MCN
B
A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client? a. Deficient knowledge of pregnancy b. Deficient fluid volume c. Anticipatory grieving d. Acute pain
A
A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called? a. Taking-in phase b. Taking-hold phase c. Letting-go phase d. Taking-over phase
A
A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? a. Change the client's position. b. Prepare for emergency cesarean birth. c. Check for placenta previa. d. Administer oxygen.
A
A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for complications? a. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level 9.8 g/dl b. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute c. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7C) d. Gravida 1 para 1001, vaginal delivery, membranes ruptured 10 hours before birth
B
A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: a. "Have you ever had osteomyelitis?" b. "Do you have any cats at home? c. "Do you have any birds at home?' d. "Have you recently had a rubeola vaccination?"
D
A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to: a. take all the missed doses as soon as she discovers the oversight. b. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle. c. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle. d. discard the pack, use an atternative contraceptive method untii her period begins, and start a new pack on the regular schedule.
B
During the first trimester, a nurse evaluates a pregnant client for factors that suggest she might abuse a child. Which parental characteristic is of most concern to the nurse? a. The client didn't graduate high school. b. The client states she is stupid and ugly. c. The client is carrying twins. The client eats fast food every day.
B
Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision? a. Assessing vital signs b. Providing for dietary needs c. Managing pain d. Providing emotional support
B
A client who's 24 weeks pregnant has sickle cell anemia. When preparing the care plan, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy? a. Sedative use b. Dehydration c. Hypertension d. Tachycardia
C
A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help confirm that she is in true labor, the nurse should assess for: a. irregular contractions b. increased fetal movement c. changes in cervical effacement and dilation after 1 to 2 hours d. contractions that feel like pressure in the abdomen and groin
B
A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to the client's concerns, the nurse should take which action? a. Make an appointment because the dent needs to be evaluated. b. Explain that these are expected problems for the latter stages of pregnancy. c. Arrange for the dent to be admitted to the birth center and prepare for birth. d. Tell the client to go to hospital; she may be experiencing a heart failure.
C
A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds. What should the nurse do next? a. Continue to monitor the baby for fetal distress. b. Notify the physician and transfer the mother to labor and delivery for imminent delivery. c. Inform the physician and prepare for discharge: this client has a reassuring strip. d. Ask the mother to eat something and return for a repeat test; the results are inconclusive.
