OB-Newborn Online 2016 A
A nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5mcg IM once today." Available is a 5mL vial with 10mcg/mL. How many mL should the nurse administer?
0.5mL
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse request the provider see first?
A client who is at 11 weeks of gestation and reports abdominal cramping-- cramping could indicate an ectopic pregnancy and manifestations of a spontaneous abortion
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
A client who is at 34 weeks gestation and reports epigastric pain-- epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect?
A heart rate of 154/min A respiratory rate of 58/min A weight of 2.6kg (5lb 12oz) ------THE EXPECTED RESP. 30-60/MIN, NB WT 2.5KG TO 4KG, HR. 110-160/MIN
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12mg IM. Which of the following outcomes should the nurse expect?
A reduction in respiratory distress in the newborn-- betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next?
Administer oxygen via a non-rebreather mask-- this helps both mother and baby to ensure adequate oxygenation
A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following assessments is the nurse's priority?
Amount of lochia-- greatest risk to the client is bleeding and postpartum hemorrhage
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non-pharmacological interventions should the nurse include in the plan of care for lactation suppression?
Apply cabbage leaves to the breasts-- plant sterols and salicylates can help relieve swelling and discomfort caused by breast engorgement
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8cm and reports back pain. Which of the following actions should the nurse take?
Apply sacral counterpressure
A nurse is assessing a client who gave birth vaginally 12 hours ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
Assist the client to empty her bladder-- this could prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
BUN 25mg/dL-- an elevated BUN could indicate dehydration
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should pan to prepare the client for which of the following diagnostic tests?
Biophysical profile-- eval of the fetus is necessary with a real-time ultrasound
A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a fourth-degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions?
Bisacodyl rectal suppository daily as needed for constipation-- a suppository or enema could cause separation of the suture line, bleeding or infection
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Chin quivering-- behavioral responses like grimacing and furrowing of the brow could indicate PAIN in newborn. PUPILS DILATE,RESPIRATION RAPID AND SHALLOW, FAST HEART RATE
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Determine respiratory function-- airway is always first to evaluate
A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?
Dry the newborn-- cold stress on the newborn
A nurse is teaching a client who is pregnant about managing nausea and vomiting. Which of the following instructions should the nurse include in the teaching?
Eat high-carbohydrate foods-- avoid spicy, fatty or fried foods
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?
Emotional lability -------Many women experience rapid and unpredictable changes in mood during pregnancy.----------------FOCUSING 3RD phase fathers emotional response to the prego COUVADE SYNDROME- father experienced pregnancy like.
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?
Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen- CAPILLARY SAMPLE VIA HEEL STICK FOR NEWBORN SCREEN
A nurse is reviewing the laboratory report of a client who is 24 hours postpartum following a vaginal delivery. Which of the following laboratory results should the nurse identify as an indication of a postpartum infection?
Erythrocyte Sedimentation Rate (ESR) 26mm/hr
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
FHR 152/min--fetal heart rate, expected range 110/min-160/min
A nurse is assessing a client who is in labor and notes early decelerations on the fetal monitor. Which of the following findings should the nurse identify as a possible cause of the early decelerations?
Fetal head compression
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication?
Flaccid uterus Excess vaginal bleeding
A nurse is an antepartal clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider?
Fundal height measurement-- fundal height should be measured in cm and is the same as the number of gestational weeks plus or minus 2 weeks from 18-32 weeks
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?
Have the client change position-- changing position may help relieve umbilical cord compression
A nurse is teaching a client who is at 35 weeks of gestation about clinical manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
Headache that is unrelieved by analgesia-- unrelieved headache with meds may indicate preeclampsia
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
I should take 600mcg of folic acid each day-- folic acid assists with preventing neural tube defects
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?
I will have blood tests because my potassium might decrease-- adverse effect of terbutaline is hypokalemia, adv. Effect - Hypotension can be administered subq every 4 hrs No more than 24hr.
A nurse is teaching a client about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
I will need this medication if I have an amniocentesis-- Rho(D) immune globulin is given following an amniocenteses because of the potential of fetal RBC's entering the maternal circulation
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Instruct the client to press the provided button each time fetal movement is detected-- this helps ensure that fetal movement is noted
A nurse is assessing a newborn 12 hours after birth. Which of the following manifestations should the nurse report to the provider?
Jaundice-----OCCURS OF BIRTH ASSOCIATED WITH ABO INCOMPATIBILITY, HEMOLYSIS OR RH.
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?
Just above the symphysis pubis-- the uterus is positioned low in the pelvis slightly above the symphysis pubis
A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior?
Lays the newborn across her lap and gently sways-- tactile stimulation promotes a sense of security for a newborn
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
Leakage of fluid from the vagina-- could indicate premature leakage of amniotic fluid
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?
Maintain the client on bed rest-- this helps decrease the risk of dislodging the clot. Nurse should apply warm compresses to the affected area to promote circulation and decrease edema.
A nurse is on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?
Massage the client's fundus-- this will expel clots and promote contractions
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil-- at 26 weeks gestation the newborn has decreased muscular tone
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers?
PALPATE THE CLIENT ABDOMEN WITH HER PALMS TO DETERMINE WHICH FETAL PART IS IN THE UTERINE FUNDUS. this step also called transverse or longitudinal cepharic or breech of the fetus.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
Perform Leopold maneuvers-- this assesses the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer NITRAZINE PAPER TEST - ASSESSING ph level.
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
Platelets 50,000mm3-- this value is below expected reference ranges with can indicate disseminated intravascular coagulation
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?
Protect the client's head and feet from cold air-- this is traditional hispanic practice during the postpartum period
A staff nurse on an obstetric unit is caring for a client who is scheduled for an induced abortion. The staff nurse informs the nurse manager that she has a moral issue with the client's decision. Which of the following actions should the nurse manager take?
Reassign the client to another staff nurse
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Remove all clothing from the newborn except the diaper-- maximum skin exposer is needed to break down excess bilirubin
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
Schedule an ultrasound examination-- a series of ultrasounds are needed to detect the possible development of fetal hydrops
A nurse is calculating a client's expected date of birth using Naegele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?
September 3rd-- subtract 3 months from the first day of the client's period, then add 7 days
A nurse is teaching a new mother about steps the nurses will take to promote the security and safety of the newborn. Which of the following statements should the nurse make?
Staff members who take care of your baby will be wearing a photo identification badge
A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions?
Step 1: Wipe the newborn's eyes from the inner canthus outward Step 2: Wash the newborn's neck by lifting the newborn's chin Step 3: Cleanse the skin around the newborn's umbilical cord stump Step 4: Wash the newborn's legs and feet Step 5: Clean the newborn's diaper area
A nurse is assessing a client who is at 30 weeks gestation during a routine prenatal visit. Which of the findings should the nurse report to the provider?
Swelling of the face-- facial, sacral and hand swelling can indicate gestational hypertension or preeclampsia
A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take?
Take photos of the newborn to give to the parents-- create a memory box that includes mementos of the newborn,
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should then nurse identify as the priority?
Temperature-- greatest risk is infection, so monitor the temp
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
To locate a pocket of fluid-- an US is done to locate the fluid and decrease the risk of injury to the fetus. This decrease the risk of injury to the fetus
A nurse is assessing the newborn of a client who took a selective serotonin re-uptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Vomiting-- fetal exposure of an SSRI can include irritability, agitation, tremors, diarrhea, and vomiting. Can last 2 days. MANIFESTATION OF FETAL EXPOSURE to SSRI INCLUDES: hypoglycemia, Tachypnea, low birth weight,
A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
You can miss your period for several other reasons. Describe your typical menstrual cycle-- amenorrhea is presumptive sign of pregnancy, not a positive sign
A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching?
You can share your room with your baby for the next few weeks-- co-sleeping can increase SIDS, bedroom sharing helps parents learn the newborns cues
A nurse is teaching a client who is at 8 weeks of gestation about exercise. Which of the following instructions should the nurse include in the teaching?
You should exercise for 30 minutes each day-- improves muscle tone
A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
You should get a 2-hour oral glucose tolerance test in 6 to 12 weeks
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?
You should leave the diaphragm in place for at least 6 hours after intercourse
A nurse is providing teaching about comfort measures to a client who is breastfeeding and is experiencing engorgement. Which of the following nonpharmacological measures should the nurse include in the teaching?
You should use cold compresses after each feeding
A client who is at 34 weeks of gestation asks the nurse how she will know when she is in labor and should go to the hospital. Which of the following responses should the nurse make?
You will notice blood-tinged discharge from your vagina-- a sign of true labor is the bloody show, this occurs when the cervix begins to efface and dilate.---TRUE LABOR LOWER ABDOMEN
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hours. Which of the following statements should the nurse make?
Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions-- this will determine if contractions are adequate for progression of labor
