NCLEX-RN (MATERNAL ANTEPARTUM/POSTPARTUM)

The nurse reviews lab test result for a pregnant client at 32 weeks gestation. What is the nurse's best action based on these results? 1. Complete the client assessment and documentation 2. Draw another sample for repeat complete blood count 3. Prepare for transfusion of packed red blood cells 4. Request a prescription for iron supplementation

1. Complete the client assessment and documentation **Normal lab values for 3rd trimester Hemoglobin (11 or more) Hematocrit (33 or more) RBCs 5.00-6.25 WBCs 5,000-15,000 Platelets 150,000-400,000

A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? SATA 1. Influenza injection 2. Influenza nasal spray 3. Measles, mumps, rubella 4. Tetanus, diphtheria and pertussis 5. Varicella

1. Influenza injection 4. Tetanus, diphtheria and pertussis

The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer? Patients Vital Signs: Temp: 100.9 BP: 125/75 HR: 109/min Respirations: 15/min SpO2: 100% 1. Acetaminophen PO PRN for fever 2. Clindamycin IV every 8 hours 3. Lactated Ringer IV bolus once 4. Methylergonovine PO every 4 hours

2. Clindamycin IV every 8 hours

A client at 39 weeks gestation with preeclampsia has a blood pressure of 170/100 mmHg, 2+ proteinuria, and moderate peripheral edema. Immediately after hospital admission, she develops seizures and uterine contractions. Magnesium sulfate is prescribed. Which finding indicates that the drug has achieved the desired therapeutic effect? 1. Blood pressure <130/80 mmHg 2. Seizure activity stops 3. Urine has 1+ protein 4. Uterine contractions stop

2. Seizure activity stops **Preeclampsia is a systemic disease characterized by hypertension and proteinuria after the 20th gestational week. **Eclampsia is onset of convulsions or seizures that cannot be attributed to other causes.

The nurse performs initial assessments of four clients in a prenatal clinic. Which client findings are abnormal and require further assessment? 1. Client at 9 weeks gestation with a normal BMI and a weight gain of 2lb from pre-pregnancy weight 2. Client at 15 weeks gestation with headaches relieved by acetaminophen 3. Client at 19 weeks gestation with bleeding gums after brushing and flossing teeth 4. Client at 20 weeks gestation with an increase in diastolic pressure of 15 mmHg since last visit.

4. Client at 20 weeks gestation with an increase in diastolic pressure of 15 mmHg since last visit.

The pediatric nurse is performing an assessment on a 4 week old client in the clinic. During the assessment the newborn's mother starts to cry and states, I am the worst mother in the world. What should the nurse ask next? 1. Do you have a support system to help process your feelings 2. Do you have any questions about how to care for your newborn 3. Have you experienced difficulty falling asleep or getting rest 4. Have you felt depressed over the last 2 weeks

4. Have you felt depressed over the last 2 weeks

A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum. Which clinical manifestation should the nurse expect? 1. Abdominal pain and low grade fever 2. Blood pressure >140/90 mmHg 3. High urine protein level 4. Moderate to high urine ketones

4. Moderate to high urine ketones ** Hyperemesis gravidarum is characterized by severe, persistent nausea/vomiting during pregnancy that usually leads to considerable weight loss. ** Clients with HG may require hospitalization for IV fluid replacement and antiemetic therapy

The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? 1. Abdominal pain rated as 8 out of 10 2. History of pelvic inflammatory disease 3. Intermittent nausea and vomiting for the past 7 days 4. Right shoulder pain and dizziness

4. Right shoulder pain and dizziness **These are symptoms of ectopic pregnancy.

A client at 35 weeks gestation is admitted to the labor and delivery unit for severe pre-eclampsia. She is started on IV magnesium sulfate for seizure prophylaxis. Which of the following signs indicate that the client has developed magnesium sulfate toxicity? SATA 1. 0/4 patellar reflex 2. Blood pressure of 156/84 mmHg 3. Client voiding 600 mL in 8 hours 4. Respirations of 10/min 5. Serum magnesium of 8.0

1. 0/4 patellar reflex 4. Respirations of 10/min 5. Serum magnesium of 8.0

The nurse is admitting a client at 41 weeks gestation for induction of labor due to oligohydramnios. Considering the client's indication for induction, what should the nurse anticipate? 1. Additional neonatal personnel present for birth 2. Intermittent fetal monitoring during labor 3. Need for forceps assisted vaginal birth 4. Need for uterotonic drugs for postpartum hemorrhage

1. Additional neonatal personnel present for birth

A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound. What should the nurse tell the client to anticipate? SATA 1. Additional ultrasound around 36 weeks gestation 2. Clearance for sexual activity if bleeding stops 3. Discharge home if bleeding stops and fetal status is reassuring 4. Scheduled cesarean birth before onset of labor 5. Weekly vaginal examinations to assess for cervical change

1. Additional ultrasound around 36 weeks gestation 3. Discharge home if bleeding stops and fetal status is reassuring 4. Scheduled cesarean birth before onset of labor

The nurse cares for a client who gave birth an hour ago to a 9 lb newborn. The client's lochia is heavy with large clots and the fundus remains boggy after fundal massage and an oxytocin bolus. Which prescription from the healthcare provider should the nurse question? Patients Vitals: BP: 169/95 HR: 98/min 1. Administer 0.2 mg methylergonovine 2. Administer 800 mcg misoprostol rectally 3. Collect a hemoglobin and hematocrit STAT 4. Initiate second IV line with 18 gauge needle

1. Administer 0.2 mg methylergonovine ** Methylergonovine is contraindicated in clients with high blood pressure because the primary mechanism is vasoconstriction. If administered to a hypertensive patient, it can lead to further blood pressure elevation, seizure or stroke.

A client indicates the desire to become pregnant. Which of the following are important preconception education topics for the nurse to provide? SATA 1. Aim for BMI of 18.5-24.9 2. Avoid alcohol consumption and tobacco products 3. Ensure daily intake of 400 mcg of folic acid 4. Obtain testing for rubella immunity 5. Schedule dental wellness appointment

1. Aim for BMI of 18.5-24.9 2. Avoid alcohol consumption and tobacco products 3. Ensure daily intake of 400 mcg of folic acid 4. Obtain testing for rubella immunity 5. Schedule dental wellness appointment

A client at 38 weeks gestation is brought to the emergency department after a motor vehicle crash. She reports severe, continuous abdominal pain. The nurse notes frequent uterine contractions and mild, dark vaginal bleeding. What actions should the nurse take? SATA 1. Anticipate emergent cesarean birth 2. Apply continuous external fetal monitoring 3. Assess routine vital signs every 4 hours 4. Draw blood for type and crossmatch 5. Initiate IV access with a 22 gauge catheter

1. Anticipate emergent cesarean birth 2. Apply continuous external fetal monitoring 4. Draw blood for type and crossmatch

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second trimester teaching? SATA 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb per week if pre-pregnancy BMI was normal 4. Increase consumption of iron rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb per week if pre-pregnancy BMI was normal 4. Increase consumption of iron rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

A nurse is caring for a postpartum client who is breastfeeding and has been diagnosed with mastitis of the right breast. Which of the following instructions should the nurse include in client teaching? SATA 1. Apply warm compresses to breast 2. Discontinue breastfeeding until symptoms resolve 3. Increase oral fluid intake 4. Take ibuprofen as needed for pain 5. Wear a tight fitting bra as much as possible

1. Apply warm compresses to breast 3. Increase oral fluid intake 4. Take ibuprofen as needed for pain

A nurse is caring for a client who had a vaginal birth 2 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment the nurse notices that the client has a boggy fundus and is deviated to the right and slightly above the umbilicus. Which intervention should the nurse perform first? 1. Assist client to use the bedpan to void 2. Begin oxytocin IV infusion at 125 milliunits/min 3. Obtain a CBC 4. Start oxygen delivery at 10L/min via nonrebreather facemask

1. Assist client to use the bedpan to void

The nurse is providing nutrition counseling during a preconception visit to a client who does not eat green vegetables. In addition to a daily prenatal vitamin, which foods can the client add to the daily diet to decrease the risk of neural tube defects? SATA 1. Black beans and rice 2. Fortified breakfast cereal and milk 3. Medium baked sweet potato 4. Peanut butter on whole wheat toast 5. Raw carrots with cheese dip

1. Black beans and rice 2. Fortified breakfast cereal and milk 4. Peanut butter on whole wheat toast

A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client received no prenatal care and reports being about 7-8 months. Which actions should the nurse anticipate? SATA 1. Blood draw for type and screen 2. Electronic fetal monitoring 3. Initiation of 2 large bore IV catheters 4. Pad counts to assess bleeding 5. Vaginal examinations for cervical dilation

1. Blood draw for type and screen 2. Electronic fetal monitoring 3. Initiation of 2 large bore IV catheters 4. Pad counts to assess bleeding

A client who is being evaluated for suspected ectopic pregnancy reports sudden onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? SATA 1. Blood pressure 82/64 mmHg 2. Crackles on auscultation 3. Distended jugular veins 4. Pulse 120/min 5. Shoulder pain

1. Blood pressure 82/64 mmHg 4. Pulse 120/min 5. Shoulder pain

The nurse is caring for a client at 30 weeks gestation who is hospitalized for preeclampsia. After reviewing the client's chart and performing an initial assessment, the nurse notes several abnormal findings. Which finding should the nurse discuss with the healthcare provider immediately? 1. Dark red vaginal bleeding 2. Edema of the hands and face 3. Elevated liver enzymes 4. Urine output of 150 mL in 4 hours

1. Dark red vaginal bleeding Placental abruption is a complication of preeclampsia related to hypertension that can be life threatening to the client or fetus.

The nurse is providing teaching to a prenatal client about the 1 hour glucose challenge test that will be performed at the next visit. Which client statement indicates a need for further teaching? 1. Fasting is required before the 1 hours glucose challenge test 2. One blood sample is obtained at the end of the test 3. The test includes drinking a 50 g glucose solution 4. The test's purpose is to screen for gestational diabetes, not diagnose it

1. Fasting is required before the 1 hour glucose challenge test

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the healthcare provider will order which lab test? 1. Hemoglobin and hematocrit levels 2. Human chorionic gonadotropin level 3. Serum folate level 4. White blood cell count

1. Hemoglobin and hematocrit levels Pica is an abnormal craving for and consumption of substances not considered nutritionally valuable or edible. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption.

The nurse assesses a client at term gestation who reports having contractions for the last 2 hours. The client states, "I'm not sure but I think my water broke." The nurse performs a nitrazine pH test which turns blue. When documenting the results of the test which client statement is most concerning to the nurse? 1. I did have sexual intercourse with my partner 1 hour before coming in today 2. I have noticed constant wetness in my panties since I thought my water broke 3. It is difficult for me to tell if my water broke or if I just peed on myself a little bit 4. With my last three pregnancies, my water never broke on its own.

1. I did have sexual intercourse with my partner 1 hour before coming in today A nitrazine pH test helps with yellow, olive or green meaning amniotic membrane is intact and the bluish, gray deep blue suggests rupture of membranes.

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? 1. Infant birth weight of 9lb 2 oz 2. Labor and birth without pain medication 3. Labor that lasted 8 hours 4. Third stage of labor lasting 20 mins.

1. Infant birth weight of 9lb 2 oz ** Postpartum hemorrhage is maternal blood loss of >500 mL after a vaginal birth A Macrosomic infant more than 8 lb 13 oz

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5 T1 P2 A1 L2. Which interpretation of this notation is correct? 1. The client had 1 birth at 37 weeks 0 days gestation or beyond 2. The client had 3 births between 20 wk 0d and 36 wk 6 d gestation 3. The client has 3 currently living children 4. The client is currently not pregnant

1. The client had 1 birth at 37 weeks 0 days gestation or beyond

The nurse is reinforcing instructions to a client at 34 weeks gestation who is preparing to travel by airplane. Which of the following instructions are appropriate? SATA 1. Avoid getting up during the flight unless you need the restroom 2. Carry a copy of your most up to date prenatal record 3. Increase fluid intake before and during the flight 4. Secure the lap belt below the abdomen and across your hips when seated 5. Wear compression hose and loose-fitting clothing

2. Carry a copy of your most up to date prenatal record 3. Increase fluid intake before and during the flight 4. Secure the lap belt below the abdomen and across your hips when seated 5. Wear compression hose and loose-fitting clothing

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention? 1. Client has not been taking prenatal vitamins 2. Client is taking lisinopril to control hypertension 3. Client reports a whitish vaginal discharge 4. Client reports mild cramping pain in the lower abdomen

2. Client is taking Lisinopril to control hypertension Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers should be avoided in clients who are planning to become pregnant. **These drugs are teratogenic, leading to fetal renal and cardiac abnormalities.

A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? SATA 1. Cervical softening on examination 2. Fetal heart tones detected by doppler device 3. Positive serum human chorionic gonadotropin test 4. Report of fetal movement felt by client 5. Visualization of fetus by ultrasound

2. Fetal heart tones detected by doppler device 5. Visualization of fetus by ultrasound

The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the healthcare provider? 1. Complaints of discomfort during fundal palpation 2. Foul smelling lochia 3. Oral temperature 100.1 4. WBC 24,000

2. Foul smelling lochia A foul odor of lochia suggests endometrial infection. The client is at increased risk of infection due to prolonged labor which involved multiple cervical examinations.

The nurse assess a client at 36 weeks gestation during a routine prenatal visit. Which statement by the client should the nurse investigate first? 1. I am not sleeping as well due to cramps in my calves at night 2. I have noticed less kicking movements as the baby grows bigger 3. Over the last few weeks, I have not been able to wear any of my shoes 4. Sometimes I feel short of breath walking up a flight of stairs

2. I have noticed less kicking movements as the baby grows bigger

The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21. Which statement by the client indicates an appropriate understanding about weight gain? 1. should gain 10-15 lb during the first trimester 2. I should gain a total of about 30 lb during my pregnancy 3. I should gain no more than 0.5 lb per week during the third trimester 4. If I gain during pregnancy, it will be easier to lose weight postpartum.

2. I should gain a total of about 30 lb during my pregnancy

The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of teaching? 1. I need to be on bed rest for the duration of my pregnancy 2. I will notify my healthcare provider if I start having low back aches 3. Pelvic pressure is to be expected after cerclage placement 4. The cerclage will be removed once my baby is at 28 weeks

2. I will notify my healthcare provider if I start having low back aches ** A cervical cerclage is placed to prevent preterm delivery. A heavy suture is placed transvaginally to keep the interval cervical os closed. Placement occurs 12-14 weeks gestation for clients with a history of cervical insufficiency. For up to 23 weeks of gestation.

The graduate nurse and supervising nurse are preparing to follow up with a client who had a spontaneous abortion at 6 weeks gestation at home. Which of the following statements by the GN are appropriate? SATA 1. Although the client is Rh negative, it is necessary to administer Rh immune globulin due to the client's early gestational age 2. I will reinforce teaching with the client about abstaining from sexual intercourse for two weeks 3. The client should call the health care provider for foul smelling vaginal discharge, heavy vaginal bleeding or severe pain 4. The client should continue prenatal vitamins with iron and take ibuprofen as needed for pain 5. To maintain perineal hygiene, the client should soak nightly in a bathtub and use mild soap

2. I will reinforce teaching with the client about abstaining from sexual intercourse for two weeks 3. The client should call the health care provider for foul smelling vaginal discharge, heavy vaginal bleeding or severe pain 4. The client should continue prenatal vitamins with iron and take ibuprofen as needed for pain

A client at 34 weeks gestation reports constipation. The client has been taking 325 mg ferrous sulfate TID for anemia since the last appointment 4 weeks ago. Which recommendations should the nurse make for this client? SATA 1. Decreased daily dairy intake 2. Increased fruit and vegetable intake 3. Moderate intensity regular exercise 4. One laxative twice daily for a week 5. Two cups of hot coffee each morning

2. Increased fruit and vegetable intake 3. Moderate intensity regular exercise

A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate? 1. Group B streptococcal culture 2. Indirect Coombs test 3. Rubella immunity titer 4. Serum alpha-fetoprotein

2. Indirect Coombs test An indirect coombs tests is performed to screen for Rh sensitization at any time of hemorrhage secondary to placental abruption is suspected.

The nurse is caring for a client in the first trimester during an initial prenatal clinic visit. Based on the information provided by the client, which factor places the client at an increased risk for preterm labor? 1. Age 25 2. Periodontal disease 3. Vegetarian diet 4. White ethnicity

2. Periodontal disease Peridontal disease is associated with preterm labor especially when untreated.

The graduate nurse is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precepting nurse which statement by the GN indicates an appropriate understanding? 1. Doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy 2. The client will require penicillin desensitization to receive appropriate treatment 3. The newborn can be treated after birth if antepartum treatment is contraindicated 4. Treatment is only effective if provided during the primary stage of syphilis

2. The client will require penicillin desensitization to receive appropriate treatment

A client with diabetes visits the clinic reporting breast tenderness, vaginal discharge and urinary frequency. Which action is most important for the nurse to perform? 1. Ask if the client performs breast self exams 2. Ask the client about characteristics of vaginal discharge 3. Assess the date of the client's last menstrual period 4. Review the client's home blood sugar logs

3. Assess the date of the client's last menstrual period

The nurse is performing assessment of several clients during routine prenatal visits. Which client should the nurse discuss with the health care provider first? 1. Client at 30 weeks gestation with darkened patches of skin on the face 2. Client at 32 weeks gestation with painless, flesh colored bumps on the perianal area 3. Client at 34 weeks gestation with intense itching on the hands and feet that worsen at night but no rash 4. Client at 38 weeks gestation with stretch marks on the abdomen that have become reddened and pruritic

3. Client at 34 weeks gestation with intense itching on the hands and feet that worsen at night but no rash **Intrahepatic cholestasis of pregnancy is a liver disorder exclusive to pregnancy that manifests with intense, generalized itching but NO rash

The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client's assessment findings are most important to report to healthcare provider? 1. Client at 28 weeks gestations with an asymptomatic systolic murmur 2. Client at 34 weeks gestation with 1+ edema of bilateral lower extremities 3. Client at 35 weeks gestation with painful genital lesions 4. Client at 39 weeks gestation with brownish, mucoid vaginal discharge

3. Client at 35 weeks gestation with painful genital lesions Painful genital lesions can be an outbreak of genital herpes simplex virus.

The nurse receives report on 4 first trimester pregnant clients. Which client should the nurse assess first? 1. Client with hydatidiform mole reporting dark brown vaginal discharge 2. Client with hyperemesis gravidarum reporting excessive vomiting and weight loss 3. Client with suspected ectopic pregnancy reporting abdominal and shoulder pain 4. Client with threatened miscarriage who says, I am a Jehovah's witness.

3. Client with suspected ectopic pregnancy reporting abdominal and shoulder pain

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? SATA 1. Avoid intake of dairy products 2. Drink large amounts of fluid with meals 3. Eat several small meals each day 4. Eliminate fried, fatty foods 5. Lie down on the left side after meals

3. Eat several small meals each day 4. Eliminate fried, fatty foods

Prior to hospital discharge the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching? 1. I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped 2. I should expect vaginal dryness and use water soluble lubricants, especially if I'm breastfeeding 3. I will begin using condoms to prevent pregnancy once menses returns 4. I will try to feed my baby before my partner and I engage in sexual activity

3. I will begin using condoms to prevent pregnancy once menses returns

The nurse provides a follow up phone call to a client who gave birth at a birthing center 5 days ago. Which statement by the client should be nurse be most concerned about? 1. I am really tired all of the time since giving birth 2. I saw some bright red blood in my bowel movement yesterday 3. My bleeding is like a really heavy period with some blood clots 4. My hands feel tingly when I hold the baby for a long time

3. My bleeding is like a really heavy period with some blood clots

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, and has a heart rate of 110/min, and admits to resent onset of anxiety. What priority action should the nurse take? 1. Assess for lower extremity warmth and redness 2. Instruct the client in relaxation breathing techniques 3. Obtain oxygen saturation reading by pulse oximeter 4. Offer the client prescribed PRN pain medication

3. Obtain oxygen saturation reading by pulse oximeter

A client who gave birth vaginally with epidural anesthesia still has limited movement and strength of the right leg and reports no urge to urinate at 2 hours postpartum. The nurse palpates the client's fundus 2 cm above the umbilicus and to the right. What should the nurse do next? 1. Assist the client to the bathroom in a wheelchair 2. Encourage the client to drink plenty of fluids 3. Perform in and out catheterization 4. Reassess for bladder distention hourly

3. Perform in and out catheterization ** By performing in and out catheterization can help prevent postpartum hemorrhage related to uterine atony

The nurse is counseling a pregnant client who is HIV positive. Which information is appropriate to discuss? 1. Infant should be exclusively breastfed for 6 months to receive maternal antibodies 2. Infant will not require treatment for HIV after breath 3. Prescribed antiretroviral therapy should be continued during pregnancy 4. Tetanus diphtheria pertussis vaccine should be avoided until after birth

3. Prescribed antiretroviral therapy should be continued during pregnancy Maternal antiretroviral therapy during pregnancy is imperative for decreasing viral load and decreasing the risk of transmission to the fetus

A pregnant client at 39 weeks gestation is brought to the emergency department in stable condition following a motor vehicle collision. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mmHg. Which action should the nurse take first? 1. Administer normal saline fluid bolus 2. Ask about any prenatal complications 3. Initiate fetal heart rate monitoring 4. Tilt the backboard to one side

4. Tilt the backboard to one side

A pregnant client in the first trimester tells the clinic nurse she will be traveling to an area with a known Zika virus outbreak and expresses concern regarding disease transmission. Which statement by the nurse is most appropriate? 1. If you experience Zika symptoms, notify your healthcare provider 2. Take precautions against mosquito bites throughout the trip 3. You are not far enough along for the Zika virus to affect your baby 4. You should consider postponing your trip until after you have the baby.

4. You should consider postponing your trip until after you have the baby.