OB (Hesi-2)
"Infants' feet appear flat because the arch is covered with a fat pad.
While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond? (OJO)
Preterm labor Multiple gestation Chromosomal anomalies Bleeding in the first trimester
Women who become pregnant for the first time at a later reproductive age (35 years or older) are at risk for what complications? Select all that apply.
Estimate fetal age
The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is used to:
Insulin
The nurse is counseling a pregnant client with type 1 diabetes about medication changes as pregnancy progresses. Which medication will be needed in increased dosages during the second half of her pregnancy?
Edema that crosses the suture line
The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succedaneum?
Use the panting-breathing pattern.
A client arrives in the birthing room with the fetal caput emerging. What should the nurse say to the client during a contraction?
Drunk a glass of orange juice and timed 10 fetal movements
A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has done what?
Neurotoxicity caused by vinblastine
A client is receiving ABVD (doxorubicin [Adriamycin], bleomycin [Blenoxane], vinblastine [Velban], and dacarbazine [DTIC]) therapy for Hodgkin disease. About halfway through the first six-month course of treatment, the client complains of burning and tingling of the feet. The nurse determines that these symptoms are a result of:
Apply brief pressure to the site
A client who is suspected of having leukemia has a bone marrow aspiration. Immediately after the procedure, the nurse should:
Slow-chest
A nurse determines that the husband of a client in the early phase of labor understands the teaching from childbirth classes when he helps his wife use the breathing pattern of:
Cesarean birth is anticipated
A nurse in the birthing unit assesses a primigravida who is at 42 weeks' gestation. Fluid is leaking from her vagina, and she is complaining of back pain. Which conclusion is supported by the data collected? (OJO)
Sudden onset of knifelike pain in one of the lower quadrants
A nurse is assessing a woman with a probable ruptured tubal pregnancy. What clinical manifestation requires immediate intervention?
Use pillows to elevate the affected arm above the level of the heart
A nurse is caring for a client during the early postoperative period after a modified radical mastectomy. What should the nurse teach her about limiting edema in the affected arm?
Greenish-tinged amniotic fluid
A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor? (OJO)
Compression by the enlarging uterus
A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:
Apply elastic stockings before arising
A client hospitalized with thrombophlebitis asks how to prevent it from occurring again. What should the nurse teach the client?
FHR baseline at150 beats/min
A client in active labor has an external fetal monitor in place. Using the monitor strip, identify the correct assessment.
Amenorrhea Breast changes Urinary frequency
A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect, including which of the following? Select all that apply.
1 cm above the ischial spines
A client in labor is admitted to the birthing room. The nurse's assessment reveals that the fetus is at −1 staƟon. Where is the presenting part?
Applying pressure against her sacrum
A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. What nursing action will help relieve this discomfort?
Progressive dilation and effacement
A client is admitted to the birthing unit in active labor. Amniotomy is performed by the health care provider. What physiologic change does the nurse expect to occur after the procedure?
Protamine sulfate
A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, the nurse should be prepared to administer:
Metabolic alkalosis
A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco2 50 mm Hg, bicarbonate 58 mEq/L, chloride 55 mEq/L, sodium 132 mEq/L, and potassium 3.8 mEq/L. The nurse determines that the results indicate:
Stop the piggyback infusion. Check the fetal heart rate (FHR). Determine whether the contractions have diminished Notify the health care provider. Administer oxygen by way of facemask. Document the responses of the client and fetus.
A client is receiving an intravenous piggyback infusion of oxytocin (Pitocin) to augment labor. The nurse identifies three contractions lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is followed in response to this observation. List in order of priority the nursing actions that should be taken.
Turn the oxytocin infusion off.
A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first?
Elevated U and flattened T waves
A client who has been experiencing chest pain and vomiting for several hours is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering the laboratory result, the nurse should monitor the client's electrocardiogram (ECG) for:
Apply cold packs and a snugly fitting bra.
A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do? (OJO)
Piggyback another 10-unit bag of oxytocin (Pitocin).
A client who is having a difficult labor is found to have cephalopelvic disproportion. Which medical order should the nurse question?
Type A or O negative
A client who is scheduled for a modified radical mastectomy decides to have family members donate blood in the event it is needed. The client has type A negative blood. Blood can be used from relatives whose blood is:
Changing the client's position
A client's membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?
Auscultating the fetal heart rate
A client's membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?
Transition
A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client reports that she is going to vomit. What phase of the first stage of labor does the nurse suspect the client has entered?
Sympathomimetic
A health care provider in the emergency department identifies that a client is in mild hypovolemic shock. Which type of drug should the nurse anticipate will be prescribed?
1 g given at 1 pm
A laboring client who is positive for Group B Streptococcus is given an initial dose of ampicillin (Omipen) 2 g at 9 am. According to established guidelines for intrapartum management of this client, the next dose should be:
Precipitous vaginal delivery
A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented?
Inborn error of metabolism
A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem?
Provide sponge baths until the stump falls off.
A new mother asks a nurse how to care for her baby's umbilical cord stump. What should the nurse teach the mother?
Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip.
A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply.
Donning sterile gloves and applying direct pressure, using sterile gauze
A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention should the nurse implement?
Neonatal morbidity
A newborn's Apgar score at 5 minutes is 5. With what condition that requires intensive monitoring of this neonate does a low Apgar score 5 minutes after birth correlate?
A
A newborn's birth was prolonged because the shoulders were very wide. With which reflex does the nurse anticipate a problem? A- Moro B- Plantar C- Babinski D- Stepping
Webbed neck Female sex organs Widely spaced nipples
A nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply. (OJO)
12th week of pregnancy
A nurse at the prenatal clinic examines a client and determines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation would the nurse expect this assessment finding to occur?
Late decelerations
A nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when during contractions the fetal heart rate shows:
May inhibit the progress of labor
A nurse helps a client to the bathroom to void several times during the first stage of labor. This is done because a full bladder:
Immediate defibrillation
A nurse in the coronary care unit (CCU) identifies ventricular fibrillation on a client's cardiac monitor. What intervention is the priority?
Diminished breath sounds
A nurse in the neonatal intensive care unit is caring for a preterm newborn with respiratory distress syndrome (RDS). What clinical finding does the nurse expect? (OJO)
Rectal pressure during contractions
A nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect?
Butorphanol (Stadol)
A nurse is caring for a primigravida during labor. At 7 cm of dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?
Absence of hair on the toes Reports of pain associated with exercising
A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply.
Spontaneous rupture of membranes 3 hours ago
A nurse is conducting the admission assessment of a client who is positive for Group B Streptococcus (GBS). Which finding is of most concern to the nurse?
Audible fetal heartbeat
A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient?
Increased blood volume Increased cardiac output Enlargement of the heart
A nurse is planning a prenatal class about the changes that occur during pregnancy and the necessity of routine health care throughout pregnancy. Which cardiovascular compensatory mechanisms should the nurse explain will occur? Select all that apply.
Increased blood pressure and decreased hormone production
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include:
The cervix is dilated.
A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor?
Empty her bladder.
A nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment?
Phenex Lofenalac
A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant? Select all that apply. OJO OJO
Blue
A nurse who is caring for a client in labor uses Nitrazine paper to test the pH of the client's leaking vaginal fluid. What color will the Nitrazine paper turn if the leakage is amniotic fluid?
Metabolism of brown fat
A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by: (OJO)
Leakage of fluid from the vagina
A pregnant client at 37 weeks' gestation is taught about signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report:
Third trimester
A pregnant client is asking the nurse when she will gain the most weight. At which time during prenatal development should the nurse tell the client to expect the greatest fetal and maternal weight gain?
"How frequent are your contractions?"
A primigravida at 36 weeks' gestation is admitted to the birthing room with ruptured membranes and a cervix that is dilated 2 cm and 75% effaced. What is the priority question the nurse should ask?
Monitor the fetal heart rate for signs of compromise. Test the fluid's pH with Nitrazine paper. Perform a vaginal examination to ascertain the progression of labor. Notify the practitioner
A primipara is admitted to the birthing room in active labor. The fetus's head is engaged and the cervix is dilated 9 cm when there is a gush of fluid from the vagina. Place the nursing actions in order of priority.
Supine
The nurse is providing discharge teaching to the parents of a 3-day-old infant. The mother expresses concern about sudden infant death syndrome (SIDS). To reduce the risk of SIDS during sleep, the nurse instructs the parents to position the infant:
Chest x-ray
The nurse is providing post-procedure care for a client that had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement?
Suction the infant.
At 10 hours of age a neonate's oral cavity is filled with mucus, and cyanosis develops. What should the nurse do first?
Fetal lung maturity is accelerated.
A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given?
Ventricular tachycardia
A client had an acute myocardial infarction. For which life-threatening complication should the nurse monitor during the first 48 hours?
Obtain an x-ray to verify that the tube is in the stomach.
A client has a nasogastric feeding tube inserted, and the health care provider prescribes the feeding to be instituted immediately. What should the nurse do first?
Don't urinate for at least 3 hours before the test."
A client in the 18th week of pregnancy is scheduled for ultrasonography. What instruction should the nurse give the client?
Abdominal girth
A client with advanced cirrhosis of the liver is receiving intravenous serum albumin. As a result of this treatment, the nurse expects a decrease in:
Urinary output
A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in:
B negative.
A nurse is caring for a client who is scheduled to have an abdominal perineal resection for colorectal cancer. A type and cross match is done because of a concern about blood loss. The client has type B-negative blood. The blood type that can be used for this client is:
Add extra salt to food
A nurse is caring for a client with Addison disease. What should the nurse teach the client to do regarding an appropriate diet?
Note the infant's color and tap or gently shake the shoulders. Position the infant supine on a firm, flat surface. Open the airway with the head tilt-chin lift method and listen for exhalation. Initiate rescue breathing at a rate of 40 to 60 breaths/min. Check the pulse at the brachial artery. Initiate chest compressions in a 30:2 ratio.
Organize the steps in infant cardiopulmonary resuscitation (CPR) in the correct sequence.
Two accelerations of 15 beats/min lasting 15 seconds
The nurse is interpreting the results of a nonstress test (NST) on a client at 41 weeks' gestation. Which result after 20 minutes is suggestive of fetal reactivity?
Stop the nurse from giving the vaccination.
While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. The nurse manager's first reaction should be to:
Auscultating the fetal heart
A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?
Right side-lying
A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position?
If the heart reacts well, my baby should do OK when I give birth."
A client is scheduled for a nonstress test in the 37th week of gestation. A nurse explains the procedure. Which statement demonstrates that the client understands the teaching?
6--8g/100 mL
A client is seen in the clinic with sickle cell anemia. The hemoglobin range that is expected to be seen in this client in sickle cell crisis would be:
Administer oxygen. Turn the client on the side. Discontinue the oxytocin infusion.
A client who is lying in the supine position while in active labor is receiving an intravenous oxytocin (Pitocin) infusion and has external monitors in place. Using the monitoring strips below, identify the appropriate nursing interventions. Select all that apply.
Low-protein
A client with chronic hepatic failure is to be discharged from the hospital. Which diet should the nurse encourage the client to follow based on the health care provider's prescription?
A reflex that is expected in the healthy newborn.
A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents? (OJO)
Decreased ammonia
A nurse administers cephulac (Lactulose) to a client with cirrhosis of the liver. Which response leads the nurse to determine that the cephulac is effective?
First
A nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify?
Cyanosis Tachypnea Retractions
A nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply.
Sickle cell screening α-Fetoprotein (AFP) testing for neural tube defects Serum glucose for gestational diabetes Fetal movement test Group B Streptococcus culture
A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a course on several tests during pregnancy. Place the tests in the order in which they should be performed during pregnancy.
Mousy or musty
A nurse is caring for a 3-week-old infant who was admitted with untreated phenylketonuria (PKU). How should the nurse document the odor of the infant's urine?
Arterial Insufficiency
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate:
Sitting Lateral Knee-chest
A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? Select all that apply. (OJO)
Panting-blowing pattern
A nurse is caring for a client in the transition phase of labor. What breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation?
4+
A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as:
Apply covered ice packs to the breasts.
A nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her about minimizing breast discomfort?
Heparin (Hep-Lock) Enoxaparin (Lovenox)
A nurse is caring for a pregnant client with thrombophlebitis. Which anticoagulant medication may be prescribed? Select all that apply.
Begin chest compressions
A nurse observes a window washer falling 25 feet to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?
Coughing and deep breathing
A nurse provides teaching for a client that is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is:
Doppler ultrasound at 10 to 12 weeks
A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with:
Hypoglycemia
A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect?
Transition
A vaginal examination reveals that a client in labor is dilated 8 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering?
Hemodilution
A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse identify as the reason for these hemoglobin and hematocrit levels?
Roast beef sandwich Chicken noodle soup Spaghetti and meatballs
The menu for a client with malabsorption syndrome must be limited because of a sensitivity to gluten. Which foods cannot be served to this client? Select all that apply.
Sinus rhythm with first degree AV block
The nurse is interpreting the client's rhythm strip and finds that the P and QRS waves are consistent, with a P wave preceding every QRS complex. The PR interval is 0.26 seconds long. The rate is 64 beats per minute. The nurse interprets this rhythm as:
Capillary refill, temperature, pulse
The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.
Hemoglobin: 10.8 g/dL
The nurse reviews the blood test results of a client at 24 weeks' gestation. Which finding should be reported to the health care provider? (OJO)
Raised to 30 degrees
The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention?
"Circumcision is a personal decision for the parents to make."
The parents of a newborn boy ask the nurse, "Is circumcision really necessary?" How should the nurse reply?
Report irregular vaginal bleeding
What should a nurse include when teaching about this oral contraceptive?
Breast bud size
Which criterion should a nurse use when assessing the gestational age of a preterm infant?
Fetal tone Fetal movement Amniotic fluid index Fetal breathing movements
Which of the following variables are scored on a biophysical profile? Select all that apply.
Muffled heart sounds Increased central venous pressure (CVP), Jugular vein distention
Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply.
Babinski.
While examining a newborn the nurse brushes a finger upward on the infant's sole. The newborn responds by fanning the toes outward. Which reflex is the nurse eliciting? (OJO)
Inspect the client's perineum for bulging
While having contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse do? .
Getting an informed consent signed by the mother of the baby
A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the medical priority?
This is the desired response at this stage of gestation
A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). What should the nurse explain to the client about the positive result?
7.5
A Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of:
Stop the transfusion Change IV administration set Run 0.9 normal saline at rapid rate Notify health care provider and blood bank
A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order.
Leg cramps, Muscle weakness
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply.
Avoid intramuscular injections. Examine the skin for ecchymosis areas.
A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.
Oatmeal Rye bread
A client is diagnosed with malabsorption syndrome. Which foods should the nurse teach the client to avoid? Select all that apply.
Check for a pulse
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?
Petechiae
A client with a distal femoral shaft fracture is at risk for developing a fat embolus. The nurse considers that a distinguishing sign that is unique to a fat embolus is:
Administer the histamine H2-receptor antagonist as prescribed.
A client with a long history of alcohol abuse develops acute pancreatitis. What should be done to best prevent stimulation of the pancreas?
Assessing the fetal heart rate
A laboring client experiences a spontaneous rupture of membranes. The nurse's priority is: (OJO)
The perineum has begun to bulge with each contraction.
A nurse is caring for a primigravida during labor. What does the nurse note that indicates that birth is about to take place?
Change nothing.
A pregnant client is found to have gestational hypertension. She tells the nurse that she has been following the recommended pregnancy diet. What should the nurse teach her about her diet at this time?
Even with the umbilicus
A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus:
Ensuring that the oxygen is continuously warmed and humidified
A preterm newborn is given oxygen by way of a hood. What should the plan of care for this neonate include?
Monthly injections of vitamin B12
After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for:
Protecting the sac with moist sterile gauze
After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1- minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn? (OJO)
Administering additional fluids every 2 hours
After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include? OJO
Diminished sensation of pain Impaired hearing of high-frequency sounds
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply.
Brachial plexus injury
An infant is admitted to the nursery after a difficult shoulder birth. For what condition should the nurse assess this newborn?
B
An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant? A- Clamping the cord a second time B- Obtaining heel blood to test the glucose level C- Starting an intravenous infusion of glucose in water D- Instilling an ophthalmic antibiotic to prevent
The most comfortable position may be assumed.
An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place? (OJO)
9
Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body.
Uteroplacental insufficiency
At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?
Accompanied by progressive cervical dilation
At 39 weeks' gestation a client asks the nurse about the difference between true and false labor. What information about true labor contractions should the nurse include in a response to the client's question?
Acute hemolytic anemia
During a prenatal examination a nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for:
Walking around until they subside
During a prenatal visit, a client at 37 weeks' gestation tells a nurse that she has painful, irregular contractions. What should the nurse recommend?
Breathe into her cupped hands.
During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?
Placing the client in the semi-Fowler position to increase cervical pressure
Early in the ninth month of pregnancy a client experiences painless vaginal bleeding and is admitted to the hospital. What should the client's plan of care include?
Opioid drug withdrawal
Five minutes after being born, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings? (OJO)
Cervical dilation
How does the nurse know that a client at 40 weeks' gestation is experiencing true labor?
Helping the client maintain control
How should a nurse direct care for a client in the transition phase of the first stage of labor?
Documenting an intact reflex .
In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior? .OJO
10 to 12 hours
In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage?
Reposition the client from supine to left lateral.
Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. The nurse should immediately:
Engagement Descent Flexion Internal rotation Extension Restitution External rotation Expulsion
List the mechanisms of labor in the correct sequence. (OJO)
Reinforcing the client's strengths and promoting reminiscing
Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client?
Chlamydia and gonorrhea
Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:
Enlarging area of caput with each contraction
The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats/min, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum?
The head is 1 cm above the ischial spines
The health care provider completes the vaginal examination by determining that the presenting part of the fetus is at -1 station. What does this information mean?
Tofu Ground beef patty
The laboratory blood tests of a client at 10 weeks' gestation reveal that she has anemia. The client refuses iron supplements. The nurse teaches her that the best source of iron is liver. What other foods does the nurse encourage the client to eat? Select all that apply.
Hypotonia Hypoplastic maxilla Small, upturned nose
The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol syndrome (FAS) in the newborn? Select all that apply. (OJO)
Promote the synthesis of prothrombin
The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:
Instruct her to void immediately before the test.
The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?
Contact the primary health care provider and discuss the possibility of simplifying the medication regimen
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?
72 to 96 hours
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every:
Tremors Hyperactivity
Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply.
Pain management with oral analgesic Assessment of the site every 15 minutes Application of an ice pack for 20-minute intervals
What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply.
Smoker Twin gestation
What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? Select all that apply. (OJO)
Uterine tetany
What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor?
Feeling of faintness Increased venous pressure Decreased systolic pressure
What findings occur with supine hypotensive syndrome? Select all that apply.
Respiratory distress
What is the most common complication for which a nurse must monitor preterm infants?
Personal feelings about terminal illness
What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill?
Abduction
When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain:
Having her pant-blow during contractions
When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. How should the nurse respond?
Irritability High-pitched cry Ineffective feeding behavior-
Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.
Blowing
Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?
Eat dry crackers before you get out of bed."
A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief
Semi-Fowler position to avoid hypotension
A nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client? (OJO)
Turning the client on her side
During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction?
Elevating the legs
During labor a client who is receiving epidural anesthesia has an episode of severe nausea, and her skin becomes pale and clammy. What is the immediate nursing action?
First
During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record?
Metabolic acidosis
During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism causes:
Instruct the client to dangle the legs
The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer?
Assessing the perineum for bulging
What is the priority nursing action during a client's second stage of labor?
Preparing the client for surgery
What is the priority nursing intervention for a laboring client with a sudden prolapse of the umbilical cord protruding from the vagina?
Promote effective pushing by the client.
What nursing action is the priority for a client in the second stage of labor?
Establishing eye contact Paraphrasing the client's message Using broad, open-ended statements.
What nursing actions best promote communication when obtaining a nursing history? Select all that apply.
Outer heel
What part of the foot is the best site to use for the puncture?
Tremors
What potentially adverse effect of an intravenous titrated drip of lidocaine (Xylocaine) should the nurse immediately report to the healthcare provider?
Destroy intestinal bacteria
What therapeutic effect should the nurse identify as the reason for administration of neomycin sulfate to a client before colon surgery?
Moderate serosa
What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?
Initiate defibrillation
When a client develops ventricular fibrillation in a coronary care unit, what is the responsibility of the first person reaching the client?
Cover the wound with a sterile towel moistened with normal saline
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler's position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?
Dependent rubor Ulcers on the toes Delayed capillary refill
When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.
Monitoring deep tendon reflexes Maintaining a dark, quiet environment Using a pump to regulate the medication Having calcium gluconate available at the bedside
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply.
Supine position
Which position does the nurse teach the client to avoid when she experiences back pain during labor?
Gamma-globulins
A client asks the nurse what advantage breastfeeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?
Use the pant-breathing pattern.
A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse tell the client to do?
Open anterior and posterior fontanels
A nurse is assessing the head of a healthy newborn after a cesarean birth. What does the nurse expect to identify? OJO
Encouraging her to void before the test
A nurse is preparing a pregnant client for an amniocentesis. What should nursing care include?
Deep-breathe slowly
A client and her partner are working together during the woman's labor. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that will alleviate the client's discomfort during contractions?
Bending and then straightening their knees
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next:
Occiput posterior
An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned:
Bulging fontanels
An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?
Vitamin C and iron
On a 6-week postpartum visit a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for:
Hypotension
The nurse is caring for a client who has just received epidural anesthesia. Which finding would be of most concern?
Weight of 6 lb 4 oz
The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb at birth. Which finding should be reported immediately to the health care provider?
