NB - Nclex
The nurse is caring for a pregnant client who was diagnosed with AIDS & asks the nurse if she will be able to breast-feed the infant after delivery. Which response by the nurse is appropriate?
"Breast-feeding is contraindicated."
A couple comes to the family planning clinic & asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be appropriate?
"Do you plan to have any other children?"
A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client would identify the need for further teaching regarding the hemorrhoids?
"Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born."
During a prenatal visit, the nurse is explaining dietary management to a client with DM. The nurse determines that the teaching has been effective when the client makes which statement?
"I need to increase the fiber in my diet to control my blood glucose & prevent constipation."
The client at 28wks' gestation is Rh negative & Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?
"I will tell the nurse at the hospital that I had RhoGAM during pregnancy."
The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?
"It is the fetal movement that is felt by the mother."
A student nurse examines an Asian-American infant's eyes & notes that the infant's eyes are crossed. Which statement by the student to the nurse indicates an understanding of this finding?
"It probably isn't strabismus but appears that way because of the child's ethnic background."
A client at 32wks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone & appears very anxious. Which statement by the nurse is therapeutic?
"Tell me about your concerns."
The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which would indicate successful learning?
"The iron is needed for the red blood cells."
A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?
"The uterus is stimulated to contract by either small amounts of oxytocin (Pitocin) or by nipple stimulation."
Which statement by a pregnant client who is HIV positive indicates her understanding of the risk to her NB during delivery?
"There is a risk of transmission from HIV-positive mothers to their NB, although the NB may be asymptomatic at birth."
During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the 3rd trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?
150 bpm
A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?
16 & 20 weeks gestation
The nurse is collecting data from a pregnant client who is at 28wks' gestation. The nurse measures the fundal height in cm & should expect which finding?
28 cm
The perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?
A diet that is high in fluids and fiber to decrease constipation
The nurse notes that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which is the explanation for this increase?
A normal finding
The nurse palpates the anterior fontanel of a NB & notes that it feels soft. What does this datum indicate to the nurse?
A normal finding
The nurse performs a blood glucose test on a NB infant whose mother has DM & obtains a reading of 50 mg/dL. What does the result indicate to the nurse?
A normal level
The nurse notes hypotonia, irritability, & a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?
Abnormal palmar creases
A pregnant woman in the 2nd trimester of pregnancy complains of constipation & describes the home care measures she is taking to relieve the problem. Which should the nurse determine is a harmful measure in preventing constipation?
Adding 1 tablespoon of mineral oil to a bowl of cereal daily
A hep B screen is performed on a pregnant client, & the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?
Administration of immune globulin & vaccine in the infant soon after birth
The clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for HIV infection?
An adolescent with multiple heterosexual contacts
The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make?
Are where fertilization occurs
The nurse is assisting in caring for a NB whose mother is Rh negative. Which is important for the nurse to include when planning the NB's care?
Ask about the NB's blood type & direct Coombs.
During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." Which would the nurse check further?
BP changes & the presence of protein in the urine
The nurse is assisting in caring for a postterm neonate immediately after admission to the nursery. The priority nursing action should be to monitor which?
Blood glucose levels
A client presents at her HCP's office 10wks pregnant with her 1st pregnancy. Which is a presumptive sign of pregnancy that the client might be expected to have?
Breast changes
The nurse is caring for a 3-hour-old infant & notes that the infant has not eaten since birth, is jittery, & has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take 1st?
Check the blood glucose level
While assisting with the measurement of fundal height, the client at 36wks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which?
Compression of the vena cava
The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?
Contact the HCP if the baby's movements are fewer than 10 times in 2 hours.
The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner & should tell the client to perform which measure?
Dorsiflex the client's foot while extending the knee
An 8-day-old infant is irritable, has a high-pitched persistent cry, & a temperature of 99.4° F. The infant is also tachypneic & diaphoretic, continues to lose weight, & is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?
Drug withdrawal
The nurse is assisting in caring for a NB with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the NB & parents?
Encourage the parents to touch their NB
A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which indicates an abnormal physical finding that necessitates further testing?
FHR of 180 bpm
The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5yo child who was delivered at 38wks, & she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document the GTPAL for this client as which?
G = 2 T = 1 P = 0 A = 0 L = 1
The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to a potential problem specifically related to the twin pregnancy?
HTN
A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?
Hemoglobin 9.1 g/dL
The nurse is reviewing the procedure for vitamin K injection in the NB with a nursing student. Which information should the nurse provide to the student?
Inject into skin that has been cleansed with alcohol
The nurse is reinforcing teaching to a pregnant woman about the physiological effects & hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?
It stimulates uterine development to provide an environment for the fetus & stimulates the breasts to prepare for lactation.
The client arrives at the prenatal clinic for her 1st prenatal assessment. The client tells the nurse that the 1st day of her LMP was October 20, 2016. Using Nägele's rule, the nurse determines the estimated DOB is which?
July 27, 2017
The nurse is reviewing the health record of a pregnant client at 16wks' gestation. The nurse should expect to note documentation that the fundus of the uterus is located at which area?
Just above the symphysis pubis
The client is in her 2nd trimester of pregnancy. She complains of frequent low back pain & ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?
Lie on the floor with the legs elevated onto a couch or padded chair, with the hips & knees at a right angle.
The nurse is assigned to assist with caring for a neonate born to a mother who is HIV positive. The nurse understands that which should be included in the plan of care?
Maintaining standard precautions at all times while caring for the neonate
The nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record would support this risk factor?
Maternal HTN
The nurse encourages the childbearing woman diagnosed with HIV to avoid alcohol & cigarettes during pregnancy & to obtain adequate rest. Which outcome is specific to this client?
Minimize the potential for developing infections.
The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client?
Monitoring fetal movement
The nurse is assisting in developing a plan of care for a NB with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?
Monitoring the anterior fontanel for bulging
The nurse is bathing a neonate & notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?
Notify the HCP of the finding.
The nurse is monitoring a NB infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F & that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?
Notify the RN
The nurse is caring for a NB whose mother had an elevated temperature during a prolonged labor. Which intervention should be important to include in the NB's plan of care?
Observe VS & CNS status frequently during the 1st 2 days
After a NB infant undergoes circumcision, which should the nurse include in the post procedure plan of care?
Observing for bleeding & monitoring for pain
A client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which treatment for acne should be avoided with this client?
Oral tetracycline hydrochloride
A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that the primary hormone that stimulates postpartum contractions is which?
Oxytocin
The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching should the nurse use?
Palpate for uterine contractions at the same time as the client
The nurse is assisting in collecting data on a large-for-gestational age (LGA) NB. Which technique should the nurse anticipate being used to check for evidence of birth trauma?
Palpating the clavicles for a fracture
The nursing instructor has taught a lecture on the reproductive cycle of the female & asks a nursing student to identify the anatomical structure that supports & protects the internal reproductive organs. The student correctly responds by identifying which structure?
Pelvis
The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if which is observed?
Petechiae, oozing from injection sites, & hematuria
The nurse is measuring the fundal height of a client who is at 30wks of gestation. In preparing to perform the procedure the nurse should take which action?
Place the client in a supine position & place a wedge under the right hip.
The nurse is caring for a pregnant client with a history of HIV. Which problem has the highest priority for this client?
Potential for infection
The nurse administers erythromycin ointment (0.5%) to the NB's eyes, & the mother asks the nurse why this is done. The nurse should give which response to the client?
Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection
The nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse tells the parents that which hormone primarily stimulates the secretion of milk?
Prolactin
The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?
Provides an exchange of nutrients & waste products between the mother and the fetus
A NB has just been circumcised. Which describes how the nurse should expect the surgical site to appear?
Reddened, with a small amount of bloody drainage
The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?
Sitz baths need to be taken q4h while awake if vaginal lesions are present.
The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client & expects that the client will indicate that which medication is prescribed?
Subcutaneous administration of heparin sodium 5000 units daily
The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?
Syphilis
The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm NB?
Tachypnea & retractions
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
Tell the client that these are common & they may occur throughout the pregnancy
The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse would indicate an understanding of a subdural hematoma?
Testing for equality of extremities when stimulating reflexes
The client is undergoing an amniocentesis at 16wks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?
The bladder must be full during the exam.
A pregnant client is seen in the health care clinic & asks the nurse what causes the breasts to change in size & appearance during pregnancy. The nurse bases the response on what information?
The breast changes are a result of the secretion of estrogen & progesterone.
While a client is holding & talking to her NB immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?
The client is experiencing a normal response to birth
The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?
The infant has evidence of significant jaundice
The nurse is reviewing the health care record of a NB admitted to the nursery; the NB is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?
The passage of bloody mucous stool
The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care?
The process of keeping the cord clean & dry will decrease bacterial growth.
The nurse is collecting data from a pregnant client with a history of cardiac disease & is checking the client for venous congestion. The nurse inspects which body area, knowing that venous congestion is commonly noted in which area?
Vulva
The nurse is collecting data from a client during the 1st prenatal visit. The client is anxious to know the gender of the fetus & asks the nurse when she will be able to know. The nurse responds to the client, knowing that the gender of the fetus can be visually recognizable as early as which week?
Week 12
A client is 8wks pregnant & has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, & she is reluctant to attend because of the nausea & vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?
"You feel you are having difficulty fulfilling your role as a wife."
A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse would be appropriate?
"You were wise to call. I will check your rubella titer screening results, & we can identify immediately if interventions are needed."
The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which?
2 umbilical arteries & 1 umbilical vein
The nurse is preparing a woman with gestational hypertension for discharge & shares with the client directions to follow which instructions? Select all that apply.
- Curtail exercise - Measure your BP daily. - Rest frequently by lying on your side. - Call the HCP if you develop dizziness
The nurse is doing a 48-hour postpartum check on a client with mild gestational hypertension (GH). Which data indicate that the GH is a concern?
The client complains of a headache & blurred vision
The nurse is monitoring a NB who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this NB? Select all that apply.
- The NB is irritable - The NB cries incessantly. - The NB is difficult to console. - The NB hyperextends & postures
A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?
"I should choose underwear with a cotton panel liner."
The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which action?
Clap the hand or slap on the mattress
The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
- Ballottement - Chadwick's sign - Uterine enlargement - Braxton Hicks contractions
The nurse is collecting data on a client with severe preeclampsia. Which s/s would be noted in severe preeclampsia? Select all that apply.
- Oliguria - Proteinuria 3+ - BP 168/116 mm Hg
A client who is 8wks pregnant calls the clinic & speaks to the nurse about complaints of nausea & vomiting every morning. Which action should the nurse suggest to promote relief?
Eat crackers before arising
The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?
History of substance abuse during this pregnancy
The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply
- Proteinuria - Hypertension - Increased pulse rate
The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3yo child who was born at 39wks' gestation. The nurse should document which gravida & para status on this client?
Gravida II, para I
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, & the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should the nurse take?
Instruct the client that these are common & may occur throughout the pregnancy.
The nurse working in a prenatal clinic reviews a client's chart & notes that the HCP documents that the client has a gynecoid pelvis. The nurse understands that which is a characteristic of this type of pelvis?
The most favorable for labor & birth
A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?
Connects the umbilical vein to the inferior vena cava
The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the HCP has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which?
A softening of the cervix
The nurse is preparing to monitor a fetal heart rate. The nurse knows that the fetal heart rate can first be heard with a fetoscope at which gestational week?
Week 20
The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse should make which statement to address the client's concern?
"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?
Drink decaffeinated coffee & tea.
A client in her 24th week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the health care provider to prescribe?
Amniocentesis for fetal surfactant level
