OB Final
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? a."You will not get pregnant while you are breastfeeding, so you will not need any birth control" b."A birth control bill that contains only estrogen is available for use while you are breastfeeding" c."Condoms are the only method of contraception that is appropriate while you are breastfeeding." d."A progestin-only pill or injection is available for use while you are breastfeeding"
"A progestin-only pill or injection is available for use while you are breastfeeding"
A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. "You will need to wait 3 months before resuming sexual intercourse." B. "You don't need to use contraception until you are 4 months postpartum." C. "As long as you breastfeed, you will experience an overproduction of vaginal lubrication." D. "A reduction in sexual interest could indicate postpartum depression."
"A reduction in sexual interest could indicate postpartum depression."
A nurse in a health clinic is reviewing contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? a."A water-soluble lubricant should be used with condoms" b."A diaphragm should be removed 2 hours after intercourse" c."Oral contraceptives can worsen a case of acne" d."A contraceptive patch is replaced once a month"
"A water-soluble lubricant should be used with condoms"
A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates understanding of the teaching? A. "Obtain an immunization against rubella early in pregnancy." B. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy." C. "A woman should avoid crowded places during pregnancy." D. "A woman should avoid consuming undercooked meat while pregnant."
"A woman should avoid consuming undercooked meat while pregnant."
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which of the following statements should the nurse make? A. "An epidural given too early during labor can cause maternal hypertension." B. "An epidural given too early during labor will not be effective in active labor." C. "An epidural given too early can cause fetal depression." D. "An epidural given too early can prolong labor."
"An epidural given too early can prolong labor."
A nurse is reinforcing teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? A. "Apply ice packs to your breasts." B. "Hand express milk from your breasts 3 times each day." C. "Try to avoid wearing a bra as much as possible throughout the day." D. "Request a prescription for medication to suppress lactation."
"Apply ice packs to your breasts."
A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions."
"Call me so I can check your baby's latch the next time you breastfeed."
A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include? A. "Cover the cord with the edge of the diaper." B. "Clean the cord stump with tap water." C. "Apply a damp cloth over the cord stump once each day." D. "You should gently tug on the cord stump in 5 days if it has not yet fallen off."
"Clean the cord stump with tap water."
A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? a."Limit the amount of time the infant nurses on each breast" b."Nurse the infant only on the unaffected breast until resolved." c."Completely empty each breast at each feeding or use a pump" d."Wear a tight-fitting brea until lactation has ceased"
"Completely empty each breast at each feeding or use a pump"
A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? A. "Do not become pregnant for at least 1 year." B. "Seek genetic counseling for yourself and your partner prior to getting pregnant again." C. "You should have an hCG level drawn in 6 weeks." D. "Have your blood pressure checked weekly for the next month."
"Do not become pregnant for at least 1 year."
A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instruction? A. "I can continue to breastfeed." B. "I still need to have my provider perform a rubella titer check during my next pregnancy." C. "I cannot receive the rubella immunization during pregnancy." D. "I can conceive anytime I want after 10 days."
"I can conceive anytime I want after 10 days."
A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis? A. "I will wear an underwire bra to provide support when my milk comes in." B. "I will apply petroleum jelly if my nipples become cracked." C. "I will apply warm compresses to my breasts twice a day." D. "I should avoid waiting too long between feedings."
"I should avoid waiting too long between feedings."
A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching? A. "I should not breastfeed for at least 3 days after receiving this immunization." B. "I will need a second rubella booster when I see my midwife at 6 weeks postpartum." C. "I should be careful to avoid becoming pregnant within the next month." D. "This vaccine will be given into my arm muscle."
"I should be careful to avoid becoming pregnant within the next month."
A nurse is providing breastfeeding education to a client who delivered 12 hours ago. Which of the following client statements indicates an understanding of the teaching? A. "I should have less cramping while I'm breastfeeding." B. "I should breastfeed at least 8 to 12 times in a 24-hour period." C. "I should wait to breastfeed until my baby awakens from her nap." D. "I should switch breasts after 5 minutes of nursing."
"I should breastfeed at least 8 to 12 times in a 24-hour period."
A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? A. "I should feed my baby 8-12 times a day, based on feeding cues." B. "My baby should have 6 or 7 wet diapers a day during the first week." C. "I should switch my baby to the other breast after 15 minutes of feeding." D. "My nipple pain should go away after a few weeks of breastfeeding."
"I should feed my baby 8-12 times a day, based on feeding cues."
A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. "I know not to eat anything after midnight." B. "I will have medication given to me to cause contractions." C. "I should press the button on the handheld marker when my baby moves." D. "I will have to stimulate my breast to cause contractions."
"I should press the button on the handheld marker when my baby moves."
A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? a."I should clean my diaphragm with alcohol each time I use it" b."I should leave the diaphragm in place for 4 hours after intercourse" c."I should replace my diaphragm every 2 years" d."I should use my vaginal lubricant to insert my diaphragm"
"I should replace my diaphragm every 2 years"
A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give lansoprazole 30 min after my baby's feedings." B. "I will lay my baby on her right side after feedings." C. "I will give my baby a bottle just before bedtime." D. "I will add rice cereal to my baby's feedings."
"I will add rice cereal to my baby's feedings."
A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."
"I will avoid any of my family members who are ill."
A nurse in an obstetrical clinic is teaching a client about using an IUD contraception. Which of the following statements by the client indicates an understanding of the teaching? a."An IUD should be replaced annually during a pelvic exam." b."I cannot get an IUD until after I've had a child" c."I should plan on regaining my 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."
A nurse is reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicated an understanding of the teaching? a."I am glad I can have my morning coffee" b."I should take folic acid to increase my milk supply" c."I will continue adding 330 calories per day to my diet" d."I will continue my calcium supplements because I don't like milk."
"I will continue my calcium supplements because I don't like milk."
A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I can store my pumped milk in the door of the refrigerator." B. "I can use the microwave to thaw my frozen breast milk." C. "I will discard any unused breastmilk that is left in the bottle." D. "I can refreeze any breastmilk after it has been thawed."
"I will discard any unused breastmilk that is left in the bottle."
A nurse is providing education to a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? A. "It will take about 10 minutes to complete the test." B. "You might have to drink orange juice during the test." C. "During the test, you will be asked to massage your nipples." D. "During the test, you will receive a medication to relax your uterus."
"You might have to drink orange juice during the test."
The nurse is teaching a client who is postpartum about the rubella vaccine. Which of the following statements should the nurse include? A. "You must not take this immunization if you've had the chickenpox." B. "You must not become pregnant for 28 days after receiving this immunization." C. "You must not breastfeed because the virus is passed in breastmilk." D. "You must not receive other vaccines at the same time as the rubella vaccine."
"You must not become pregnant for 28 days after receiving this immunization."
A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm pregnancy. Which of the following information should the nurse provide to the client? a."You should wait until 4 weeks after conception to be tested" b."You should be off any medications for 24 hours prior to the test" c."You should be NPO for at least 8 hours prior to the test" d."You should collect urine from the first morning void"
"You should collect urine from the first morning void"
A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks gestation." D. "You should schedule a cesarean birth after your water breaks."
"You will have a cesarean birth prior to the onset of labor."
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
-Ask the client to lie on her back with her knees flexed. -Place a hand just above the client's symphysis pubis. -Position a hand around the top of the client's fundus. -Rotate the upper hand to massage the client's uterus. -Use slight downward pressure to compress the client's fundus.
What is normal blood glucose, bilirubin, and hemoglobin for infant
-Blood glucose: 40-60 mg/dL -Bilirubin: 24 hrs: 2-6 mg/dL, 48 hrs: 6-7 mg/dL, 3-5 days: 4-6 mg/dL. -Hemoglobin: 14-24 g/dL
A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives? a.A client who smokes 2 packs of cigarettes per week b.A client who is breastfeeding a 7 month old infant c.A client who is taking an anticonvulsant medication d.A client who is taking anti-HIV protease inhibitors
A client who is breastfeeding a 7 month old infant
A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome
A newborn who is large for gestational age
A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindication 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
A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? (Select all that apply.) A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus beta-hemolytic E. TORCH infection
A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus beta-hemolytic
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 caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn
A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor
A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°
A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°
A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? A. Check the fetal heart tones B. Assess the uterine contraction pattern C. Measure maternal vital signs D. Obtain a biophysical profile
Check the fetal heart tones
A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp
Check the integrity of the cord clamp
A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection
Administer immune globulin to the client to prevent fetal isoimmunization
A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? a.Encourage the mother to breastfeed b.Administer the hepatitis B vaccine prior to discharge c.Implement contact and droplet precautions d.Collect a cord blood specimen to test for presence of HIV
Administer the hepatitis B vaccine prior to discharge
A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? a.Administer Vitamin K SubQ b.Administer erythromycin eye ointment within 12 hours c.Administer erythromycin eye ointment from the outer canthus toward inner canthus d.Administer vitamin K in newborn's thigh
Administer vitamin K in newborn's thigh
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water sitz bath for the client's perineum B. Encourage the client to sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Administer an acetaminophen suppository rectally
Apply cold ice packs to the client's perineum
A nurse is caring for a client in active labor. When examined 2 hr ago, the client's cervix was 3 cm 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 the fingers c.Administer oxygen at 10/L min via a face mask d.Initiate IV fluids
Apply pressure to the presenting part with the fingers
A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks gestation
At 28 weeks gestation
A nurse is admitting a child who has a UTI and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? a.Attach a latex allergy alert identification band b.Initiate contact precautions c.Post signs in the client's bathroom to strain the client's urine d.Administer folic acid with meals
Attach a latex allergy alert identification band
A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy? a.Quickening b.Breast tenderness c.Uterine enlargement d.Auscultation of a fetal heart rate
Auscultation of a fetal heart rate
A nurse is discussing with a newly licensed nurse about how to obtain informed consent from a client who is scheduled to undergo an epidural procedure. Which of the following ethical principles should the nurse include in the teaching? A. Beneficence B. Autonomy C. Paternalism D. Justice
Autonomy
A nurse is caring for an infant who begins displaying manifestation of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? a.Swaddle the infant with arms and legs extended b.Administer Naloxone IM c.Avoid eye contact during feedings d.Discourage the mother from handling the infant during the withdrawal phase
Avoid eye contact during feedings
A nurse is assessing a client before administering the Hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? a.Shellfish b.Gelatin c.Baker's yeast d.Eggs
Baker's yeast
A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include? A. "This test is an invasive procedure that presents minimal risk to the fetus." B. "If the test is reactive, that means your baby's heart rate is healthy." C. "When your baby moves, the test should record the baby's heart rate decreasing by about 15 beats per minute." D. "The results of the test will be recorded as positive if no fetal movement occurs during the 20-minute testing period."
"If the test is reactive, that means your baby's heart rate is healthy."
A nurse is preparing to administer a Vitamin K injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? a."It assists with blood clotting." b."It promotes maturation of the bowel." c."It is a preventative vaccine." d."It provides immunity."
"It assists with blood clotting."
A nurse in a clinic is caring for a client who is postoperative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? a."It is good to know that I won't have a tubal pregnancy in the future" b."The doctor said that this surgery can affect my ability to get pregnant again" c."I understand that one of my fallopian tubes had to be removed." d."Ovulation can still occur because my ovaries were not affected"
"It is good to know that I won't have a tubal pregnancy in the future"
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 statements should the nurse 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"
"It is needed to counteract hypotension"
A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. "This will resolve in 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This appearance is expected at birth, so you don't need to worry."
"This will resolve in 3 to 6 weeks without treatment."
A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? A. "True contractions will begin irregularly and then become regular in timing." B. "True contractions will go away with ambulation." C. "False contractions increase in frequency and duration the closer you are to your due date." D. "False contractions are first felt in the pelvic area and then in the lower back and abdomen."
"True contractions will begin irregularly and then become regular in timing."
A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include? A. "Take an herbal galactagogue." B. "Gradually increase the time between feedings." C. "Wear an underwire bra." D. "Use your finger to release suction after feeding."
"Use your finger to release suction after feeding."
A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? a.Measure the infant's intake and output b.Measure the infant's head circumference c.Check the infant's lower extremity function d.Monitor the infant's blood pressure
Measure the infant's head circumference
A nurse is caring for a client who requests an IUD for contraception. Which of the following findings is contraindicated for this device? a.Hypertension b.Menorrhagia c.History of multiple gestations d.History of thromboembolic disease
Menorrhagia
A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine
Methylergonovine
A nurse is caring for a 2 day old infant who has myelomeningocele. Which of the following actions should the nurse take? a.Monitor the infant's head circumference b.Position the infant supine c.Place the infant under a radiant warmer d.Tape a piece of plastic over the protruding membranes
Monitor the infant's head circumference
How to calculate EDD?
Naegele's rule - Subtract 3 months and add 7 days
A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature? a.Pale, translucent skin b.Nails extending over fingers c.Weak gag reflex d.Thin covering of fine hair on shoulders and back
Nails extending over fingers
A nurse in an emergency department is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report as an indication of impending airway obstruction? A. Bradycardia B. Respiratory depression C. Nasal flaring D. Barking cough
Nasal flaring
A nurse is assessing a newborn. Which of the following findings should the nurse immediately report to the provider? A. Milia B. Epstein pearls C. Nasal flaring D. Meconium stools
Nasal flaring
A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign or pregnancy? a.Nausea in the morning b.Positive home pregnancy test c.Increased sensitivity of the cervix noted upon examination d.Gestational sac observed by transvaginal ultrasound
Nausea in the morning
A nurse is assessing a 7-month old infant during a well-child visit and notes presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant? a.Congenital heart disease b.Hearing loss c.Neurological disorder d.Amblyopia
Neurological disorder
A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? a.Copper IUD b.Combination pill c.Vaginal ring d.Medroxyprogesterone injection
Copper IUD
A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect? A. Maternal serum alpha-fetoprotein B. Pregnancy-associated plasma protein A C. Chorionic villus sampling D. HbA1c
HbA1c
A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? A. Nausea and vomiting B. Tachycardia C. Hypotension D. Respiratory depression
Hypotension
A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? A. Platelet count 97,000/mm^3 B. Deep tendon reflexes 4+ C. Urine protein 1+ D. BUN 22 mg/dL
Deep tendon reflexes 4+
A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability
Impaired placental perfusion
A nurse is caring for a client in the early stage of labor who has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions
Implement seizure precautions
A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use? a.Large for gestational age b.Hypotonicity c.Incessant crying d.Craniofacial anomalies
Incessant crying
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
Dizziness
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence
Double vision
A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. The nurses should recognize that which of the following is an example of a teratogen? A. Consuming caffeine during pregnancy B. A family history of a genetic disorder C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy
Drinking alcohol during pregnancy
A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? a.Weigh the newborn b.Instill erythromycin ophthalmic ointment in the newborn's eyes c.Administer Vitamin K to the newborn d.Dry the newborn
Dry the newborn
A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states "I missed one menstrual cycle and cannot be pregnant because I have an IUD." The nurse should suspect which of the following? a.Missed abortion b.Ectopic pregnancy c.Severe preeclampsia d.Hydatidiform mole
Ectopic pregnancy
A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Increase the rate of the primary IV infusion C. Position the client in a semi-Fowler's position D. Provide glucose via oral hydration or IV
Increase the rate of the primary IV infusion
A nurse is preparing to help with a vacuum-assisted birth. Which of the following actions should the nurse plan to take? A. Instruct the client to stop pushing during contractions B. Inform the client that caput succedaneum resolves in a few days C. Monitor the newborn for decreased levels of bilirubin after birth D. Identify that the newborn is at risk for facial palsy
Inform the client that caput succedaneum resolves in a few days
A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? a.Oflocacin b.Nystatin c.Erythromycin d.Ceftriaxone
Erythromycin
A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1-2 hr of delivery? a.Naloxone b.Erythromycin ophthalmic ointment c.Poractant alfa d.Rotavirus immunization
Erythromycin ophthalmic ointment
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? a.Extended periods of sleep b.Poor muscle tone c.Respiratory rate 50/min d.Exaggerated reflexes
Exaggerated reflexes
A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations
Expiratory grunting
A nurse is teaching a client who is at 12 weeks gestation about manifestations of potential complications that she should report to her provider. Which of the following pieces of information should the nurse include in the teaching? A. Facial swelling B. Urinary frequency C. White vaginal discharge D. Intermittent nausea
Facial swelling
A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus
Feeling of warmth
A nurse is caring for a client who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy? a.Positive serum pregnancy test b.Amenorrhea c.Fetal heart tones auscultated by Doppler d.Chadwick sign
Fetal heart tones auscultated by Doppler
A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Periodic numbness of fingers
Frequent headaches
A nurse working on a maternal-newborn unit is teaching a group of newly licensed nurses about assisting new mothers with breastfeeding. The nurse should include which of the following infant conditions as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism
Galactosemia
A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth
Gestational diabetes
A nurse is caring for a newborn. The nurse should obtain informed consent before taking which of the following actions? a.Administering erythromycin ophthalmic ointment b.Conducting a newborn hearing screening c.Giving the hepatitis B vaccine d.Screening for congenital heart disease
Giving the hepatitis B vaccine
A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands
Grunting with expiration
A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Encourage the client to pump the breasts B. Instruct the client to take a warm shower twice per day C. Tell the client to massage the breasts D. Instruct the client to apply cold compresses
Instruct the client to apply cold compresses
A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O negative. Which of the following actions should the nurse take? A. Administer a dose of Rho(D) immune globulin B. Request a prescription for an antibiotic until delivery C. Instruct the client to obtain a rubella immunization after delivery D. Inform the client that she will need to deliver via cesarean birth
Instruct the client to obtain a rubella immunization after delivery
A nurse is teaching a group of clients who are pregnant about Vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? a.Altered carbohydrate metabolism b.Hyperbilirubinemia c.Intracranial hemorrhage d.Hypoglycemia
Intracranial hemorrhage
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
Keep a daily record of fetal kick counts
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
Keep the diaper folded below the cord
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.
Keep the diaper folded below the cord.
A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following factors is the nurse's priority to evaluate? A. Psychological readiness B. Partner support C. Socioeconomic status D. Nutritional status
Nutritional status
A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A. Perform a vaginal examination to determine cervical dilation B. Obtain blood samples for baseline laboratory values C. Place a spiral electrode on the fetal presenting part D. Prepare the client for a transvaginal ultrasound
Obtain blood samples for baseline laboratory values
A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine
Oxytocin
A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? A. Painless, bright red bleeding B. Board-like uterus C. Persistent uterine contractions D. Abdominal pain
Painless, bright red bleeding
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? a.Palpable fetal movement b.Chadwick's sign c.Positive pregnancy test d.Amenorrhea
Palpable fetal movement
A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? a.Fasten the diaper loosely b.Cleanse the meningeal sac with povidone-iodine daily c.Palpate the abdomen for bladder distention d.Cover the sac with dry, sterile gauze dressing
Palpate the abdomen for bladder distention
A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids
Palpating the client's fundus
A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event? A. Paralysis of a client's lower extremities occurred following epidural anesthesia. B. A client fall during ambulation did not result in client injury. C. A client's family member complained that a nurse was culturally insensitive. D. Surgery to the wrong site was stopped prior to a procedure.
Paralysis of a client's lower extremities occurred following epidural anesthesia.
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent urinary tract infections C. Previous cesarean birth D. Pelvic inflammatory disease (PID)
Pelvic inflammatory disease (PID)
A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take? a. Increase the rate of intravenous fluid infusion b. Discontinue the infusion of oxytocin c. Re-evaluate the FHR tracing in 15 minutes d. Request a prescription for an amnioinfusion
Re-evaluate the FHR tracing in 15 minutes
A nurse is caring for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition? a.No alteration in menses b.Transvaginal ultrasound indicating a fetus in the uterus c.Blood progesterone greater than the expected reference range d.Report of severe shoulder pain
Report of severe shoulder pain
A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? a.Reduced menstrual flow b.Breast tenderness c.Shortness of breath d.Increased appetite
Shortness of breath
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? A. Continuous lochia flow and a flaccid uterus B. Report of increasing pain and pressure in the perineal area C. Slow trickle of bright vaginal bleeding and a firm fundus D. Gush of rubra lochia when the uterus is massaged
Slow trickle of bright vaginal bleeding and a firm fundus
A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis? a.Staphylococcus aureus b.Chlamydia trachomatis c.Klebsiella pneumonia d.Clostridium perfringens
Staphylococcus aureus
A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect? a.Symmetric rib cage b.Dry, wrinkled skin c.Vernix over the entire body d.Abundant lanugo on the back
Symmetric rib cage
A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib
Tension pneumothorax
A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in breech presentation. For while of the following possible complications should the nurse observe? a.Precipitous labor b.Premature rupture of membranes c.Postmaturity syndrome d.Prolapsed umbilical cord
Prolapsed umbilical cord
A nurse is caring for an infant who is preoperative for treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? a.Side lying b.Supine c.Prone d.Semi-Fowler's
Prone
A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? A. Severe hypotension B. Proteinuria C. Elevated platelet count D. Seizures
Proteinuria
A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a sitz bath with warm water for the client C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake
Provide a sitz bath with warm water for the client
A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? A. The fundal height measures greater than gestational age. B. A rigid abdomen is noted on palpation. C. The client reports a pain level of 8 on a 0-to-10 pain scale. D. A urine drug screen is positive for cocaine.
The fundal height measures greater than gestational age
A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? a.Abduction and extension of the arms are asymmetric b.The opposite leg flexes while a leg is extended and the sole of the foot is stimulated c.Toes hyperextended with dorsiflexion of the great toe d.The legs move in a similar pattern of response to the arms
The legs move in a similar pattern of response to the arms
A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord. B. They can cause delayed cord separation. C. They can cause swelling of the surrounding tissue. D. They can cause skin discoloration.
They can cause delayed cord separation.
A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? a.Rooting b.Moro c.Tonic neck d.Babinski
Tonic neck
A nurse is caring for a client at 37 weeks gestation who is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? A. Use vibroacoustic stimulation on the client's abdomen for 3 sec B. Report the nonreactive test result to the provider immediately C. Request a prescription for an internal fetal scalp electrode D. Auscultate the FHR with a Doppler transducer
Use vibroacoustic stimulation on the client's abdomen for 3 sec
A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? A. Uterine tone B. Fetal heart rate C. Blood pressure D. Amount of bleeding
Uterine tone
A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression
Uteroplacental insufficiency
A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements per hour
Vaginal bleeding
A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 1? a.Heart rate 116/min b.Weak cry c.Flaccid muscles d.No response to stimuli
Weak cry
A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicated an understanding of the teaching? a.The parent places a few drops of water on their nipple before feeding b.The parent gentle removes their nipple from the infant's mouth the break suction c.When they are ready to breastfeed. The parent gently strokes the newborn's neck with a finger d.When latched on the infants nose, cheek, and chin are touching the breast
When latched on the infants nose, cheek, and chin are touching the breast
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 your intake of calcium" d."You should avoid taking antibiotics." e."Irregular vaginal spotting can occur."
a."Weight fluctuations can occur." c."You should increase your intake of calcium" e."Irregular vaginal spotting can occur."
A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following manifestations could indicate postpartum depression? (SATA) a.Fatigue b.Insomnia c.Euphoria d.Flat affect e.Delusions
a.Fatigue b.Insomnia d.Flat affect
A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? 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 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 in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations of which of the following? (SATA) a.Moderate variability b.FHR accelerations c.FHR decelerations d.Normal baseline FHR e.Fetal tachycardia
a.Moderate variability b.FHR accelerations d.Normal baseline FHR
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (SATA) a.Precipitous delivery b.Obesity c.Inversion of the uterus d.Oligohydramnios e.Retained placental fragments
a.Precipitous delivery c.Inversion of the uterus e.Retained placental fragments
A nurse is 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 25 ml/hr c.Hyperreflexic DTR d.Decreased level of consciousness e.Flushing and sweating
a.Respirations less than 12/min b.Urinary output less than 25 ml/hr d.Decreased level of consciousness
A nurse is performing a physical assessment of a full term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (SATA) a.Thumb and forefinger forming a "C" b.Legs extending before pulling upward c.Arms and legs adducting d.Arms falling backward after startling e.Head turning to the right
a.Thumb and forefinger forming a "C" b.Legs extending before pulling upward
A nurse is caring for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of the condition? (SATA) a.UTI b.Multifetal pregnancy c.Oligohydramnios d.Diabetes mellitus e.Uterine abnormalities
a.UTI b.Multifetal pregnancy d.Diabetes mellitus e.Uterine abnormalities
A nurse is providing education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? (SATA) 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 providing care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing the condition? (SATA) a.Fetal position b.Blunt abdominal trauma c.Cocaine use d.Maternal age e.Cigarette smoking
b.Blunt abdominal trauma c.Cocaine use e.Cigarette smoking
A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? (SATA) a.Paranoid that their infant will be harmed b.Concerns about lack of income to pay bills c.Anxiety about assuming a new role as a parent d.Rapid decline in estrogen and progesterone e.Feeling of inadequacy with new role as a parent
b.Concerns about lack of income to pay bills c.Anxiety about assuming a new role as a parent d.Rapid decline in estrogen and progesterone e.Feeling of inadequacy with new role as a parent
A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? a.Montgomery's glands b.Goodell's sign c.Ballottement d.Chadwick's sign e.Quickening
b.Goodell's sign c.Ballottement d.Chadwick's sign
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 term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. there are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? a.request a prescription for continuous positive airway pressure (CPAP) b.initiate close observations of the newborn for indications of respiratory distress c.consult a respiratory therapist for chest physiotherapy d.request an order for nitric oxide therapy
initiate close observations of the newborn for indications of respiratory distress
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr B. Blood pressure 144/92 mmHg C. +2 edema of the feet D. 1+ protein in urine
480 mL urine output in 24 hr
A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? a.7 b.8 c.9 d.10
9
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue your IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."
"The bleeding is minimal until I discontinue your IV medication."
A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore." D. "My baby may sometimes feed every hour for several hours in a row."
"My baby may sometimes feed every hour for several hours in a row"
A nurse is caring for a client who is at 34 weeks gestation and has a prescription for Terbutaline for preterm labor. Which of the following statements by the client is the priority? a."My ankles are swollen at the end of the day" b."I can feel the baby kicking my ribs, and it is very uncomfortable"\ c."I'm growing more and more worried every day" d. "My heart feels like it is racing"
"My heart feels like it is racing"
A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amounts of milk from your breasts frequently."
"Place fresh cabbage leaves on your breasts."
The student nurse asks the nurse how Rho(D) IG prevents antibody formation when sensitization is possible in an Rh-negative mother. Which explanation should the nurse provide?
"The Rho(D) IG suppresses the immune response of the Rh-negative mother to the Rh antigens in the fetal blood before the maternal immune system forms antibodies against them."
A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include? A. "The fibroid will shrink during the pregnancy." B. "The fibroid can increase the risk of postpartum hemorrhage." C. "You will receive an injection of medroxyprogesterone acetate to shrink the fibroid." D. "You will have to undergo a cesarean birth because of the fibroid."
"The fibroid can increase the risk of postpartum hemorrhage."
A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? a."The newborn will have a decreases muscle tone" b."The newborn will have a continuous high-pitched cry" c."The newborn will sleep for 2 to 3 hours after feeding." d."The newborn will have mild tremors when disturbed"
"The newborn will have a continuous high-pitched cry"
A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide? A. "This test will determine if you are likely to deliver within the next week." B. "This test will help determine if your baby is healthy." C. "This test can see how your baby responds when you have contractions." D. "This test will determine if your baby's lungs are mature."
"This test will help determine if your baby is healthy."
A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. "You should supplement your baby with formula until you notice that your breasts become firm and full." B. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat." C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." D. "It is typical for your nipples to hurt for the first few weeks while you are breastfeeding."
"Your milk supply will noticeably increase in volume around the third or fourth day after delivery."
A nurse is providing teaching to a client who has come to the family planning clinic requesting an IUD. Which of the following pieces of information should the nurse provide the client? a."If you lose weight, you will need to have your IUD refitted." b."An IUD provides protection from certain STIs" c."Your risk for ectopic pregnancy increases with an IUD" d."You shouldn't use an IUD if you want to have children later"
"Your risk for ectopic pregnancy increases with an IUD"
A nurse is providing teaching to a client who has come to the family-planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse provide the client? A. "If you lose weight, you will need to have your IUD refitted." B. "An IUD provides protection from certain sexually transmitted infections." C. "Your risk for ectopic pregnancy increases with an IUD." D. "You shouldn't use an IUD if you want to have children later."
"Your risk for ectopic pregnancy increases with an IUD."
The umbilical cord comprises how many arteries and veins?
2 Arteries, 1 Vein
A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease
Assess the newborn's blood glucose level
A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? a.Assist the client into the left-lateral position b.Apply a fetal scalp electrode c.Insert an IV catheter d.Perform a vaginal exam
Assist the client into the left-lateral position
A nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. The client's temperature is 37.8°C (100°F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take? A. Notify the provider about the client's elevated temperature B. Assist the client to empty her bladder C. Administer a bisacodyl suppository D. Massage the client's fundus
Assist the client to empty her bladder
A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer? a.Betamethasone b.Misoprostol c.Methylergonovine d.Poractant alfa
Betamethasone
A nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? a.Betamethasone b.Indomethacin c.Nifedipine d.Methylergonovine
Betamethasone
A nurse is caring for a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? a.Betamethasone b.Nifedipine c.Indometacin d.Verapamil
Betamethasone
A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching? A. Nausea upon awakening B. Leg cramps while sleeping C. Increased white vaginal discharge D. Blurred or double vision
Blurred or double vision
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? a.Protamine sulfate b.Naloxone c.Calcium gluconate d.Flumazenil
Calcium gluconate
A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote to magnesium sulfate? A. Betamethasone B. Terbutaline C. Calcium gluconate D. Indomethacin
Calcium gluconate
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
Ceftriaxone
A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Anterior fontanel of 5 cm B. Central cyanosis C. Edematous scrotum D. Capillary refill of under 2 seconds
Central cyanosis
A nurse is caring for a client who is at 39 weeks gestation and shows manifestations of labor. Which of the following findings will alert the nurse that the client is in true labor? A. Contractions felt in the upper abdomen B. A small amount of bloody discharge C. Contractions occurring every 2 to 10 min D. Changes in cervical dilation or effacement
Changes in cervical dilation or effacement
A nurse is caring for a newborn immediately following birth. Which of the following nursing intervention is the highest priority? a.Initiating breastfeeding b.Performing initial bath c.Giving Vitamin K injection d.Covering the newborn's head with a cap
Covering the newborn's head with a cap
A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss? a.Over the shoulder b.Supine c.Chin supported d.Cradle
Cradle
A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A. Hypothermia B. Dark brown vaginal discharge C. Decreased urinary output D. Fetal heart tones
Dark brown vaginal discharge
A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? A. Increased platelet count B. Fetal distress C. Decreased urinary output D. Dark red vaginal bleeding
Dark red vaginal bleeding
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 food to touch the 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 onto the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward
Hold onto the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea; vomiting; and scant, prune colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect? a.Hyperemesis gravidarum b.Threatened abortion c.Hydatidiform mole d.Preterm labor
Hydatidiform mole
A nurse is teaching a newly hired nurse about caring for an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor an infant for which of the following complications? a.Hydrocephalus b.Congenital hypotonia c.Otitis media d.Osteomyelitis
Hydrocephalus
A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure (CPAP) B. Initiate close observation of the newborn for indications of respiratory distress C. Consult a respiratory therapist for chest physiotherapy D. Request an order for nitric oxide therapy
Initiate close observation of the newborn for indications of respiratory distress
A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? A. Check for a full bladder B. Massage the fundus C. Measure vital signs D. Administer carboprost IM
Massage the fundus
A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? A. Perform a vaginal examination B. Perform continuous external fetal monitoring C. Insert a large-bore IV catheter D. Obtain a blood sample for laboratory testing
Perform a vaginal examination
A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and feeling of letdown. Which of the following conditions are associated with these manifestations? a.Postpartum fatigue b.Postpartum psychosis c.Letting go phase d.Postpartum blues
Postpartum blues
A nurse is caring for a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? A. Decrease IV fluids B. Give oxygen at 2 L/min via nasal cannula C. Place the client in a lateral position D. Administer indomethacin
Place the client in a lateral position
A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? A. Place the client in a side-lying position B. Discontinue the oxytocin infusion C. Apply oxygen to the client via a face mask D. Check for umbilical cord prolapse
Place the client in a side-lying position
A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? a.Perform a detailed physical assessment b.Place the newborn directly on the client's chest c.Give the newborn IM Vitamin K d.Administer erythromycin ophthalmic ointment
Place the newborn directly on the client's chest
A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%
Platelet count 135,000/mm^3
A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy? a.Report of fetal movement by the client b.Auscultation of the fetal heart rate with Doppler ultrasound c.Presence of Chadwick's sign on pelvic examination d.Report of Braxton-Hicks contractions by the client
Report of fetal movement by the client
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. Respiratory depression B. Hypothermia C. Hypoglycemia D. Jaundice
Respiratory depression
A nurse is caring or a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to magnesium sulfate therapy? a.Respiratory depression b.Hypothermia c.Hypoglycemia d.Jaundice
Respiratory depression
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
A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitate infant feeding? a.Stepping b.Moro c.Rooting d.Babinski
Rooting
A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? a.Weak cry b.Absent Moro cry c.Constipation d.Tremors
Tremors
A nurse is assessing a client at 35 weeks gestation who is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider? A. Deep tendon reflexes 2+ B. Blood pressure 150/96 mmHg C. Urinary output 20 mL/hr D. Respiratory rate 16/min
Urinary output 20 mL/hr
