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?

Increase the infusion rate every 30 to 60 min.

A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The nurse should recognize that pregnancy is a contraindication the administration of which of the following medications?

Isotretinoin

A nurse is calculating estimated date of birth using Naegele's rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated delivery in the next year?

March 28

A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take?

Measure from the upper border of the pubis to the upper border of the fundus.

A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device. Which of the following interventions should the nurse include in the plan of care?

Monitor for bleeding every 15 min for the first hour.

A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?

Oatmeal

A nurse manager is revising a maternal unit policy to ensure proper identification of newborns. Which of the following should the nurse include in the policy?

Obtain an imprint of the infant's feet prior to taking him to the nursery.

A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching?

Place newborn bassinets at least 3 feet apart.

A nurse is assisting with a precipitous delivery of a term newborn. After the head emerges, the nurse palpates the cord around the newborn's neck. Which of the following actions should the nurse take?

Slip the cord over the newborn's head.

A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

Platelet count 60,000/mm3

A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?

Postpartum hemorrhage

A nurse is reviewing the immunization status of a client who is pregnant. The nurse should inform the client that it is safe for her to receive which of the following immunizations during pregnancy?

Tetanus

A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? a. The client will identify individual family member roles.

The client will have adequate nutritional intake.

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Transient circumoral cyanosis

A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical fndings should the nurse identify as an indication of postpartum infection?

Unilateral breast pain

A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory testused to evaluate this condition?

Urine ketones

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider?

Urine output 20 mL/hr

A nurse is assessing client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider?

Urine protein of 3+

A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?

Use an automatic puncture device on the heel.

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

Verify that the informed consent is obtained prior to administration.

A nurse is caring for a newborn immediately following birth notes a large amount of mucus in the newborn's mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe.

b. Compress the bulb syringe (1) a. Lace the bulb syringe in the newborn's mouth (2) d. Set the bulb syringe suction the newborn's nose (3) c. Assess the newborn for reflex bradycardia (4)

A nurse is reviewing the medical record of a client who had vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (SATA)

b. Vacuum-assisted delivery c. Labor induction with oxytocin e. History of uterine atony

A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

prepare the client for what to expect the fetus to look like


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