OB Hesi 2020
The mother of a breastfeeding 24 hr old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is "doing it right." She tells the nurse, "I just know my daughter is not getting enough to eat." What response would be best for the nurse to make?
if your baby's urine is straw-colored, she is getting enough milk*
A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse's assessment reveals approximately 30 ml of bright red vaginal bleeding, FHR of 130 to 140 beats/min, no contraction, and no complaints of pain. What is the most likely case of this client's bleeding?
placenta previa
The nurse adds 20 units of oxytocin to 1 L of LR's which should infuse over 8 hours for a client who delivered 2 hours ago. How many mL/hr should the nurse add to the infusion pump?
125
A 32-week primigravida client who is in preterm labor (PTL) receives a prescription for an infusion of D5W 500 mL with magnesium sulfate 20 g at 1g/hr. How many mL/hr should the nurse program the infusion pump?
25
Which fetal heart rate pattern requires immediate nursing intervention?
A decrease in the fetal heart rate that occurs after the peak of a contraction
The charge nurse working on a postpartum unit is making assignments for a staff consisting of a nurse, practical nurse and 2 unlicensed assistive personnel. which client should the charge nurse assign to the practical nurse?
A multagraida who delivered during c section 20 min ago and needs her vital signs taken.
The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?
A primiparous adolescent living at home with her parents and SO
Vaginal examinations reveal that a laboring client cervix is dilated 2cm, 70% effaced, with presenting part at -2 station. The client tells the nurse " I need my epidural now! This hurts!" The nurse response to the client should be based on which information.
Administering an epidural at this point would slow the labor process.
When planning care for a laboring client, the nurse identifies the need to withhold solid foods while the client is in labor. What is the most important reason for this nursing intervention?
An increase risk for aspiration can occur if general analgesic is needed.
The nurse is providing care for a client at 30-weeks gestation who is experiencing preterm labor. Which maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?
Betamethasone (Celestone) 12 mg deep IM.
The nurse is caring for a newborn infant who was recently diagnosed with a congenital heart defect. Which assessment finding warrants immediate intervention by the nurse?
Bluish tinge on the tongue
A client in the first trimester of pregnancy calls the prenatal clinic to report she is nauseated and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? Select all that apply
Changes in color and consistency of stool are normal
A pregnant woman in the first trimester of pregnancy has a Hb 8.6 mg/dL and HCT 25.1%. What food should the nurse encourage this client to include in her diet?
Chicken
A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge.
Continue prenatal vitamins with B12 while breastfeeding
Following a traumatic delivery, an infant receives an initial apgar score of 3. Which intervention is most important for the nurse to implement?
Continue resuscitative efforts
A newborn with a respiratory rate of 40 bpm at one minute after birth is demonstrating cyanosis of the hands and feet. What action should the nurse take?
Continue to monitor
The healthcare provider prescribes 10 units/L of oxytocin via IV drip to augment a clients labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
Contraction duration of 100 seconds
A diabetic client delivers a full term large for gestational age infant who is jittery. What action should the nurse take first?
Determine the infant's blood sugar level.
The home health nurse visits a client who delivered a full term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curd-like patches on the newborns oral mucous membranes. What action should the nurse implement?
Discuss the need for medication to treat curd-like oral patches
A 26 week gestation primigravida who is carrying twins is seen in the clinic today. Her final height is measured at 29 cm. Based on these finding, what action should the nurse implement.
Document the finding in the medical record.
At her first prenatal visit, a client discloses that her first child has phenylketonuria (PKU) disease, and she is concerned about her new baby being born with the same disease. Which information should the nurse provide?
Each pregnancy has a 25% chance of resulting in a child with PKU disease
The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
Heart rate and blood pressure
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's...
Heat loss
Which action should the nurse take if an infant, who wa born yesterday weighing 7.5 lbs
Inform and assure the mother that this is normal weight loss.
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm hg, respiratory rate is 18 breaths/minute, heart rate is 74 bpm, and temperature is 96.6F (37C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?
Notify the healthcare provider of the assessment findings
The nurse is providing anticipatory guidance for an African-American client who is at 24-weeks gestation. Which prenatal lab assessment, prescribed at 28-weeks, should the nurse includes
One-hour glucose screen
Following the vaginal delivery of a 10 pound infant, the nurse assess a new mothers vaginal bleeding and finds that she has saturated two pads in 30 min and has a boggy uterus. What action should the nurse implement first?
Perform fundal massage until firm.
Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
Pulse rate of 56 bpm
A multiparous client at 38- weeks gestation is admitted to labor and delivery with a compliant of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. What action should the nurse take first?
Push the call light for help
A newborn's head circumference is 12 inches (30.5cm), and his chest measurement is 13 inches (33cm). The nurse notes that this infant has no molding, and was at breech presentation delivery by c section. What action should the nurse take based on these data?
Record the finding on the chart. They are within normal limits.
A client in the third trimester of pregnancy complains of frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5cm during the pregnancy. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
Record the respiratory finding in the client's record as normal
A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse-midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. Which response should the nurse provide?
The newborn's blood type should be tested to determine the need for RhoGAM .
A female client arrives in the clinic for her first postpartum visit and states she does not feel that she is bonding with her baby. Which is the best response that the nurse should provide?
This is common for new mothers
The client will need to be catheterized before the epidural can be administered. A client who is HIV+ is receiving zidovudine during labor. Which information should the nurse provide to the client?
This treatment helps prevent transmission of the virus to the fetus.
Vaginal prostaglandin gel is used to induce for a women who is at 42-weeks gestation. Thirty minutes after insertion of the gel, the client complains of vaginal warmth, and is experiencing 90 second contractions with fetal heart decelerations. What action should the nurse implement first?
Turn to a side lying position
A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?
Ultrasonography and nonstress test.
A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?
Use alternative form of birth control until new diaphragm can be obtained.
Prior to performing a postpartum assessment, the client tells the b nurse "I have pain in my stitches". The nurse knows that the client has a mid-line episiotomy. Which action should the nurse take first?
Visualize the perineum and check the epistiomy
At 34 weeks gestation, a primigravida is assessing at her bimonthly clinic visit. Which assessment finding is important for the nurse to report to the HCP.
Weight gain of 7 lbs
A postpartum who is breastfeeding arrives for her 6-week postpartum visit and reports that she is still having vaginal discharge. How should the nurse respond?
Please describe the discharge
A client at 20 week gestation comes to the antepartum clinic complaining of vaginal warts. HPV What information should the nurse provide?
The client should be treated with acyclovir.
A client in preterm labor has had an infusion of magnesium sulfate running 8 hrs. Current assessment finding are: RR 14 bpm, UOP 24
The finding indicate potential toxicity to magnesium sulfate and close follow up is indicated.
An oxytocin induction was started for a gravid client 6 hours ago. When assessing the FHR on the electronic fetal monitor, the nurse notes a "U-shaped" pattern... Which intervention should the nurse implement first?
Change the position of the client
A 32 week multipara with a history of preeclampsia arrives at the clinic for her routine appointment. The nurse observes the client has an elevated blood pressure of 155/90 resting. Which action should the nurse take?
Inquire about a history if migraines
A new mother asks the nurse why her infant son has a needle mark on his leg. Which response is best for the nurse to provide the mother?
Your baby was given an injection of vitamin K to prevent bleeding
When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the HCP?
101.2 F oral temp
During a prenatal visit, a client at 30-weeks gestation reports persistent heartburn during the past two weeks. The nurse notes the client has 3+ bilateral, pitting, pedal edema. Which action should the nurse implement?
Ask if blurred vision and headache have occurred.
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in the care plan?
Assess temp q 1h
the nurse notes that a newborn at 24hrs of age has a large cephalhematoma. Which intervention has the highest priority.
Assess the infant for jaundice every 8 hours
A three hour old newborn of a gestational diabetic mother who is asymptomatic and successful breastfed after birth, heel stick glucose level is 36 mg/dL. Which intervention should the nurse do first?
Assist the mother to breastfeed the infant
A young Ashkenazi Jewish woman is planning to become pregnant and asks the nurse if she should be tested for any genetic disorders. What action should the nurse implement?
Explain the risk for carrying genes for Tay-Sachs disease
The nurse is caring for a female client, a primigravida with preeclampsia. Finding include +2 proteinuria, BP 172/112 mmHg, Facial and hand sweating, complaints of blurry vision, and a severe frontal headache. Which medication should the nurse anticipate for this client?
Magnesium sulfate
A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per minute. What intervention is most important for the nurse to perform?
encourage the client to empty her bladder
