OB HESI
The healthcare provider prescribes zidovudine 100 mg by mouth five times daily for a pregnant woman who is HIV positive. The drug is available in a 240 mL bottle labeled, "50 mg/5 mL". How many mL should the nurse administer? (Enter numeric value only.)
a. 10
A multigravida client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringer's 1,000 mt. with Oxytocin 20 units. The nurse should program the infusion pump to deliver how many mL/hour? (enter numeric value only.)
a. 12
The healthcare provider prescribes a maintenance dose of magnesium sulfate 2 grams per hour intravenously (IV) for client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5 % in water 500 mL. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only.)
a. 50
The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 min after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this finding? a. Both the lower uterine segment and the fundus must be massaged. b. The uterus should be firm to prevent intrauterine infection. c. A firm uterus prevents the endometrial lining from being sloughed. d. Clots may form inside a boggy uterus and need to be expelled.
a. Both the lower uterine segment and the fundus must be massaged.
A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus. Which action should the nurse take first? a. Call the healthcare provider. b. Administer ibuprofen 800 mg by mouth. c. Encourage the client to void. d. Increase the intravenous fluid to 150 mL/hour.
a. Call the healthcare provider.
The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture lines. Which condition should the nurse document in the medical record? a. Hydrocephalus b. Cephalhematoma. c. Caput succedaneum. d. Microcephaly.
b. Cephalhematoma.
A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. Which information should the nurse provide prior to discharge? a. Continue prenatal vitamins with B12 while breastfeeding. b. Avoid using lanolin-based nipple cream or ointment. c. Weight the baby weekly to evaluate the newborn's growth. d. Offer iron-fortified supplemental formula daily.
a. Continue prenatal vitamins with B12 while breastfeeding.
A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. To promote parent-infant attachment behaviors, which intervention should the nurse implement? a. Encourage rooming-in while in the hospital b. Ask if she has help to care for her baby at home c. Provide a video on newborn safety and care d. Explore the basis of fears with the client
a. Encourage rooming-in while in the hospital
A client at 18 weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide? a. Explain that a sonogram should be scheduled for definitive results. b. Discuss options for intrauterine surgical correction of congenital defects. c. Inform her that a repeat alpha-fetoprotein (AFP) should be evaluated. d. Reassure the client that the AFP results are likely to be a false reading.
a. Explain that a sonogram should be scheduled for definitive results.
A client arrives to the clinic reporting she is unable to conceive for the last year. The obstetrical history includes: a live birth at 28 weeks and one at 22 weeks who lived for 2 days, and 3 miscarriages in the first trimester. Which GTPAL should the nurse document? a. G5 P0231 b. G6 P0131 c. G6 P0221 d. G5 P0141
a. G5 P0231
A new mother who is breastfeeding her 4 week old infant has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement? a. Inform her that a decreased need for insulin occurs while breastfeeding. b. Advise the client to breastfeed more frequently. c. Counsel her to increase her caloric intake. d. Schedule an appointment for the client with the diabetic nurse educator.
a. Inform her that a decreased need for insulin occurs while breastfeeding.
Four clients at full term present to the labor and delivery unit at the same time. Which should the nurse assess first? a. Multipara scheduled for non-stress test and biophysical profile. b. Primipara with burning on urination and urinary frequency c. Multipara with contractions occurring every 3 minutes. d. Primipara with vagina show and leaking membranes.
a. Multipara scheduled for non-stress test and biophysical profile.
A 30-year-old primigravida delivers a 9-pound (4082 grams) infant vafinally after a 30-hour labor. What is the priority nursing action for this client? a. Observe for signs of uterine hemorrhage b. Assess the blood pressure for hypertension c. Encourage direct contact with the infant d. Gently massage fundus every 4 hours
a. Observe for signs of uterine hemorrhage
The nurse is receiving a report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite? a. Prepare to start an IV b. Begin a pad count c. Monitor amniotic fluid for meconium d. Take the client's temperature
a. Prepare to start an IV
A multiparous client at 28 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the baby crying. Which action should the nurse take first? a. Push the call light for help. b. Turn on the infant warmer. c. Notify a healthcare provider. d. Inspect the client's perineum.
a. Push the call light for help.
A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority? a. Risk for injury related to uterine atony b. Impaired parenting related to inexperience c. Ineffective breastfeeding related to fatigue d. Acute pain related to abdominal incision
a. Risk for injury related to uterine atony
A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non-immune. Which intervention should the nurse implement? a. Transfuse two units of packed red blood cells. b. Administer ampicillin 2 grams intravenously. c. Inject hepatitis B immune globulin 0.5 mL. d. Give measles, mumps, rubella vaccine 0.5 mL.
a. Transfuse two units of packed red blood cells.
The nurse is planning 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? a. Ampicillin 1 Gram IV push q8h b. Betamethasone 12 mg deep IM c. Butorphanol tartrate 1 mg IV push q2h PRN pain d. Terbutaline 0.25 mg subcutaneously q15 minutes x 3
b. Betamethasone 12 mg deep IM
The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds at 36 weeks gestation. This amniocentesis is being performed to obtain which information? a. Gender of the fetus. b. Fetal lung maturity. c. Presence of a neural tube defect. d. Chromosomal abnormalities.
b. Fetal lung maturity.
A newborn's assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication? a. Preeclampsia. b. Folic acid deficiency. c. Short interval pregnancy. d. Tobacco use.
b. Folic acid deficiency.
A 3 hour old male infant's hands and feet are cyanotic, and he has an axillary temperature of 96.5F (35.8 C), a respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. What nursing intervention is best for the nurse to implement? a. Notify the pediatrician of the infant's unstable vital signs. b. Gradually warm the infant under the radiant heat source. c. Perform a heel-stick to monitor blood glucose level. d. Administer oxygen by mask at 2 L /minute.
b. Gradually warm the infant under the radiant heat source.
A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes. The nurse observes several shallow, small vesicles on the pubis, labia, and perineum. The nurse should recognize the client is exhibiting symptoms of which condition? a. Genital warts. b. Herpes simplex virus. c. German measles. d. Syphilis.
b. Herpes simplex virus.
The mother of a breastfeeding 24 hour 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." Which response would be best for the nurse to make? a. Feed your baby hourly until you feel confident that your child is receiving enough milk. b. If your baby's urine is straw-colored, she is getting enough milk. c. Since you are so concerned, you should probably supplement breastfeeding with formula. d. Don't worry, soon your milk will come in and you will feel how full your breast are.
b. If your baby's urine is straw-colored, she is getting enough milk.
Twelve hours after the birth of a healthy infant the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm, and at midline, with moderate, rubra lochia. Which action should the nurse take? a. Apply a fresh pad and check in one hour. b. Inspect client's perineal and rectal areas. c. Check the suprapubic area for distention. d. Instruct the client to take a warm sitz bath.
b. Inspect client's perineal and rectal areas.
The newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn's admission. What action should the nurse take to ensure adequate instillation of the ophthalmic ointment? a. Mummy wrap the infant before instilling the ointment. b. Instill a thin ribbon into each lower conjunctival sac. c. Occlude the inner canthus after retracting the eyelids. d. Stabilize the instilling hand on the neonate's heads.
b. Instill a thin ribbon into each lower conjunctival sac.
A 15-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 this client's nursing care plan? a. Keep an airway at the bedside b. Monitor blood pressure, pulse, and respirations every 4 hours. c. Assess temperature every hour. d. Allow liberal family visitation.
b. Monitor blood pressure, pulse, and respirations every 4 hours.
Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15 minute old infant has a gestational age of 42-weeks. Based on this finding, which intervention is most important for the nurse to implement? a. Apply a pulse oximeter to the foot. b. Obtain capillary blood glucose. c. Draw arterial blood gases. d. Provide blow-by oxygen.
b. Obtain capillary blood glucose.
The nurse is caring for a multiparous client who is 8cm dilated, 100% effaced, and the fetal head is at a 0 station, the client is shivering and states extreme discomfort with the urge to bear down. Which intervention should the nurse implement? a. Administer intravenous pain medication b. Perform a vaginal exam c. Reposition to side lying d. Encourage pushing with each contraction
b. Perform a vaginal exam
A mother spontaneously delivers her newborn infant in the taxi cab while on the way to the hospital. The emergency room nurse reports that the mother has active herpes (HSV II) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery? a. Obtain blood specimen for serum glucose level. b. Place the newborn in the isolation area of the nursery. c. Document the temperature on the flow sheet. d. Administer the vitamin K injection.
b. Place the newborn in the isolation area of the nursery.
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, fetal heart rate of 130 to 140 beats/minute, no contractions, and no complaints of pain. What is the most likely cause of this client's bleeding? a. Normal bloody shows indication of labor. b. Placenta previa. c. A ruptured blood vessel in the vaginal vault. d. Abruptio placenta.
b. Placenta previa.
The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication? a. Improve insufficient dietary intake. b. Prevent hemorrhagic disorders. c. Stimulate the immune system. d. Help an immature liver.
b. Prevent hemorrhagic disorders.
A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse? a. Dizziness when standing. b. Sinus tachycardia. c. Absent patellar reflexes. d. Lower back pain.
b. Sinus tachycardia.
Which fetal heart rate pattern requires immediate nursing intervention? a. An increase in the fetal heart rate to 180 that quickly returns to baseline. b. A fetal heart rate deceleration that mirrors the contraction. c. A decrease in the fetal heart rate that occurs after the peak of a contraction. d. A fetal heart rate deceleration that occurs at the acme of the contraction.
c. A decrease in the fetal heart rate that occurs after the peak of a contraction.
A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the healthcare provider? a. Spontaneous rupture of membranes. b. Absences of uterine contractions within 20 minutes. c. A pattern of fetal late decelerations. d. Fetal heart rate accelerations with fetal movement.
c. A pattern of fetal late decelerations.
Vaginal examination reveals that a laboring client's cervix is dilated to 2 cm, 70% effaced, with the presenting part at -2 station. The client tells the nurse, "I need my epidural now! This hurts! " The nurse's response to the client should be based on which information? a. The client will need to be catheterized before the epidural can be administered. b. The client should be dilated to at least 8 cm before receiving an epidural. c. Administering an epidural at this point would slow the labor process. d. The baby needs to be at a zero station before an epidural can be administered.
c. Administering an epidural at this point would slow the labor process.
What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery? a. Remind her to push three times with each contraction. b. Re-evaluate the need for medication. c. Assisting her to maintain control. d. Assessing the strength of uterine contractions.
c. Assisting her to maintain control.
Following a traumatic delivery, an infant receives an initial apgar score of 3. Which intervention is most important for the nurse to implement? a. Repeat the Apgar assessment in 5 minutes. b. Page the pediatrician STAT. c. Continue resuscitative efforts. d. Inform the parents of the infant's condition.
c. Continue resuscitative efforts.
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? a. Four contractions in 10 minutes b. Uterus is soft c. Contraction duration of 100 seconds. d. Early decelerations of fetal heart rate.
c. Contraction duration of 100 seconds.
A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time? a. Cervical dilation is 1 cm b. Membranes are intact c. Contractions decrease with walking d. 2+ pitting edema in lower extremities
c. Contractions decrease with walking
A client at 31-weeks gestation with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide to the client for the ultrasounds? a. Assessment for congenital anomalies. b. Determination of fetal presentation. c. Evaluation of fetal growth. d. Recalculation of gestational age.
c. Evaluation of fetal growth.
On the first postpartum day, the nurse examines the breast of a new mother. Which condition is the nurse most likely to find? a. Soft, with no change from before delivery. b. Firm, larger, and very tender to touch. c. Filling and secreting colostrum. d. Slightly firm with immediate let-down response.
c. Filling and secreting colostrum.
The nurse working in an antepartal clinic measures a 38 cm fundal height on a client who is at 30 weeks gestation by dates. Which action is most important for the nurse to take? a. Record the findings so that an on-going assessment can be properly evaluated. b. Ask the client to return to the clinic next week for reassessment of fundal height. c. Obtain a prescription for an ultrasound and schedule it as soon as possible. d. Explain to the client that this finding could indicate she has a twin pregnancy.
c. Obtain a prescription for an ultrasound and schedule it as soon as possible.
A client who is 24 weeks gestation arrives at the clinic reporting swollen hands. On examination, the nurse notes the client has had a rapid weight gain over six weeks. Which action should the nurse implement next? a. Examine the client for pedal edema. b. Observe and time the client's contractions. c. Obtain the client's blood pressure d. Review the previous blood pressure in the chart.
c. Obtain the client's blood pressure
A pregnant client mentions in her history that she changes a cat's litter box daily. Which test should the nurse anticipate the healthcare provider to prescribe? a. Fern test b. Biophysical profile c. TORCH Screening d. Amniocentesis
c. TORCH Screening
A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which is most important for the nurse to provide the client? a. After the vitamin K injection is given to the baby. b. When ambulating to void does not cause dizziness. c. When there is no significant vaginal bleeding. d. After the baby no longer demonstrates acrocyanosis.
c. When there is no significant vaginal bleeding.
In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has a loud cry with stimulation, good muscle tone, and his color is acrocyanotic. What Apgar score should the nurse assign? a. 7 b. 10 c. 8 d. 9 (Quizlet)
d. 9 (Quizlet)
The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period? a. A primiparous woman who has recently immigrated to the U.S. with her spouse. b. A multiparous female with a large family living in the community. c. A multiparous client who lives with her husband and his family members. d. A primiparous adolescent living at home with her parents and significant other.
d. A primiparous adolescent living at home with her parents and significant other.
A newborn with a respiratory rate of 40 breaths/minute at one minute after birth is demonstrating cyanosis of the hands and feet. What actions should the nurse take? a. Assist with intubation. b. Assess bowel sounds. c. Rub the infant's back. d. Continue to monitor.
d. Continue to monitor.
A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment finding warrants immediate intervention by the nurse? a. Leaking amniotic fluid. b. Onset of uterine contractions. c. Ruptured amniotic membrane. d. Fetal heart rate 60 beats/minute.
d. Fetal heart rate 60 beats/minute.
A client tells the nurse that she thinks she is pregnant. Which sign or symptom provides the best indication that the client is pregnant? a. Morning sickness. b. Amenorrhea. c. Breast Tenderness. d. Hegar's sign.
d. Hegar's sign.
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7- pound (3,175 gram) 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 beats/minute, and temperature is 98.6 F (37C). The client's fundus is firm and one fingerbreadths above the umbilicus. Which action should the charge nurse implement first? a. Obtain a STAT hemoglobin and hematocrit. b. Assign a practical nurse (PN) to reassess the client's vital signs. c. Determine if the client received anesthesia during delivery. d. Notify the healthcare provider of the assessment findings.
d. Notify the healthcare provider of the assessment findings.
A primigravida at 36 weeks gestation, who is Rh negative, experience abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Trace of protein in the urine b. Fetal heart rate of 162 beats/minute. c. Mild contractions every 10 minutes. d. Positive fetal hemoglobin testing.
d. Positive fetal hemoglobin testing.
A newborn's head circumference is 12 inches (30.5 cm), and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and was a breech presentation delivered by cesarean section. What action should the nurse take based on these data? a. No action needs to be taken. This is normal for an infant born by cesarean section to have a small head circumference. b. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal. c. Notify the pediatrician immediately. These findings support the possibility of hydrocephalus. d. Record the findings on the chart. They are within normal limits
d. Record the findings on the chart. They are within normal limits
The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first? a. Assess cervical dilation. b. Administer oxygen via facemask. c. Change the client's position. d. Turn off the oxytocin infusion.
d. Turn off the oxytocin infusion.
A client in the first trimester of pregnancy calls the prenatal clinic to report that she is nauseated and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? (SATA) a. Drink a glass of tea with each iron tablet b. Take the iron supplement at bedtime c. Come to the clinic today. d. Increase the consumption of milk while taking iron. e. Changes in color and consistency of stool are normal.
e. Changes in color and consistency of stool are normal.
