MNPE
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 teaching a prenatal class regarding false labor. Which of the following information should the nurse include?f
"Your contractions will become temporarily regular."
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 client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
Administer a pneumococcal immunization to the newborn within 4 hr following birth. - this is given after testing the baby for reaction to HIV antigen and if negative, vaccine will be given after 4 hours of birth to baby
A nurse is caring for a client who has bladder distention following a vaginal birth. Which of thefollowing actions should the nurse take first?
Assist the client to the bathroom
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 report to the provider?
BUN 25 mg/dl
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 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. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Compress the bulb syringe Place the bulb syringe in newborn's mouth Use bulb syringe to suction newborn's nose Assess the newborn for reflex bradycardia
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 action should the nurse take?
Decrease maintenance IV solution infusion rate. - too much contraction is happening due to the oxytocin hence decreasing the dose is the correct answer
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 should the nurse take?
Demonstrate how to hold the newborn and allow client to practice.
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 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 assessing a full-term newborn. Which of the following findings should the nurse report to the provider?
Heart rate 72/min
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?
I can eat grilled chocken on a bun at lucnch time
Nagele's rule: Aug 20
May 27
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 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 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 in a clinic caring for a client who is in her second trimester pregnancy. The client expresses concern about preparing her 2-yearold- 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 teaching a newly licensed nurse about the use of ultrasonography in the first trimester. The nurse indicates an understanding of the teaching.
Ultrasound is used to determine gestational age in the first semester.
A nurse is assessing four newborns. Which of the following clinical findings...
a 2 day old infant who was a resp rate of 70/min
A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
a. Administer broad-spectrum antibiotics
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
allow the by to feed at least every 3hr
A nurse is caring for a client who is 12hr. postpartum and has a fourth degree laceration of the perineum
apply a moist, warm compress to the perineum
A nurse is assessing a client and observes the umbilical cord protruding from the vaginal, after calling
apply upward pressure against the presenting part
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?
assess the newborn latxh while breastfeeding
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?
avoid using lotion or ointment on the newborns skin
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
swaddle the newborn in a flexed position
A nurse is caring for a client who is postpartum following repair of a vaginal laceration. The client has a firm fundus, moderate lochia rubra, and reports moderate perineal discomfort and pressure. Which of the following actions should the nurse take?
check the perineal area
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?
continue to monitor the client
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?
the newborn is beginning to cough
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 has had a pudendal nerve block. The nurse should monitor for which of the following findings as an adverse effect?
decreased ability to bear down
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
ensure the newborn's eyes are closed beneath the shield
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 petachie
A nurse is providing prenatal teaching to a client who practices of vegan diet and is trying to increase intake on vitamin B12. Which of the following foods should the nurse recommend?
fortified soy milk
A nurse is monitoring a client who has preeclampsia and is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse report to the provider?
urinary ouput 200 ml/hr
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 the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
Administer nitric oxide inhalation therapy to the newborn
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 caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
Apply a cap to the newborn head. - the newborn is slightly hypothermic, and a bath would likely cause the newborn to suffer hypothermia more after the water has evaporated from newborn's skin
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 after feedings.
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 - this medication is contraindicated for hypertension
A nurse is assessing a client who is at 39 weeks of gestation and determines that the fetus is in a left occipitoanterior position. 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 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 the newborn bassinets at least 3 feet apart
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.
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
This medication prevents seizures."
A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection?
Unilateral breast pain
A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following should the nurse report to the provider?
Urine protein of 3+
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 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 newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV trans placenta Lee. Which of the following findings should the nurse expect the newborn to exhibit?
hearing loss
A nurse is caring for a client who has preeclampsia and receiving magnesium sulfate. Which of the following clinic?
increased muscle weakness
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?
lentils
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?
make a loud noise above the newborn
A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5-day old male newborn at home. Which of the following statements should the nurse make to the client?
notify your baby's pediatrician if he urinates less than 6 times per day
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines the client is 80% and 8cm. The nurse realizes that the client is at risk for which of the following conditions
postpartum hemmorhage
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?
resp rate 10/min
Rh immunoglobulin injection, who would you expect to give it to
rh negative mom, rh positive dad (i think this is the answer)
A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy.
sharp pelvic pain
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?
subconjuctival hemmorrhage
A nurse is assessing a client who is 6 hours postpartum and has endometritis. Which of the following findings should the nurse expect?
urine tenderness
A nurse is assisting the provider to administer a dinoprostone (Cervidil) 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
