OB ATI focused review
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 Until 2 years of age.
A nurse is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? a. Calcium gluconate b. indomethacin c. nifedipine d. betamethasone
d. betamethasone
A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (SATA) a. Fetal distress b. preterm labor c. vaginal bleeding d. cervical dilation greater than 6 cm e. severe gestational hypertension
a. fetal distress c. vaginal bleeding d. cervical dilation greater than 6 cm
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. The nurse should understand that the fetus is at risk for which of the following? A. Intrauterine growth restriction B. Hyperglycemia C. Meconium aspiration D. Polyhydramnios
c. meconium aspiration postterm neonates are at risk for aspiration of meconium
A nurse is reviewing the laboratory findings of a client who is at 37 weeks of gestation and has hypertension. Which of the following results should the nurse notify the provider? a. BUN 19mg/dL b. hematocrit 37% c. creatinine 0.9mg/dL d. platelet 50000/mm3
d. platelet 50000/mm3 normal range 150000 - 400000 BUN 10 - 20 Hematocrit > 33% Creatinine 0.5 - 1.1
Carboprost tromethamine (Hemabate). correct statement a. this medication can cause diarrhea b. this medication will make you sleepy c. this medication will be given by mouth d. this medication can cause a decrease in your blood pressure
a. this medication can cause diarrhea Carboprost tromethamine is a medication given to control postpartum bleeding and prevent hemorrhage by causing uterine contractions and vasoconstriction. Adverse effects include diarrhea, nausea, vomiting, headache, tachycardia, hypertension, fever, and chills.
A nurse is providing education to a client who is 2hr postpartum and has 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 caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states, "my water broke" The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. place the client in the Trendelenburg position b. apply pressure to the presenting part with fingers c. administer oxygen at 10L/min via face mask d. Initiate IV fluids.
b. Apply pressure to the presenting part with fingers.
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse recognizes the adverse effect of this contraction pattern is: A. prolonged labor. B. reduced fetal oxygen supply. C. delayed cervical dilation. D. increased maternal stress.
b. reduced fetal oxygen supply inadequate uterine relaxation results in reduced oxygen supply to the fetus.
A Nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following is a manifestation of this condition? a. Hgb 12.2g/dL b. urine ketones present c. alanine aminotransferase 20 IU/L d. Blood glucose 114 mg/dL
b. urine ketones present is associated with the breakdown of proteins and fats that occurs in a client who has hyperemesis gravidarum
preparing to administer medroxyprogesterone. which actions should the nurse take? a. massage the injection site for 15 sec after administration b. vigorously shake the contents of the vial before drawing up the dosage of medication c. administer the medication every 4 to 6 weeks after a menstrual cycle d. teach the client that fertility returns within one month of stopping this medication
b. vigorously shake the contents of the vial before drawing up the dosage of medication
A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kubler-Ross model, which stage of grief is the client experiencing? a. Anger. b. Denial c. Bargaining d. Acceptance
c. Bargaining The client is bargaining by attempting to negotiate more time to live to see the child get married.
A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? a. I will take this pill with my breakfast b. I will take this medication with a glass of milk c. I plan to drink more orange juice while taking this pill d. I plan to add more calcium-rich foods to my diet while taking this medication
c. I plan do drink more orange juice while taking this pill A diet with increased vitamin C improves the absorption of ferrous sulfate.
A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (SATA) a. remove the dentures from the body b. make sure the body is lying completely flat c. apply fresh linens and place a clean gown on the body d. remove all equipment from the bedside e. dim the light in the room.
c. apply fresh linens and place a clean gown on the body d. remove all equipment from the bedside e. dim the light in the room
A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following is an appropriate response for the nurse to make? a. it is needed to promote increased urine output. b. it is needed to counteract respiratory depression c. it is needed to counteract hypotension d. it is needed to prevent oligohydramnios
c. it is needed to counteract hypotension Maternal hypotension can occur during epidural block and can be offset by administering an IV fluid bolus
A nurse is discussing an oral glucose tolerance test with a client who is at weeks of gestation. which of the following statements should the nurse make? a. you should plan to have the test when you are 32 weeks pregnant b. you should be on a low-carb diet for 3 days before testing c. you should not eat or drink anything after midnight the night prior to the test d. you should avoid smoking 2 hours prior to the test.
c. you should not eat or drink anything after midnight the night prior to the test.
A nurse is caring for a client who is pregnant and is undergoing a none stress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? a. It is used to stimulate uterine contractions b. It will decrease the incidence of uterine contraction c. It lulls the fetus to sleep d. It awakens the sleeping fetus.
d. It awakens the sleeping fetus The acoustic vibration deice is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus.
A nurse is caring for a client who is admitted to the L&D unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A. Precipitous labor B. Premature rupture of membranes C. Postmaturity syndrome D. Prolapsed umbilical cord
d. Prolapsed umbilical cord
A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? a. Nifedipine b. Pyrioxine c. ferrous sulfate d. calcium gluconate
d. calcium gluconate. is the antidote for meg-suflate
A nurse is caring for a client who has a terminal illness. Death is expected within 24hr. The client's family is at the bedside and asks the nurse what to expect at this time. Which of following findings should the nurse include? a. regular breathing pattern b. warm extremities c. increased urine output d. decreased muscle tone
d. decreased muscle tone. Muscle relaxation is an expected finding when a client is approaching death.
Postoperative care to a client following a cesarean birth. which action? a. remove the indwelling urinary catheter on the third postpartum day b. allow the client to use a straw for drinking beverage c. encourage the client to remain in bed while hospitalization d. instruct the client to splint their incision with a pillow when coughing.
d. instruct the client to splint their incision with a pillow when coughing client should splint their incision with a pillow when repositioning or coughing. this provides support to the incision and decreases the discomfort associated with repositioning or coughing.
A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? a. use a condom with sexual intercourse b. avoid bubble bath solution when taking a tub bath c. wipe from the back to front when performing perineal hygiene. d. Keep a daily record of fetal kick counts.
d. keep a daily record of fetal kick counts The client should record daily fetal kick counts
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. Which of the following actions should the nurse take? a. administer oxygen via nasal cannula at 2L/min b. apply a warm blanket c. assist the client to a side-lying position d. place an oxygen mask over the client's nose and mouth.
d. place an oxygen mask over the client's nose and mouth The client is experiencing hyperventilation caused by low blood levels of PCO2. Placing an oxygen mask over the client's nose and mouth or having the client breathing into a paper bag will reduce the intake of oxygen, allowing the PCO2 to rise and alleviate the numbness and tingling.
a nurse is caring for a newborn who is receiving phototherapy for hyperbilirubinemia. which of the following actions should the nurse take? a. swaddle the newborn snuggly prior to placing them under the phototherapy lights b. supplement newborn feedings with glucose water every 2 hr c. obtain blood for a universal newborn screening every 8 hr d. remove the eye mask on the newborn prior to every feeding
d. remove the eye mask on the newborn prior to every feeding to assess the eyes and provide for visual stimulation
A nurse is assessing a client who has gestational diabetes. Which of the following manifestations are findings of hyperglycemia? a. acetone breath odor b. decreased urinary output. c. tinnitus d. diarrhea
a. acetone breath odor. Acetone or fruity breath odor is a manifestation of hyperglycemia. additionally, increased thirst; abdominal pain; polyuria; flushed dry skin; rapid breathing; drowsiness; and a weak, rapid pulse rate.
A nurse is assessing a client who is 10 days postpartum and reports manifestations of mastitis. Which of the following findings should the nurse identify as a manifestation of this condition? a. breast engorgement b. a small white pearl visible on the tip of the nipple c. erythema on the breast d. temperature 37.7 (99.9)
c. erythema on the breast Manifestations of mastitis include fever, aches, chills, headaches, and erythema. Erythema can be detected by palpating for warmth; in some clients the skin might appear reddened.
A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of 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 nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. She notes the pad to be 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 blood loss C. Light lochia rubra D. Scant lochia serosa
A. Moderate lochia rubra The client has moderate lochia rubra containing small clots, which is an expected finding for the second day postpartum.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, andat the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? 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 Lochia typically trickles from the vaginal opening but flows more steadily during uterine contractions. Massaging the uterus or ambulation can result in a gush of lochia with the expression of clots and dark blood that has been pooled in the vagina, but it should soon decrease back to a trickle of bright red lochia in the early puerperium.
A nurse is teaching a client who is at 8 weeks of gestation about nutrition during pregnancy. Which of the following statements should the nurse include in the teaching? a. "You should consume 2 cups of milk daily." b. "You should consume 4 ounces of grains each day." c. "You should consume 2 cups of vegetables each day." d. "You should consume 6 ounces of protein foods daily."
D. "You should consume 6 ounces of protein foods daily." The nurse should instruct the client to consume 5.5-6.5oz of protein foods each day.
A nurse is conducting an initial assessment for a client. The client reports, "My last period began May 15" Using Nagele's rule, the nurse should calculate that which of the following dates is the expected date of birth. (EDB)? a. Feb 22 b. Jan 22 c. Feb 8 d. Jan 8
a. Feb 22 Subtract 3 months and add 7 days 5 - 3 = 2 (February) 15 + 7 = 22
A nurse is caring for a client who has been in labor for 12 hours with intact membranes. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? a. fetal engagement b. fetal lie c. fatal attitude d. fatal posistion
a. Fetal engagement Prior to the performance of an amniotomy, it is imperative that the fetus is engaged at 0 station and at the level of the maternal ischial spines to prevent prolapse of the umbilical cord.
A nurse is caring for a client who is 42 weeks gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnioinfusion? (Select all that apply) a. oligohydramnios b. Hydramnios c. Fetal cord compression d. Hydration e. Fetal immaturity
a. Oligohydramnios c. Fetal cord compression Oligohydramnios is an indication for an amnioinfusion because inadequate amniotic fluid can contribute to intrauterine growth restriction of the fetus, restrict fetal movement, and cause fetal distress during labor. Oligohydramnios results in fetal cord compression, which decreases fetal oxygenation. Amnioinfusion prevents cord compression.
39 weeks of gestation and has a prescription for oxytocin. which of the following findings is a contraindication for the medication? a. placenta previa b. Bishop score of 10 c. Vertex presentation d. Fetal heart rate of 120/min
a. Placenta previa Placenta previa, acute fetal distress, previous uterine incisions that prohibits a trial of labor, and uncontrolled hemorrhaging are contraindications for the administration of oxytocin.
A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following complications should the nurse include? a. Vaginal bleeding b. Swelling of the ankles c. Heartburn after eating d. Lightheadedness when lying on back
a. Vaginal bleeding
A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." which of the following statements should the nurse make to facilitate mourning for the partner? (SATA) a. Would you like me to contact chaplain to come and speak with you? b. You will feel better soon. You have been expecting this for a while now. c. Let's talk about your children and how they are going to react d. You know, it is quite normal to feel anger toward your loved one at this time. e. Tell me more about how you are feeling.
a. Would you like me to contact chaplain to come and speak with you? Asking whether the grieving individual desires spiritual support at this time is an accepted nursing intervention to facilitate mourning.
client who has mild hyperemesis gravidarum. which actions should the nurse take? a. administer pyridoxine b. encourage intake of high fat foods c. administer morphine d. encourage an intake of low protein foods.
a. administer pyridoxine hyperemesis gravidarum is excessive vomiting during pregnancy which can lead to imbalance of fluid and electrolytes. The nurse should administer pyridoxine to correct the fluid and electrolyte imbalances.
A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (SATA) a. decreased fetal movement b. intrauterine growth restriction (IUGR) c. postmaturity d. placenta previa e. amniotic fluid emboli
a. decreased fetal movement b. intrauterine growth restriction (IUGR) c. postmaturity
A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? (SATA) a. Diabetes b. multifetal pregnancy c. maternal age greater than 40 d. gestational trophoblastic disease e. oligohydramnios
a. diabetes b. multifetal pregnancy d. gestational trophoblastic disease
A nurse is administering oxytocin to a client for augmentation of labor. The nurse observes uterine contractions every 1 to 2 min with a duration of 70 to 80 seconds. Which of the following actions should the nurse take? a. discontinue the oxytocin infusion b. check the client's cervix c. administer misoprostol d. ambulate the client
a. discontinue the oxytocin infusion because more than five contractions in 10 min is indicative of uterine hyperstimulation which does not allow adequate fetal oxygenation and can cause fetal distress.
A nurse is caring for a client who is at 40 weeks of gestation and experiencing contractions every 3-5min and becoming stronger. A vaginal exam reveals that the client's cervix is 3cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? a. encourage use of patterned breathing techniques b. insert an indwelling urinary catheter c. administer opioid analgesic medication d. suggest application of cold. e. provide ice chips
a. encourage use of patterned breathing techniques c. administer opioid analgesic medication d. suggest application of cold
A nurse is teaching a client who is 2 hours postpartum and had a midline episiotomy. Which of the following instructions should the nurse include in the teaching? a. fill the sitz bath half full with water b. use the sitz bath once daily c. cleanse your perineum with an iodine solution after voiding. d. change your perineal pad three times per day.
a. fill the sitz bath half full with water.
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A. Hands and knees B. Lithotomy C. Trendelenburg D. Supine with rolled towel under one hip
a. hands and knees can help the fetus rotate from a posterior to an anterior position
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 Hypospadias involves a defect in the location of the urethral opening and is a contraindication to circumcision A family history of hemophilia is a contraindication for circumcision Epispadias involves a defect in the location of the urethral opening and is a contraindication to circumcision
A nurse is caring for a client who is in the second stage of labor. The client's labor has been progressing, and she is expected to deliver vaginally in 20min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? a. pudendal b. epidural c. spinal d. paracervical
a. pudendal A pudendal block is a transvaginal injection of local anesthetic that anesthetizes the perineal area for the episiotomy and repair, and expulsion of the fetus.
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. Mongolian spots are commonly found over the lumbosacral area of newborns who have dark skin and can be linked to genetics
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 feedings."
A. "Apply cold compresses between feedings."
A nurse is providing discharge teaching for a non-lactating client. Which of the following instructions should the nurse include in the teaching? A. "Wear a supportive bra continuously for the first 72 hours." B. "Pump your breast every 4 hours to relieve discomfort." C. "Use breast shells throughout the day to decrease milk supply." D. "Apply warm compresses until milk suppression occurs."
A. "Wear a supportive bra continuously for the first 72 hours."
A nurse in a health clinic is reviewing contraceptive use with a group of adolescent clients. Which of the following statements by an adolescent reflects an understanding of the teaching? 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 caring for a client who has gonorrhea. Which of the following medications should the nurse anticipate the provider will prescribe? a. Ceftriaxone b. Fluconazole c. Metronidazole d. Zidovudine
A. Ceftriaxone Ceftriaxone IM or doxycycline orally for 7 days is prescribed for the treatment of gonorrhea.
A nurse is admitting client who is in labor and has HIV. Which of the following intervention should the nurse identify as contraindicated for this client? (Select all that apply.) a. Episiotomy b. Oxytocin infusion c. Forceps d. Cesarean birth e. Internal fetal monitoring f. Vacuum extractor
A. Episiotomy C. forceps E. internal fetal monitoring F. Vacuum extractor An episiotomy should be avoided for a client who is HIV + due to the risk of maternal blood exposure. The use of forceps during delivery should be avoided due to the risk of fetal bleeding. Internal fetal monitoring should be avoided due to the risk of fetal bleeding. The use of vacuum extractor should be avoided due to the risk of exposing the fetus to maternal blood
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. GBS e. TORCH infection
A. Gonorrhea B. Chlamydia C. HIV D. GBS
A nurse is caring for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of this condition? a. urinary tract infection b. multifetal pregnancy c. hydramnios d. diabetes mellitus e. uterine abnormalities
All of the above. a. urinary tract infection b. multifetal pregnancy c. hydramnios d. diabetes mellitus e. uterine abnormalities
A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given 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 months to see if I have developed immunity."
B. "I need a second vaccination at my postpartum visit." A second varicella immunization is needed at 4 to 8 weeks following delivery by clients who had no history of immunity.
A nurse is providing care to four 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 third-degree laceration B. A client who does not wash her hands between perineal care and breastfeeding C. A client who is not 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 her hands between perineal care and breastfeeding
A nurse is caring for a newborn who was born at 38 weeks gestation, weighs 3200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neotate 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 caring for a client who is at 29 weeks of gestation and is in labor. The fetal monitor tracing reveals a series of late decelerations. After placing the client in a lateral position, which of the following actions should the nurse take? a. Prepare the client for an amnioinfusion b. Increase the IV fluid rate c. Administer oxygen at 2 L/min via nasal cannula d. Apply fundal pressure.
B. Increase IV fluid rate Providing a fluid bolus can improve fetal hypoxia
A nurse is caring for a newborn who has a blood glucose of 28 mg/dL. Which of the following actions should the nurse take? a. Assess the newborn's blood glucose level 2 hr after feeding. b. Assist with breastfeeding. c. Administer oral glucose water. d. Administer a lactated ringer's IV bolus.
B. The nurse should assist the mother with breastfeeding because 28 is below the expected reference range.
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 the uterine atony? A. Poor involution B. Urinary retention C. Hemorrhage D. Infection
B. Urinary retention a distention of bladder can cause uterine atony and lateral displacement from the midline.
A nurse is discussing prenatal care with a primigravida client at her first prenatal visit. Which of the following statements should the nurse make? a. "You should feel your baby moving at 12 weeks." b. "You should expect your blood glucose level to be checked during each visit." c. "You will have to have a group B streptococcus culture at 35 weeks of your pregnancy." d. "You will have an appointment every other week starting at 36 weeks of gestation."
C. :You will have a group B streptococcus culture at 35 weeks of your pregnancy" The nurse should instruct the client to expect a culture of the vagina and rectum to test for group B strep between 35-37 weeks of pregnancy.
A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time she sneezes or coughs. 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 providing discharge instructions for a client. At 4 weeks postpartum, the client should contact her provider for which of the following client findings? A. Scant, nonodorous 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 providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. "His circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form," C."I will clean his penis with each diaper change." D."I will give him a tub bath within a couple of days."
C."I will clean his penis with each diaper change." should be cleaned with warm water with each diaper change.
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 CMV is detected during pregnancy." c. "A women should avoid crowded places during pregnancy." d. "A women should avoid consuming undercooked meat while pregnant."
D. "A women should avoid consuming undercooked meat while pregnant."Toxoplasmosis, a TORCH infection, is contracted by consuming undercooked meat.
A nurse is completing a newborn assessment and observes small white nodules on the roof of the newborn's mouth. This finding 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
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 prevents the urine from the diaper getting into the cord site
A nurse in an obstetrical clinic is teaching a client about using IUD for contraception. Which of following statement by the client indication as 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
I will check to be sure the strings of the IUD are still present after my periods The client should check for presence of IUD strings following each menstruation to ensure the device is still present. A change in the length of the strings should be reported to the provider.
A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version? a. Prostaglandin gel b. Magnesium sulfate c. Rho(D) immune globulin d. Oxytocin
Rho(D) immune globulin Rho(D) is administered to an Rh-negative client at 28 weeks of gestation. Because this client had no prenatal care, it should be given prior to the version to prevent isoimmunization
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly licensed nurses. Which of the following statements by a nurse indicated understanding of the teaching? a. "They are tablets administered vaginally" b. "they act by absorbing fluid from tissues" c. "They include an amniotomy" d. "They promote dilation of the OS."
a. "they are tablets administered vaginally."
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? (SATA) a. "weight fluctuations can occur" b. "You are protected against STIs" c. "You should increase intake of calcium" d. "You should avoid taking antibiotics" e. "irregular vaginal spotting can occur"
a. "weight fluctuations can occur" c. "You should increase intake of calcium" e. "irregular vaginal spotting can occur"
A client who is at 7 weeks of gestation is experiencing nausea & vomiting in the morning. Which of the following information should the nurse include? a. Eat crackers or plain toast before getting out of bed b. Awaken during the night to eat a snack c. Skip breakfast & eat lunch after nausea has subsided d. Eat a large evening meal
a. Eat crackers or plain toast before getting out of bed Nausea and vomiting during the first trimester might be relieved by eating crackers or plain toast prior to rising in the monring.
providing care for a client who has HIV and her newborn. which actions should the nurse take first when providing care for the newborn immediately following birth? a. Bathe the newborn b. place the newborn skin-to-skin c. administer hep B vaccine d. perform a newborn screening
a. bathe the newborn. to remove the amniotic fluid and any maternal blood prior to administering any IM injections or performing heel sticks.
A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (Select all that apply.) a. Breast tenderness b. Urinary frequency c. Epistaxis d. Dysuria e. Epigastric pain
a. breast tenderness b. urinary frequency c. epistaxis.
A nurse is caring for a client who is having labor augmented with oxytocin. The fetal monitor tracing reveals early deceleration. Which of the following actions should the nurse take? a. Continue to monitor the client. b. Discontinue the oxytocin. c. assist the client to a Trendelenburg position d. Administer oxygen 2 L/min via nasal cannula.
a. continue to monitor the client. The nurse should recognize that early decelerations result from fetal descent and head compression. This condition and fetal heart rate is commonly seen during labor and requires no interventions.
A nurse is reviewing the results of a biophysical profile for a client who is at 37 gestation. The nurse notes the result are 3 out of 10. Which of the following actions should the nurse plan to take? a. prepare for birth of the fetus b. assess the client's deep tendon reflexes c. initiate fundal massage d. administer a tocolytic medication
a. prepare for birth of the fetus A biophysical profile of 3 out of 10 indicates the presence of probable fetal hypoxia. Because the fetus is near term, the nurse should plan to prepare for birth of the fetus.
A nurse is administering magnesium sulfate IV for seizure prophylaxis to a client who has severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? (SATA) a. Respirations less than 12/min b. Urinary output less than 25mL/hr c. hyperreflexic deep-tendon reflexes d. decreased level of consciousness e. flushing and sweating
a. respirations less than 12/min b. urinary output less than 25mL/hr d. decreased level of consciousness.
A client who is at 8 wks of gestation tells the nurse "I am not sure I am happy about being pregnant." Which of the following responses should the nurse make? a. "I will inform the provider that you are having these feelings." b. "It is normal to have these feelings during the first few months of pregnancy." c. "You should be happy that you are going to bring new life into the world." d. "I am going to make an appointment with the counselor for you to discuss these thoughts."
b. "It is normal to have these feelings during the first few months of pregnancy."
A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? a. frequency of every 2 min b. duration of 90 to 120 seconds c. intensity of 60 to 90 mmHg d. resting tone of 15 mmHg
b. Duration of 90 to 120 seconds Oxytocin is discontinues if uterine tachysystole occurs with contraction duration longer than 90 seconds
A nurse is reviewing the laboratory result of a newborn who is 22 hours old. which of the following findings should the nurse report to the provider? a. platelet count 165000/mm3 b. hemoglobin 12g/dL c. Bilirubin 5 mg/dL d. blood glucose 50mg/dL
b. Hemoglobin 12g/dL The expected range 14 - 24 platelet 150000 - 300000 Bilirubin 2 - 6 (<24hr old) blood glucose 40 - 60 (<24hr old)
32 weeks of gestation and receiving magnesium therapy IV as a tocolytic. Client's RR 10/min, deep tendon reflexes are absent, and urinary output is 20mL/hr. which of the following action should the nurse take? a. implement seizure precautions b. administer calcium gluconate c. check the client's blood glucose level d. initiate a 24 hour urine collection.
b. administer calcium gluconate since the client is showing signs of magnesium toxicity
A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? a. blood tinged sputum b. dizziness c. pallor d. somnolence
b. dizziness dizziness and lightheadedness are associated with orthostatic hypotension which occurs when taking nifedipine
A nurse is reviewing findings of a clients biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (SATA) a. Fetal weight b. Fetal breathing movement c. Fetal tone d. Fetal position e. Amniotic fluid volume
b. fetal breathing movement c. fetal tone e amniotic fluid volume
A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (SATA) a. Tinnitus b. Irregular vaginal bleeding c. Weight gain d. Nausea e. Gingival hyperplasia
b. irregular vaginal bleeding c. weight gain d. nausea
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? a. alpha-fetoprotein (AFP) b. lecithin/sphingomyelin (L/S) c. kleihauer-bette test d. indirect Coomb's test
b. lecithin/sphingomyelin (L/S) a test of the l/s ratio is done as a part of an amniocentesis to determine fetal lung maturity
30 weeks of gestation and has a prescription for terbutaline. Which of the following conditions is a contraindication for the med? a. Hpothyroidism b. Preeclampsia c. History of ectopic pregnancy d. Rheumatoid arthritis
b. preeclampsia Preeclampsia, cardiac disease, gestational diabetes, and severe gestational hypertension are all contraindications
A nurse is caring for a client who is in active labor. The client reports lower-back-pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client? a. abdominal effleurage b. sacral counterpressure c. showering if not contraindicated d. back rub and massage
b. sacral counterpressure.
A nurse is teaching about the quadruple marker screen to a client who is pregnant. Which of the following information should the nurse include in the teaching? a. the sample is collected during an amniocentesis b. the test is a screening tool for chromosomal syndromes c. the test uses ultrasound to measure the fetus. d. this screening is done before 12 weeks of gestation.
b. the test is a screening tool for chromosomal syndromes. The quadruple marker screen measures alpha-fetoprotein, unconjugated estriol, hCG, and inhibin A to detect chromosomal anomalies. If the results are abnormal the client should be offered further testing.
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. for 24 hours to prevent the skin edges from sticking to the diaper
A nurse is teaching a group of clients who are pregnant about measure to relieve backache during pregnancy. Which of the following measures should the nurse include? (Select all that apply) a. Avoid any lifting b. Perform kegel exercises twice a day c. Perform the pelvic rock exercise every day d. Use proper body mechanics e. Avoid constrictive clothing
c. Perform the pelvic rock exercise every day d. Use proper body mechanics The pelvic rock or tilt exercise stretches the muscles of the lower back and helps relieve lower-back pain Use of proper body mechanics prevents back injury due to the incorrect use of muscles when lifting.
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? a. Allowing the client to function independently will strengthen muscle and promote healing. b. The client needs privacy at times for self-reflecting and organizing life. c. The client's sense of loss can be lessened through retaining control of some areas of life. d. Performing ADLs is a requirement prior to discharge from an acute care facility.
c. The client's sense of loss can be lessened through retaining control of some areas of life. Allowing the client as much control as possible maintains dignity and self-esteem.
A nurse is caring for a client who has HIV and is in labor. Which of the following actions should the nurse take? a. apply a fetal scalp electrode to monitor the fetal heart rate b. obtain maternal white blood cell counts every 2 hr during labor. c. administer zidovudine IV during the intrapartum period. d. assist provider with rupturing the client's membranes
c. administer zidovudine IV during the intrapartum period should be administered 3 hours prior to a C/S
A nurse is completing an assessment. Which of the following data indicate the newborn is adapting to extrauterine life? (SATA) 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 periods of apnea lasing less than 15 seconds are an expected finding. Newborns are obligatory nose breathers
A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following? A. Reduced menstrual flow. B. Breast tenderness. C. Shortness of breath. D. Headaches.
c. shortness of breath can indicate a pulmonary embolus or myocardial infarction and should be reported to the provider immediately.
A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? a. you will lay on your right side during the procedure. b. you should not eat anything for 24 hours prior to the procedure c. you should empty your bladder prior to the procedure. d. the test is done to determine gestational age.
c. you should empty your bladder prior to the procedure. The client's bladder should be empty to avoid an inadvertent puncture during the procedure.
A nurse is discussing common discomforts that may occur during the first trimester of pregnancy with a client who is 6 weeks of gestation. Which of the following manifestations should the nurse include? a. Heartburn b. Periodic tingling of the fingers c. Pruritus d. Epistaxis
d. Epistaxis Nasal stuffiness and epistaxis are common manifestations during the first trimester. Epistaxis is related to increased level of estrogen.
A nurse is assessing the reflexes of a newborn in checking 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 lateral surface of each foot d. hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall back ward.
d. hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall back ward. the moro-reflex is elicited by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backward.
