MN 2019 updated version
A nurse is providing teaching to a postpartum client who has type 1 diabetes mellitus and is breastfeeding her newborn. Which of the following instructions should the nurse give the client? A. "Maintain scheduled mealtimes for yourself.". B. "Check your blood glucose levels every 8 hours.". C. "Take more insulin with each meal than you did prior to pregnancy.". D. "Limit your carbohydrate intake to 30 grams per day.".
A. "Maintain scheduled mealtimes for yourself.".
A nurse is teaching a newly hired nurse about Apgar scoring. Which of the following statements by the newly hired nurse indicates an understanding of the teaching? A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth.". B. "The nurse should identify that the newborn is in severe distress with an Apgar score of 8.". C. "The nurse should wait for the first Apgar score before initiating resuscitation efforts.". D. "The nurse should measure the newborn's muscle tone when assigning an Apgar score.".
A. "The nurse should determine the Apgar score at 2 and 7 minutes after birth.".
A nurse is teaching a newly licensed nurse about the uses of ultrasonography in the first trimester of pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Ultrasound is used to determine gestational age in the first trimester.". B. "Ultrasound is used to perform a biophysical profile in the first trimester.". C. "Ultrasound is used to observe for placental maturity in the first trimester.". D. "Ultrasound is used to detect intrauterine growth restriction in the first trimester.".
A. "Ultrasound is used to determine gestational age in the first trimester.".
A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor which of the following findings has an adverse effect. A. Fetal bradycardia. B. Decreased ability to bear down. C. Maternal hypertension. D. Uterine hyperstimulation.
A. Fetal bradycardia.
A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex? A. Make a loud noise above the newborn. B. Touch the newborn's cheek with a finger. C. Tap the newborn's forehead with a finger. D. Turn the newborn's head to one side.
A. Make a loud noise above the newborn.
Exhibit 1. Exhibit 2. Diagnostic results. Exhibit 3. Escherichia coli infection resulting in necrotizing enterocolitis. Hgb 10g/dL. Platelet counts 50,000 mm3. WBC count 4,000 mm3. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take? A. Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr. B. Insert an orogastric decompression tube with low wall suction. C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. D. Administer nitric oxide inhalation therapy to the newborn.
A. Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr.
A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take? A. Perform vibroacoustic stimulation. B. Place the client in the Trendelenburg position. C. Conduct a vaginal exam. D. Collect a specimen for an indirect Coombs' test.
A. Perform vibroacoustic stimulation.
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take? A. Position the client in a knee-chest position. B. Administer a bolus infusion of lactated Ringer's. C. Give terbutaline subcutaneously. D. Apply oxygen via a nonrebreather face mask at 2 L/min.
A. Position the client in a knee-chest position.
A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? A. The newborn's respiratory rate is irregular. B. The newborn's respiratory rate is 32/min. C. The newborn's pulse oximetry is 91%. D. The newborn is beginning to cough.
A. The newborn's respiratory rate is irregular.
A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication? A. Urine output 20 mL/hr. B. Hypertension. C. Hyperglycemia. D. Respiratory rate 16/min.
A. Urine output 20 mL/hr.
A nurse is caring for a newborn immediately following birth and 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. A. Assess the newborn for reflex bradycardia. B. Use the bulb syringe to suction the newborn's nose. C. Place the bulb syringe in the newborn's mouth. D. Compress the bulb syringe.
ABCD
A nurse is providing discharge teaching to a postpartum client about caring for her 5-day-old male newborn at home. Which of the following statements should the nurse make to the client? A. "Swaddle your baby tightly with his legs extended before laying him down to sleep.". B. "Notify your baby's pediatrician if he urinates less than six times a day.". C. "Retract the foreskin to clean your baby's penis during each bath.". D. "Place triple antibiotic ointment on your baby's umbilical cord twice per day."
B. "Notify your baby's pediatrician if he urinates less than six times a day.".
A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first? A. A client who has placenta previa and a hematocrit of 36%. B. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L. C. A client who has diabetes mellitus and an HbA1c of 5.8%. D. A client who has preeclampsia and a creatinine level of 1.1 mg/dL.
B. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take? A. Provide the client with a cool sitz bath. B. Administer methylergonovine 0.2 mg IM. C. Apply a moist, warm compress to the perineum. D. Apply povidone-iodine to the client's perineum after she voids.
B. Administer methylergonovine 0.2 mg IM.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? A. Offer the newborn 30 mL (1 oz) of water between feedings. B. Allow the baby to feed at least every 3 hr. C. Feed the newborn 5 to 10 min per breast. D. Expect two to four wet diapers every 24 hr.
B. Allow the baby to feed at least every 3 hr.
A nurse is reviewing the laboratory results of a client who is at 20 weeks of gestation and has type 1 diabetes mellitus. Which of the following findings should the nurse report to the provider? A. Hct 34%. B. BUN 25 mg/dL. C. Platelets 170,000/mm. D. HbA1c 6%.
B. BUN 25 mg/dL.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings places the client at risk for postpartum haemorrhage? (Select all that apply.) A. Newborn weight 2.948 kg (6 lb 8 oz). B. History of uterine atony. C. Labor induction with oxytocin. D. History of human papillomavirus.
B. History of uterine atony.
Exhibit 1. Exhibit 2. Exhibit 3. Nurses' notes:. Decreased activity level over the last 12 hr. Abdominal distention. Three bloody stools over the last 4 hr. Superficial rash on the abdominal wall. Light palpation of the abdomen leads to fist clenching, thrashing, and crying. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take? A. Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr. B. Insert an orogastric decompression tube with low wall suction. C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr. D. Administer nitric oxide inhalation therapy to the newborn.
B. Insert an orogastric decompression tube with low wall suction.
A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse identify as the priority to report to the provider? A. Bluish discoloration of the hands and feet. B. Overlapping of the cranial bones. C. Forward and lateral positioning of the ears. D. Small, distended white sebaceous glands on the face.
B. Overlapping of the cranial bones.
A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take? A. Decrease maintenance IV solution infusion rate. B. Place the client in a lateral position. C. Administer oxygen via face mask at 2 L/min. D. Administer misoprostol 25 mcg vaginally.
B. Place the client in a lateral position.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? A. Incompetent cervix. B. Postpartum hemorrhage. C. Ectopic pregnancy. D. Hyperemesis gravidarum.
B. Postpartum hemorrhage.
A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? A. Blood glucose 110 mg/dL. B. Urine protein of 3+. C. Hemoglobin 13 g/dL. D. Deep tendon reflexes of 2+.
B. Urine protein of 3+.
A nurse is caring for a client who is in active labour and reports sudden, severe lower abdominal pain. The nurse observes a drop in the client's blood pressure and notes cool skin and pallor. The fetal heart rate tracing shows prolonged bradycardia. Which of the following complications should the nurse suspect? A. Amniotic fluid embolism. B. Uterine rupture. C. Umbilical cord prolapse. D. Placenta previa.
B. Uterine rupture.
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect? A. Temperature 37.4°C (99.3°F). B. Uterine tenderness. C. WBC Count 9,000/mm. D. Scant lochia.
B. Uterine tenderness.
A nurse is teaching a prenatal client about listeriosis and dietary modifications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I can have a mid-day snack with soft cheese.". B. "I can purchase a seafood salad from the grocery store.". C. "I can eat grilled chicken on a bun at lunchtime.". D. "I can still have a hot dog at the ballpark.".
C. "I can eat grilled chicken on a bun at lunchtime.".
A nurse in a clinic is caring for a client who is in her second trimester of 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? A. "Move your toddler to his new bed 2 months before the baby comes home.". B. "Avoid bringing your toddler to prenatal visits.". C. "Let your toddler see you carrying the baby into the home for the first time.". D. "Require scheduled interactions between the toddler and the baby.".
C. "Let your toddler see you carrying the baby into the home for the first time.".
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care? A. Administer broad-spectrum antibiotics. B. Monitor the rectal temperature every 4 hr. C. Cleanse the site with povidone-iodine. D. Prepare for surgical closure after 72 hr.
C. Cleanse the site with povidone-iodine.
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 sex of the fetus. Which of the following responses should the nurse make? A. "You cannot have an amniocentesis until you are at least 35 years of age.". B. "We can schedule the procedure for later today if you'd like.". C. "This procedure determines if your baby has genetic or congenital disorders.". D. "Your provider will schedule a chorionic villus sampling to determine the sex of your baby.".
C. "This procedure determines if your baby has genetic or congenital disorders.".
A nurse is providing teaching to a client about postpartum care. Which of the following information should the nurse include? A. "You should begin performing Kegel exercises 6 to 7 weeks after delivery.". B. "You don't need to use birth control if you are exclusively breastfeeding.". C. "You can expect your breasts to be firm and tender 3 to 5 days after delivery.". D. "Your bleeding will remain bright red for the next 6 to 8 weeks.".
C. "You can expect your breasts to be firm and tender 3 to 5 days after delivery.".
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A. A client who is taking a thiazide diuretic. B. A client who is vomiting. C. A client who has salicylate intoxication. D. A client who has diarrhea.
C. A client who has salicylate intoxication.
A nurse is performing an assessment for a newborn and notes breast tissue that has a flat areola with no bud. The nurse should identify that this finding indicates which of the following conditions? A. Preterm gestational age. B. Decreased maternal hormones during pregnancy. C. Congenital anomaly. D. Ambiguous secondary sex characteristics.
C. Congenital anomaly.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan? A. Apply a thin layer of lotion to the newborn's skin every 4 hr. B. Give the newborn 1 oz of glucose water every 4 hr. C. Ensure the newborn's eyes are closed beneath the shield. D. Dress the newborn in a thin layer of clothing during therapy. Show correct answer and explanation
C. Ensure the newborn's eyes are closed beneath the shield.
A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report? A. Increased fetal movement. B. Increased urinary output. C. Increased muscle weakness. D. Increased respiratory rate.
C. Increased muscle weakness.
A nurse is providing teaching about increasing dietary fibre to an antepartum client who reports constipation. Which of the following food selections has the highest fibre content per cup? A. Oatmeal. B. Cabbage. C. Lentils. D. Asparagus.
C. Lentils.
A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication? A. Blood pressure 136/88 mm Hg. B. Moderate fetal heart rate variability. C. Respiratory rate 100/min. D. Urinary output 120 mL in 2 hr.
C. Respiratory rate 100/min.
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? A. Place the client in a semi-Fowler's position for 1 hr after administration. B. Instruct the client to avoid urinary elimination until after administration. C. Verify that informed consent is obtained prior to administration. D. Allow the medication to reach room temperature prior to administration.
C. Verify that informed consent is obtained prior to administration.
A nurse is providing teaching to a client who reports that her baby has yellow discharge forming at the circumcision site. Which of the following is an appropriate response by the nurse? A. "I will need to obtain a sample of the discharge for laboratory testing.". B. "Apply povidone-iodine solution twice daily to the circumcision site.". C. "Wipe the discharge away gently with a washcloth and warm water for the next 48 hours.". D. "The discharge is common during the first 24 to 72 hours following a circumcision.".
D. "The discharge is common during the first 24 to 72 hours following a circumcision.".
A nurse is providing teaching to a client about the purpose of her upcoming indirect Coombs' test. Which of the following statements should the nurse include in the teaching? A. "This test determines if your baby is at risk for developing hypoglycemia after birth.". B. "This test will determine the amount of amniotic fluid around the fetus.". C. "This test studies blood flow in the fetus and placenta using ultrasound waves.". D. "This test will detect the presence of Rh-positive antibodies in your blood."
D. "This test will detect the presence of Rh-positive antibodies in your blood."
A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client? A. Intense contractions lasting 45 to 60 seconds. B. Progressive sacral discomfort during contractions. C. A sense of excitement and warm, flushed skin. D. An urge to have a bowel movement during contractions.
D. An urge to have a bowel movement during contractions.
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? A. Telangiectatic nevi. B. Erythema toxicum. C. Periauricular papillomas. D. Facial petechiae.
D. Facial petechiae.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase her intake of vitamin B12. Which of the following foods should the nurse recommend? A. Fresh citrus fruits. B. Brown rice. C. Raw carrots. D. Fortified soy milk.
D. Fortified soy milk.
A nurse is reviewing the medical record for a client who is receiving treatment for gestational diabetes mellitus. Which of the following medications should the nurse expect to administer? A. Levothyroxine. B. Nifedipine. C. Chlorpromazine. D. Glyburide
D. Glyburide
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia? A. Abdominal distention. B. Petechiae. C. Increased muscle tone. D. Jitteriness.
D. Jitteriness.
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit? A. 39 Page of 51 B. Prepared by Dr Paul Mugo' C. Hearing loss. D. Cataracts. E. Macrosomia.
A. 39 Page of 51
A nurse on an antepartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first? A. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache. B. A client who is at 12 weeks of gestation and is experiencing nausea and vomiting. C. A client who is at 38 weeks of gestation and is experiencing painful urination. D. A client who is at 39 weeks of gestation and is experiencing cramping and spotting.
A. A client who is at 34 weeks of gestation and is experiencing epigastric pain and headache.
A nurse is monitoring a client who is undergoing a nonstress test at 35 weeks of gestation. Which of the following findings requires intervention by the nurse? A. An FHR that peaks 20 beats above the baseline. B. Three uterine contractions within a 20-min period. C. One acceleration of the FHR within a 20-min period. D. Uterine contractions lasting 20 to 30 seconds each.
A. An FHR that peaks 20 beats above the baseline.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care? A. Avoid using lotion or ointment on the newborn's skin. B. Dress the newborn in lightweight clothing. C. Keep the newborn supine throughout treatment. D. Measure the newborn's temperature every 6 hr.
A. Avoid using lotion or ointment on the newborn's skin.
A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? A. Blood pressure 80/50 mm Hg. B. Respiratory rate 55/min. C. Heart rate 72/min. D. Temperature 36.5°C (97.7°F).
A. Blood pressure 80/50 mm Hg.
A nurse is caring for a client who is in active labor and is receiving oxytocin via IV infusion. The nurse has applied an internal fetal heart monitor and recognizes an early deceleration of the fetal heart rate tracing. Which of the following actions should the nurse take? A. Continue to monitor the client. B. Discontinue the oxytocin. C. Assist the client to lay on her right side. D. Administer oxygen at 8 L/min per mask.
B. Discontinue the oxytocin.
A nurse is admitting a client who is at 38 weeks of gestation following a spontaneous rupture of membranes. The nurse performs a vaginal examination and palpates the umbilical cord. Which of the following actions should the nurse take? A. Request that the provider insert an intrauterine pressure catheter. B. Exert continuous upward pressure on the presenting part. C. Initiate oxytocin via continuous IV infusion. D. Place the client in the left-lateral position.
B. Exert continuous upward pressure on the presenting part.
A nurse is caring for a client who has developed eclampsia. Which of the following actions should the nurse implement after the client experiences a convulsion? A. Place the client in a Trendelenburg position. B. Assist the client to void. C. Administer oxygen to the client via face mask at 10 L/min. D. Give calcium gluconate to the client.
C. Administer oxygen to the client via face mask at 10 L/min.
A nurse is reviewing the laboratory report for a client who is in active labor. The client tested positive for group B streptococcus B-hemolytic. Which of the following medications should the nurse plan to administer to the client? A. Doxycycline. B. Cefotetan. C. Ampicillin. D. Fluconazole.
C. Ampicillin.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take? A. Have the client limit the length of breastfeeding to 5 min per breast. B. Offer supplemental formula between the newborn's feedings. C. Assess the newborn's latch while breastfeeding. D. Instruct the client to wait 4 hr between daytime feedings.
C. Assess the newborn's latch while breastfeeding.
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? A. Offer the client a sitz bath. B. Insert a urinary catheter. C. Assist the client to the bathroom. D. Pour warm water over the client's perineum.
C. Assist the client to the bathroom.
A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion? A. Scant, bright red spotting. B. Elevated hCG. C. Cervical dilation. D. Slight abdominal cramps.
C. Cervical dilation.
A nurse in the labour and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn? A. Administer IV antibiotics to the newborn. B. Encourage the mother to breastfeed her newborn. C. Cleanse the newborn immediately after delivery. D. Initiate contact precautions for the newborn.
C. Cleanse the newborn immediately after delivery.
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? A. Rust-stained urine. B. Single palmar creases. C. Subconjunctival hemorrhage. D. Transient circumoral cyanosis.
C. Subconjunctival hemorrhage.
A nurse is developing an educational program about hemolytic disease in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease? A. The mother and the father are both Rh positive. B. The mother is Rh positive and the father is Rh negative. C. The mother is Rh negative and the father is Rh positive. D. The mother and the father are both Rh negative.
C. The mother is Rh negative and the father is Rh positive.
A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele's Rule, which of the following is the client's estimated date of delivery? A. May 20. B. May 3. C. May 13. D. May 17.
D. May 17.
A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin administration. The nurse should anticipate the use of which of the following medications? A. Betamethasone. B. Hydralazine. C. Terbutaline. D. Methylergonovine.
D. Methylergonovine.
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? A. Allow parents to enter the nursery if they are wearing a mask. B. Maintain airborne precautions in the nursery. C. Place the newborn's foot on a sterile field during a heelstick. D. Place newborn bassinets at least 3 feet apart.
D. Place newborn bassinets at least 3 feet apart.
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take? A. Swaddle the newborn with his legs extended. B. Schedule larger volume feedings at less frequent intervals. C. Maintain eye contact with the newborn during feedings. D. Plan care to minimize handling of the newborn.
D. Plan care to minimize handling of the newborn.
A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect? A. Bright, red vaginal discharge. B. Scaphoid abdomen. C. Elevated blood pressure. D. Sharp pelvic pain.
D. Sharp pelvic pain.
