N326 Final Exam Practice Questions
The absence of menstrual flow that is a clinical symptom of a variety of disorders, but is most commonly a result of pregnancy and is a classic sign of anorexia nervosa is called? A. Amenorrhea B. Dysmenorrhea C. Menorrhagia D. Polymenorrhea
A. Amenorrhea
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? A. Staphylococcus aureus B. Chlamydia trachomatis C. Klebsiella pneumonia D. Clostridium perfringens
A. Staphylococcus aureus
A pregnant client experiencing severe abruptio placentae would most likely exhibit: A. Maternal bradycardia B. Painless vaginal bleeding C. Rigid, board-like abdomen D. Vague abdominal discomfort
C. Rigid, board-like abdomen
A nurse is instructing a client who is taking oral contraceptives about manifestations to report to the provider. Which of the following manifestations should the nurse include? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Increased appetite
C. Shortness of breath
A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following findings? A. Scant, no odorous white vaginal discharge B. Uterine cramping during breastfeeding C. Sore nipple with cracks and fissures D. Decreased response with sexual activity
C. Sore nipple with cracks and fissures
A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash
C. Sunken fontanels
On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, she seems to remember very little of the teaching. The nurse understands this memory lapse is due to: A. The taking-hold phase B. Postpartum hemorrhage C. The taking-in phase D. Epidural anesthesia
C. The taking-in phase
Choose the correct teaching regarding a planned C-section. A. Oral intake will be limited to clear fluids for 12 hr before surgery B. IV fluids are usually continued for two days after birth C. The woman will be asked to take deep breaths and cough regularly after birth D. The nurse will help her ambulate to the restroom to urinate within 4 hr after birth
C. The woman will be asked to take deep breaths and cough regularly after birth
A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls
D. Epstein's pearls
During a prenatal examination, the nurse notes scarring on and around the woman's genitalia. Which of the following questions is most important for the nurse to ask in relation to these observations? A. Have you ever had a severe infection of your sex organs? B. Have you worn any piercings in your genital area? C. Have you ever had a tattoo removed from your genital area? D. Have you ever been forced to have sex without your permission?
D. Have you ever been forced to have sex without your permission? Rationale: This is to assess for any abuse that could be occurring.
A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. Apply cold compresses to the affected extremity B. Massage the affected extremity C. Allow the client to ambulated D. Measure leg circumference
D. Measure leg circumference
A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. Encourage the parents to touch and explore the neonate's features B. Limit noise and interruption in the delivery room C. Place the neonate at the client's breast D. Position the neonate skin-to-skin on the client's chest
D. Position the neonate skin-to-skin on the client's chest
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding? A. Hand the parent the newborn, and suggest that they change the diaper B. Ask the parent why they are so anxious and nervous C. Tell the parent that they will grow accustomed to the newborn D. Provide education about infant care when the parent is present
D. Provide education about infant care when the parent is present
A nurse is monitoring a client who was receiving an amnioinfusion. Which of the following assessments is critical for the nurse to make in order to prevent a serious complication related to the procedure? A. Color of the amniotic fluid B. Maternal blood pressure C. Cervical effacement D. Uterine resting tone
D. Uterine resting tone
A nurse is giving instructions to a parent about how to breastfed their newborn. Which of the following actions by the parent indicates understanding of the teaching? A. The parent places a few drops of water on their nipple before feeding B. The parent gently removes their nipple from the infant's mouth to break the suction C. When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finger D. When latched on, the infant's nose, cheek, and chin are touching the breast
D. When latched on, the infant's nose, cheek, and chin are touching the breast
A nurse in a health clinic is reviewing contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? A. "A water-soluble lubricant should be used with condoms." B. "A diaphragm should be removed 2 hours after intercourse." C. "Oral contraceptives can worsen a case of acne." D. "A contraceptive patch is replaced once a month."
A. "A water-soluble lubricant should be used with condoms."
A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? A. "It assists with blood clotting." B. "It promotes maturation of the bowel." C. "It is a preventative vaccine." D. "It provides immunity."
A. "It assists with blood clotting."
The nurse is caring for a woman who is 32 weeks gestation G8 P7007 with placenta previa. Which of the following interventions will the nurse expect to perform? (Select all that apply.) A. Daily contraction stress test B. Blood type and crossmatch C. Bedrest with passive range of motion exercises D. Weekly biophysical profiles
B. Blood type and crossmatch D. Weekly biophysical profiles
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? (Select all that apply.) A. Paranoia that their infant will be harmed B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a parent D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a parent
B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a parent D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a parent
An appropriate nursing action for a woman with a postspinal headache is: A. Keep her in bed in a semi-Fowler's position B. Encourage the intake of fluids that she enjoys C. Have her ambulate at least every 4 hours D. Restrict intake of high-carbohydrate foods
B. Encourage the intake of fluids that she enjoys
The primary expected outcome for nursing care associated with the administration of magnesium sulfate would be met if which assessment finding is present? The woman: A. Exhibits a decrease in both systolic and diastolic blood pressure B. Experiences no seizures C. States that she feels more relaxed and calm D. Urinates more frequently resulting in a decrease in pathologic edema
B. Experiences no seizures
A doctor orders a narcotic analgesic for a laboring client. Which of the following situations would lead a nurse to hold the medication? A. Contraction pattern is every 3 min X 60 sec B. Fetal monitoring tracing shows late decelerations C. Client sleeps between contractions D. The blood pressure is 150/90
B. Fetal monitoring tracing shows late decelerations
A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following actions should the nurse take? A. Come back later when the client is more cooperative B. Give the client time to express feelings C. Tell the client they need to be quiet so the assessment can be completed D. Redirect the client's focus so that they will become quiet
B. Give the client time to express feelings
Cervical neoplasia has been linked to which of the following STIs? A. Herpes simples virus (HSV) B. Human papillomavirus (HPV) C. Human immunodeficiency virus (HIV) D. Chlamydia
B. Human papillomavirus (HPV)
A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (Select all that apply.) A. Tinnitus B. Irregular vaginal bleeding C. Weight gain D. Nausea E. Gingival hyperplasia
B. Irregular vaginal bleeding C. Weight gain D. Nausea
In which of the following clinical situations would it be appropriate for an OB to order a labor nurse to perform an amnioinfusion? A. Placental abruption B. Meconium stained fluid C. Polyhydramnios D. Late decelerations
B. Meconium stained fluid Rationale: Amnioinfusion could also be indicated in the case of significant cord compression.
A woman's preeclampsia has advanced to the severe stage. She is admitted to the hospital and her primary health care provider has ordered an infusion of magnesium sulfate be started. In implementing this order, the nurse should: (Select all that apply.) A. Prepare a solution of 20g of magnesium sulfate in 100 mL of 5% glucose in water B. Monitor maternal vital signs FHR patterns and uterine contractions C. Expect the maintenance dose to be approximately 2g/hr D. Administer a loading dose of 4 to 6 g over 15 to 30 minutes E. Prepare to administer Apresoline if signs of toxicity appear F. Report a respiratory rate of 12 breaths or less to the Primary health care provider immediately
B. Monitor maternal vital signs FHR patterns and uterine contractions C. Expect the maintenance dose to be approximately 2g/hr D. Administer a loading dose of 4 to 6 g over 15 to 30 minutes F. Report a respiratory rate of 12 breaths or less to the Primary health care provider immediately
A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching? A. Wear a supportive bra continuously for the first 72 hr B. Pump your breast every 4 hr to relieve discomfort C. Use breast shells throughout the day to decrease milk supply D. Apply warm compresses until milk suppression occurs
B. Pump your breast every 4 hr to relieve discomfort
A client who is 24 weeks pregnant is being seen in the prenatal clinic. She states, "I've had a terrible headache for the past two days." Which of the following is the most appropriate action for the nurse to perform next? A. Inquire whether or not the client has allergies B. Take the woman's blood pressure C. Assess the fundal height D. Ask the woman about stressors at work
B. Take the woman's blood pressure
The nurse is monitoring a woman (G2 P1001 and 41 weeks gestation) in labor. At 12 PM, assessment revealed: cervix 4cm, 80% effaced, -3 station, FHT moderate variability. At 5 PM, assessment revealed: cervix 6cm, 90% effaced, -3 station, FHT 124 with moderate variability. At 10 PM, assessment revealed: cervix 8cm, 100% effaced, -3 station, FHT 128 with moderate variability. Based on the assessments, which of the following should the nurse include? A. Labor is progressing well B. The woman may be carrying a macrosomic infant C. The baby is in fetal distress D. The woman will be in second stage of labor in three hours
B. The woman may be carrying a macrosomic infant Rationale: Big clue is that the station never changed as her labor progressed.
A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? A. Apical heart rate 104 B. Urinary output 240mL in 24 hr C. Blood pressure 160/120 mm Hg D. Temperature 100F
B. Urinary output 240mL in 24 hr
A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of uterine atony? A. Poor involution B. Urinary retention C. Hemorrhage D. Infection
B. Urinary retention
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. "Limit the amount of time the infant nurses on each breast." B. "Nurse the infant only on the unaffected breast until resolved." C. "Completely empty each breast at each feeding or use a pump." D. "Wear a tight-fitting bra until lactation has ceased."
C. "Completely empty each breast at each feeding or use a pump."
A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements by the parent indicates understanding of the teaching? A. "The circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form." C. "I will clean the penis with each diaper change." D. "I will give him a tub bath within a couple of days."
C. "I will clean the penis with each diaper change."
A nurse is reviewing discharge teaching with a client who has a UTI. Which of the following statements by the client indicates understanding of the teaching? (Select all that apply.) A. "I will perform perineal care and apply a perineal pad in a back-to-front direction." B. "I will drink grape juice to make my urine more acidic." C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." D. "I will go back to breastfeeding after I have finished taking the antibiotic." E. "I will take Tylenol for any discomfort."
C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." E. "I will take Tylenol for any discomfort."
A woman comes to the clinic to report she had unprotected intercourse the previous night. She is nervous she may get pregnant and asks the nurse for Plan B. Which of the following instructions given by the nurse is correct? A. "You will need to take a dose now and repeat the dose in 12 hours." B. "This medication will cause heavy bleeding." C. "This medication will likely cause nausea and vomiting. You can take an over-the-counter antiemetic." D. "If you cannot tolerate taking oral contraception, this medication is not a good option for you."
C. "This medication will likely cause nausea and vomiting. You can take an over-the-counter antiemetic."
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the client's uterus to be firm and midline & at the level of the umbilicus. The nurse interprets this finding as: A. Evidence of a possible vaginal hematoma B. An indication of a cervical or perineal laceration C. A normal postural discharge of lochia D. Abnormally excessive lochia rubra flow
C. A normal postural discharge of lochia
A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10 second periods D. Obligatory nose breathing E. Crackles and wheezing
C. Apnea for 10 second periods D. Obligatory nose breathing
A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement? A. Apply Gelfoam powder to the site B. Place the newborn in the prone position C. Apply petroleum gauze to the site D. Avoid changing the diaper until the first voiding
C. Apply petroleum gauze to the site
A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? A. Front seat, rear-facing B. Front seat, forward-facing C. Back seat, rear-facing D. Back seat, forward-facing
C. Back seat, rear-facing
Which of the following infections may lead to pelvic inflammatory disease (PID) and increase a woman's risk for infertility? A. Vulvovaginal candidiasis B. Group B streptococci C. Chlamydia D. Human papillomavirus (HPV)
C. Chlamydia
A new breastfeeding mother asks the nurse how to prevent nipple soreness. The nurse tells this woman that the key to preventing sore nipples is: A. Limiting the length of breastfeeding to 10 minutes a side until the mature milk comes in. B. Apply lanolin to each nipple and areola after each feeding. C. Correct latch and removal from breast. D. Using breast shields to protect the nipples and areola between feedings.
C. Correct latch and removal from breast.
A woman with severe preeclampsia is receiving nifedipine (Procardia). She asks the nurse what this medication is far. The nurse should tell her that nifedipine is used to: A. Prevent seizures B. Relieve the headache she is beginning to have. C. Decrease her blood pressure. D. Reduce the edema in her hands and legs
C. Decrease her blood pressure.
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone
C. Erythromycin
A newborn was not dried completely after birth. This places the risk at risk for which of the following types of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation
C. Evaporation
The nurse is teaching a new mother how to bottle feed her newborn. Instructions the new mother should receive regarding this feeding method include.... A. Check the nipple before feeding to ensure that it allows passage of formula in a slow stream. B. Feed the newborn water in between feedings at least 2 ounces a day. C. Expect a 2 week old newborn to eat every 3 to 4 hours during the day. D. Microwave formula for about 2 minutes before feeding the newborn.
C. Expect a 2 week old newborn to eat every 3 to 4 hours during the day.
A woman is determined to be group B streptococcus (GBS) positive at the onset of labor. The nurse should prepare this woman for: A. Cesarean birth B. Isolation of her newborn after birth C. Intravenous antibiotic prophylaxis (IAP) using penicillin G during labor D. Application of acyclovir to her labial lesions
C. Intravenous antibiotic prophylaxis (IAP) using penicillin G during labor
A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. Burp the newborn at the end of the feeding B. Hold the newborn close in a supine position C. Keep the nipple full of formula throughout the feeding D. Refrigerate any unused formula
C. Keep the nipple full of formula throughout the feeding
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A. Sit-ups B. Pelvic tilt exercises C. Kegel exercises D. Abdominal crunches
C. Kegel exercises
A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? A. Ask the parent to state their full name B. Look at the name on the newborn's bassinet C. Match the parent's identification band with the newborn's band D. Compare name on the bassinet and room number
C. Match the parent's identification band with the newborn's band
Following vaginal birth 2 hours ago a woman with preeclampsia is experiencing a heavy flow as a result of a boggy uterus. It is determined that she will require medication to reduce the amount of blood loss. Which medication would the nurse anticipate administering? A. Methylergonovine (Methergine) B. Calcium gluconate C. Oxytocin (Pitocin) D. Labetalol (Normodyne)
C. Oxytocin (Pitocin)
A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use a disinfectant wipe to clean the lid of the formula can B. Store prepared formula in the refrigerator for up to 72 hr C. Place used bottles in the dishwasher D. Check the nipple for appropriate flow of formula E. Use tap water to dilute concentrated formula
C. Place used bottles in the dishwasher D. Check the nipple for appropriate flow of formula E. Use tap water to dilute concentrated formula
When caring for a woman with mild preeclampsia, it is critical that during assessment the nurse be alert for signs of progress to severe preeclampsia. Progress to severe preeclampsia is indicated by this assessment finding: A. Proteinuria greater than 2+, in two specimens collected 6 hours apart B. Platelet count of 180,000/mm3 C. Positive ankle clonus D. Blood pressure of 154/94 and 156/100, 6 hours apart
C. Positive ankle clonus Rationale: Think about the effects on the CNS, specifically hyperreflexia.
The postpartum nurse is caring for a client who gave birth to twins earlier today. The nurse will assess for symptoms of: A. Increased blood pressure B. Hypoglycemia C. Postpartum hemorrhage D. Postpartum infection
C. Postpartum hemorrhage
A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? A. "Obtain an immunization against rubella early in pregnancy." B. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy." C. "A client should avoid crowded places during pregnancy." D. "A client should avoid consuming undercooked meat while pregnant."
D. "A client should avoid consuming undercooked meat while pregnant."
A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam." B. "I cannot get an IUD until after I've had a child." C. "I should plan on regaining fertility 5 months after the IUD is removed" D. "I will check to be sure the strings of the IUD are still present after my periods"
D. "I will check to be sure the strings of the IUD are still present after my periods"
A nurse is assessing the reflexes of a newborn. In check for the Moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table B. Stimulate the pads of the newborn's hands with stroking or massage C. Stimulate the soles of the newborn's feet on the outer surface of each foot D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward
D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward
An insulin-dependent diabetic woman will require higher doses of insulin as which of the following pregnancy hormones increases in her body? A. Estrogen B. Progesterone C. Human chorionic gonadotropin D. Human placental lactogen/human chorionic somatomammotropin
D. Human placental lactogen/human chorionic somatomammotropin
A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following instructions should the nurse include in the teaching? A. Cover the cord with a small gauze square B. Trickle clean water over the cord with each diaper change C. Apply hydrogen peroxide to the cord twice a day D. Keep the diaper folded below the cord
D. Keep the diaper folded below the cord
A woman at 42 weeks gestation is admitted to the labor and delivery suite for induction. A biophysical profile report on the client's chart states a score of 6/10. The nurse should monitor this client carefully for which of the following? A. Maternal hypertension B. Maternal hyperglycemia C. Increased fetal heart rate variability D. Late fetal heart rate decelerations
D. Late fetal heart rate decelerations
The nurse should suspect puerperal (postpartum) infection when the client exhibits which of the following? A. Temperature 100.2F B. White blood cell count of 14,500/mm3 C. Diaphoresis during the night D. Malodorous lochial discharge
D. Malodorous lochial discharge
The nurse determines the fundus of a postpartum client to be boggy. Initially, the nurse should: A. Document the findings B. Assess maternal vital signs C. Call the primary care provider D. Massage the fundus and reassess
D. Massage the fundus and reassess
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? A. Postpartum fatigue B. Postpartum psychosis C. Lettinggo phase D. Postpartum blues
D. Postpartum blues
A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? A. Spits up clear mucus B. Attempts to place their hand in their mouth C. Turns the head toward sounds D. Lies quietly with their eyes open
B. Attempts to place their hand in their mouth
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? A. Moderate lochia rubra B. Excessive lochia serosa C. Light lochia rubra D. Scant lochia serosa
A. Moderate lochia rubra
A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn's birth weight is 1100g. Which of the following are expected findings in this newborn? (Select all that apply.) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face
A. Lanugo C. Weak grasp reflex D. Translucent skin
A nurse in a clinic is teaching a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Weight fluctuations can occur." B. "You are protected against STIs." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "Irregular vaginal spotting can occur."
A. "Weight fluctuations can occur." C. "You should increase your intake of calcium." E. "Irregular vaginal spotting can occur."
The nurse in the OB office is caring for four 25 week gestation prenatal clients who are carrying singleton pregnancies. With which of the following clients should the nurse carefully review the signs and symptoms of preterm labor? A. 38-year-old registered nurse in an abusive relationship B. 32-year-old secretary whose first child was post-term C. 26-year-old attorney whose baby has a 2-vessel cord D. 20-year-old college student with a history of irregular menstrual periods
A. 38-year-old registered nurse in an abusive relationship Rationale: The abusive relationship is very stressful. Stress can induce preterm labor.
A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make? A. Apply cold compresses between feedings B. Take a warm shower right after feedings C. Apply breast milk to the nipples and allow them to air dry D. Use the various infant positions for feeding
A. Apply cold compresses between feedings
A patient, who is 32 weeks pregnant and complaining of a severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bedrest, the physician ordered the following four items. Which of the orders should the nurse perform first? A. Assess deep tendon reflexes B. Obtain CBC C. Assess baseline weight gain D. Obtain urine for protein
A. Assess deep tendon reflexes Rationale: Proteinuria is no longer a diagnostic requirement for preeclampsia.
A nurse on the postpartum unit is assessing a client who is being admitted with a suspected DVT. Which of the following clinical findings should the nurse expect? (Select all that apply.) A. Calf tenderness to palpation B. Mottling of the affected extremity C. Elevated temperature D. Area of warmth E. Report of nausea
A. Calf tenderness to palpation C. Elevated temperature D. Area of warmth
A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse expect the provider will prescribe? A. Ceftriaxone B. Fluconazole C. Metronidazole D. Zidovudine
A. Ceftriaxone
A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those of family members E. Interprets the newborn's behavior as meaningful and a way of expressing needs
A. Demonstrates apathy when the newborn cries C. Views the newborn's behavior as uncooperative during diaper changing
A nurse is discussing risk factors for UTIs with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (Select all that apply.) A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic exams D. History of UTIs E. Vaginal birth
A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic exams D. History of UTIs
A pregnant diabetic has been diagnosed with polyhydramnios. Which of the following would explain this finding? A. Excessive fetal urination B. Recurring hypoglycemic episodes C. Fetal sacral agenesis D. Placental vascular damage
A. Excessive fetal urination
A nurse is caring for a postpartum client who delivered their 3rd infant 2 days ago. Which of the following manifestations could indicate postpartum depression? (Select all that apply.) A. Fatigue B. Insomnia C. Euphoria D. Flat affect E. Delusions
A. Fatigue B. Insomnia D. Flat affect
A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? (Select all that apply.) A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus beta-hemolytic E. TORCH infection
A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus beta-hemolytic Rationale: Erythromycin is administered to the infant immediately after delivery to prevent gonorrhea and chlamydia. Retrovir is prescribed to a client in labor who is HIV positive. Penicillin G or ampicillin may be prescribed to treat positive GBS.
A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (Select all that apply.) A. Hypospadias B. Hydrocele C. Family history of hemophilia D. Hyperbilirubinemia E. Epispadias
A. Hypospadias C. Family history of hemophilia E. Epispadias
Which of the following signs and symptoms will the nurse expect to see in a woman with placental abruption? A. Increasing fundal height measurements B. Pain-free vaginal bleeding C. Fetal heart rate accelerations D. Hypertension with +3 proteinuria
A. Increasing fundal height measurements
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemic caused by hemorrhage? A. Increasing pulse and decreasing blood pressure B. Dizziness and increasing respiratory rate C. Cool, clammy skin, and pale mucous membranes D. Altered mental status and level of consciousness
A. Increasing pulse and decreasing blood pressure
A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which off the following findings should the nurse expect? (Select all that apply.) A. Joint pain B. Malaise C. Rash D. Urinary frequency E. Tender lymph nodes
A. Joint pain B. Malaise C. Rash E. Tender lymph nodes
A client has just done a fetal kick count assessment. She noted six movements during the last hour. If taught correctly, what should her next action be? A. Nothing, because further action is not warranted B. Call the provider to set up a NST C. Redo the test during the next 30 min D. Drink a glass of orange juice and redo the test
A. Nothing, because further action is not warranted
A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration fo synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate
A. Oxygen saturation
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Precipitous delivery B. Obesity C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments
A. Precipitous delivery C. Inversion of the uterus E. Retained placental fragments
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. Preeclampsia B. Thrombophlebitis C. Placenta previa D. Hyperemesis gravidarum
A. Preeclampsia
A method to prepare the cervix for induction of labor the following day is: A. Prostaglandin preparations B. Fetal fibronectin C. Oral oxytocin tablets D. Amniotomy
A. Prostaglandin preparations Rationale: Misoprostol (Cytotec) or Cervidil will be administered.
A 15-year-old client is being seen for her first prenatal visit. Because of this client's special nutritional needs, the nurse evaluates the client's intake of: A. Protein and magnesium B. Calcium and iron C. Carbohydrates and zinc D. Folic acid and thiamine
A. Protein and magnesium
A woman's glucose challenge test (GCT) results are 155 mg/dL at 1 hour post-glucose ingestion. Which of the following actions, as ordered by the physician, is appropriate? A. Send the woman for a glucose tolerance test. B. Teach the woman how to inject herself with insulin. C. Notify the woman of the normal results. D. Provide the woman with oral hypoglycemic agents.
A. Send the woman for a 3 hr glucose tolerance test (GTT)
During the recovery period after low forceps birth with a median episiotomy, the nurse should: A. Assess for purulent drainage from the episiotomy B. Apply cold packs to the perineal area promptly C. Expect a larger quantity of lochia rubra D. Limit oral intake to ice chips until transfer to a room
B. Apply cold packs to the perineal area promptly Rationale: Prevent hematoma formation.
A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age
B. Appropriate for gestational age
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. This is more commonly seen in newborns who have dark skin B. This is a finding indicating hyperbilirubinemia C. This is a forceps mark from an operative delivery D. This is related to prolonged birth or trauma during delivery
A. This is more commonly seen in newborns who have dark skin
Which of the following factors would be contraindicated with use of oral contraception with estrogen and progesterone? (Select all that apply.) A. Uncontrolled hypertension B. History of asthma C. Active liver disease D. History of endometriosis E. Undiagnosed vaginal bleeding
A. Uncontrolled hypertension C. Active liver disease E. Undiagnosed vaginal bleeding
A nurse is providing education to a client who is 2 hr postpartum and has a perineal laceration. Which of the following information should the nurse include? (Select all that apply.) A. Use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed C. Apply a topical anesthetic cream or spray to the perineum D. Wipe the perineum thoroughly with a back-and-forth motion E. Apply cold or ice packs to the perineum
A. Use a perineal squeeze bottle to cleanse the perineum C. Apply a topical anesthetic cream or spray to the perineum E. Apply cold or ice packs to the perineum
A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? (Select all that apply.) A. Vacuum extractor B. Oxytocin infusion C. The use of forceps during delivery should be avoided due to the risk of fetal bleeding D. Cesarean birth E. Internal fetal monitoring
A. Vacuum extractor C. The use of forceps during delivery should be avoided due to the risk of fetal bleeding E. Internal fetal monitoring Rationale: The use of a vacuum extractor should be avoided due to risk of exposing the fetus to maternal blood. The use of forceps during delivery and internal fetal monitoring should be avoided due to the risk of fetal bleeding.
A woman at 35 weeks of gestation with preeclampsia, has a seizure. Immediately after the seizure, the nurse's priority action is to: A. Evaluate FHR and pattern for signs of decreasing variability, late decelerations, or bradycardia B. Assess status of the maternal airway, respiratory effort, and pulse C. Determine if membranes have ruptured and if the amniotic fluids contain meconium D. Prepare to increase the amount of magnesium sulfate being infused from 1g/hr to 2g/hr
B. Assess status of the maternal airway, respiratory effort, and pulse
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? A. "I will need to use contraception for 3 months before considering pregnancy." B. "I need a second vaccination at my postpartum visit." C. "I was given the vaccine because my baby is O-positive." D. "I will be tested in 3 mo. to see if I have developed immunity."
B. "I need a second vaccination at my postpartum visit."
A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "The newborn will have decreased muscle tone." B. "The newborn will have a continuous high-pitched cry." C. "The newborn will sleep for 2-3 hr after a feeding." D. "The newborn will have mild tremors when disturbed."
B. "The newborn will have a continuous high-pitched cry."
A nurse is caring for a client who is 2 days postpartum. The client states, "My 4 year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training agents." B. "Your son is showing an adverse sibling response." C. "Your son may need counseling." D. "You should try sending your son to preschool to resolve the behavior."
B. "Your son is showing an adverse sibling response."
Which of the following pregnant clients is most high risk for PPROM (preterm premature rupture of membranes)? A. 30 weeks gestation with prolapsed mitral valve B. 32 weeks gestation with urinary tract infection C. 34 weeks gestation with gestational diabetes D. 36 weeks gestation with deep vein thrombosis
B. 32 weeks gestation with urinary tract infection
A nurse is providing care to 4 clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episiotomy that is erythematous and has extended into a 3rd-degree laceration B. A client who does not wash their hands between perineal care and breastfeeding C. A client who is breastfeeding and is using measures to suppress lactation D. A client who has a cesarean incision that is well-approximated with no drainage
B. A client who does not wash their hands between perineal care and breastfeeding
A nurse on the postpartum unit is caring for 4 clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? A. A client who experienced a precipitous labor less than 3 hr in duration B. A client who had premature rupture of membranes and prolonged labor C. A client who delivered a large for gestational age infant D. A client who had a boggy uterus that was not well-contracted
B. A client who had premature rupture of membranes and prolonged labor
A gestational diabetic, who requires insulin therapy to control her blood glucose levels, telephones the triage nurse complaining of dizziness and headache. Which of the following actions should the nurse take at this time? A. Have the client proceed to the office to see her physician B. Advise the client to drink a glass of milk C. Instruct the client to inject yourself with regular insulin D. Tell the client to immediately telephone her medical doctor
B. Advise the client to drink a glass of milk Rationale: These are signs of hypoglycemia, so the patient should be instructed to consume something that will help raise the blood sugar.
What's the nurse's first action immediately following rupture of membranes of a woman in labor? A. Document the color and consistency of fluid B. Assess the fetal heart rate C. Look for presence of the umbilical cord at the vaginal orifice D. Keep her in bed until the MD is contacted
B. Assess the fetal heart rate
A nurse is caring for a client who is at 42 weeks of gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? A. "Your baby will have excess body fat." B. "Your baby will have flat areola without breast buds." C. "Your baby's heels will easily move to his ears." D. "Your baby's skin will have a leathery appearance."
D. "Your baby's skin will have a leathery appearance."
A nurse administers magnesium sulfate via infusion pump to a preeclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? A. Client has no patellar reflex response B. Urinary output 30 mL/hr C. Respiratory rate 16 D. Client has no tonic-clonic convulsion signs
D. Client has no tonic-clonic convulsion signs
A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving a vitamin K injection D. Covering the newborn's head with a cap
D. Covering the newborn's head with a cap
A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss? A. Over-the-shoulder B. Supine C. Chin-supported D. Cradle
D. Cradle
A client has just had an external version. The nurse monitors this client carefully for which of the following? A. Decreased urinary output B. Elevated blood pressure C. Severe occipital headache D. Variable fetal heart decelerations
D. Variable fetal heart decelerations
