RN Maternal Newborn Nursing_ATI 11.0
(Ch 8) A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses. Which of the following statements by a nurse indicates an understanding of the teaching?
"A client should avoid consuming undercooked meat while pregnant."
(Ch 14) A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hrs. Which of the following statements which the nurse make?
"A distended bladder reduces pelvic space needed for birth."
(Ch 1) A health clinic nurse reviews contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?
"A water-soluble lubricant should be use with condoms."
(Ch 19) A nurse is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make?
"Apply a cold compress between feedings."
(Ch 21) A nurse is teaching a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make?
"Completely empty each breast at each feeding or use a pump."
(Ch 17) A nurse is completing postpartum discharge teaching to a client who had no immunity to varicella and was given the varicella vaccine. Which of the following statements by the client indicates an understanding of the teaching?
"I need a second vaccination at my postpartum visit."
(Ch 9) A nurse is reviewing a new ferrous sulfate prescription with a client at 12-weeks gestation. Which of the following statements by the client indicates an understanding of the teaching?
"I plan to drink more orange juice while taking this pill."
(Ch 1) A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching?
"I will check to be sure the string of the IUD are still present after my period."
(Ch 26) A nurse is providing discharge teaching to the parent of a newborn regarding circumcision care. Which of the following statements made by the parent indicates an understanding of the teaching?
"I will clean the penis with each diaper change."
(Ch 5) A nurse reviews postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a group member indicates an understanding of the teaching?
"I will continue my calcium supplements because I don't like milk."
(Ch 21) A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates an understanding of the teaching? (Multiple answers)
"I will drink large amounts of fluids to flush the bacteria from my urinary tract." "I will take Tylenol for any discomfort."
(Ch 24) A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given?
"It assists with blood clotting."
(Ch 6) A nurse is caring for a pregnant client and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make?
"It awakens a sleeping fetus."
(Ch 13) A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (Multiple answers)
"It can detect abnormal fetal heart tones early." "It allows for accurate readings with maternal movement." "It can measure uterine contraction intensity."
(Ch 2) A nurse in a clinic is caring for a client who is postoperative following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification?
"It is good to know that I won't have a tubal pregnancy in the future."
(Ch 12) A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following statements should the nurse make?
"It is needed to counteract hypotension."
(Ch 4) A client at 8 weeks of gestation tells the nurse, "I am not sure I am happy about being pregnant." Which of the following responses should the nurse make?
"It is normal to have these feelings during the first few months of pregnancy."
(Ch 2) A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates an understanding of the infertility assessment process?
"The male is the easiest to assess, and the provider will usually begin there."
(Ch 27) A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"The newborn will have a continuous high-pitched cry."
(Ch 14) A nurse is caring for a client and partner during the second stage of labor. The client's partner asks the nurse to explain how to know when crowing occurs. Which of the following responses should the nurse make?
"The vaginal area will bulge as the baby's head appears."
(Ch 15) A nurse educator in the labor and delivery unit reviews chemical agents' use to promote cervical ripening with a group of newly licensed nurses. Which of the following statements y a nurse indicates an understanding of the teaching?
"They are tablets administered vaginally."
(Ch 3) A nurse in a prenatal clinic is caring for a pregnant client and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?
"This is due to the weight of the uterus on the vena cava."
(Ch 23) A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish-brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching?
"This is more commonly seen in newborns who have dark skin."
(Ch 19) A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching?
"Wear a supportive bra continuously for the first 72 hours."
(Ch 1) A nurse in a clinic is teaching a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Multiple answers)
"Weight fluctuations can occur." "You should increase your intake of calcium." "Irregular vaginal spotting can occur."
(Ch 3) A nurse in a clinic receives a phone call from a client who would like to be tested in the clinic to confirm a pregnancy. Which of the following information should the nurse provide to the client?
"You should collect urine from the first morning void."
(Ch 6) A nurse is teaching a pregnant client about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching?
"You should empty your bladder prior to the procedure."
(Ch 27) A nurse is caring for a client who is at 42-weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?
"Your baby's skin will have a leathery appearance."
(Ch 18) A nurse is caring for a client who is 2 days postpartum. The client states, "My 4-year-old son was toilet trained, and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client?
"Your son is showing an adverse sibling response."
(Ch 5) A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report t the provider?
3.6 kg (8 lbs.) weight gain and is in the first trimester
(Ch 19) A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at the greatest risk for developing a postpartum infection?
A client who does not wash their hands between perineal care and breastfeeding
(Ch 21) A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection?
A client who had premature rupture of membranes and prolonged labor
(Ch 2) A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a generic counselor?
A client whose partner has von Willebrand disease
(Ch 17) During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?
A normal postural discharge of lochia
(Ch 19) A nurse is providing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following findings?
A sore on the nipple with cracks and fissures
(Ch 23) A nurse is completing an assessment. Which of the following data indicates the newborn is adapting to extrauterine life? (Multiple answers)
Apnea for 10-second periods. Obligatory nose breathing.
(Ch 26) A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement?
Apply petroleum gauze to the site
(Ch 16) A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states, "My water broke." The monitor reveals an FHR of 80 to 85 bpm, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of the umbilical cord in the client's vagina. Which of the following actions should the nurse perform first?
Apply pressure to the presenting part with the fingers
(Ch 23) A nurse is caring for a newborn who was born at 38-weeks gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestation age, the nurse should classify this neonate as which of the following?
Appropriate for gestational age
(Ch 22) A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority?
Ask the client if they have thoughts of hurting themselves or their infant
(Ch 13) A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take?
Assist the client into a left-lateral position
(Ch 25) A nurse is caring for a newborn. Which of the following actions by the nurse indicates readiness to feed?
Attempts to place their hand in heir mouth
(Ch 26) A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding care seat position?
Back seat, rear-facing
(Ch 10) A nurse is providing care for a client who is in preterm labor at 32-weeks gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity?
Betamethasone
(Ch 7) A nurse is caring for a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe?
Betamethasone
(Ch 7) A nurse is providing care of a client who has a marginal abruptio placentae. Which of the following finding are risk factors for developing the condition? (Multiple answers)
Blunt abdominal trauma. Cocaine use. Cigarette smoking.
(Ch 4) A nurse is teaching a client at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (Multiple answers)
Breast tenderness. Urinary frequency. Epistaxis.
(Ch 9) A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if mag. toxicity is suspected?
Calcium gluconate
(Ch 20) A nurse on the postpartum unit is assessing a client who is being admitted with a suspected deep-vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? (Multiple answers)
Calf tenderness to palpation. Elevated temperature. Area of warmth.
(Ch 8) A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse expect the provider will prescribe?
Ceftriaxone
(Ch 11) A nurse is caring for a client who is 40-weeks gestation and reports having a large gush of fluid from the vagina while walking to the bathroom. Which of the following actions should the nurse take first?
Check the FHR
(Ch 3) A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (Multiple answers)
Client has delivered one newborn at term. Client has had two prior pregnancies. Client has one living child.
(Ch 22) A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following manifestations? (Multiple answers)
Concern about lack of income to pay bills. Anxiety about assuming a new role as a parent. Rapid decline in estrogen and progesterone. Feeling of inadequacy with the new role as a parent.
(Ch 24) A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority?
Covering the newborn's head with a cap
(Ch 25) A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss?
Cradle
(Ch 5) A nurse in a prenatal clinic is providing education to a client who is at 8 weeks of gestation. The client states, "I do not like milk." Which foods should the nurse recommend as a good source of calcium?
Dark green leafy vegetables
(Ch 6) A nurse is caring for a pregnant client who is to undergo a contraction stress test (CST). Which of the following findings are indications of this procedure? (Multiple answers)
Decreased fetal movement. Intrauterine growth restriction (IUGR) Postmaturity.
(Ch 14) A nurse is planning care for a newly admitted client who reports, "I am in labor, and I have been having vaginal bleeding for 2 weeks." Which of the following should the nurse include in the plan of care?
Defer vaginal examination
(Ch 18) A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Multiple answers)
Demonstrates apathy when the newborn cries. Views the newborn's behavior as uncooperative during diaper changing.
(Ch 9) A nurse is caring for a client who is at 14-weeks gestation and has hyperemesis gravidarum. The nurse should identify which of the following as risk factors for the client? (Multiple answers)
Diabetes. Multifetal pregnancy. Gestational trophoblastic disease.
(Ch 10) A nurse is caring for a client receiving nifedipine for preterm labor. The nurse should monitor the client for which of the following manifestations?
Dizziness
(Ch 15) A nurse is caring for a client receiving oxytocin for labor induction and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin?
Duration of 90 to 120 seconds
(Ch 4) A client at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include?
Eat crackers or plain toast before getting out of bed
(Ch 7) A nurse in the ED is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device." The nurse should suspect which of the following?
Ectopic pregnancy
(Ch 12) A nurse is caring for a client who is 40-weeks gestation and experiencing contractions every 3 to 5 min. and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? (Multiple answers)
Encourage use of patterned breathing techniques. Administer opioid analgesic medication. Suggest application of cold.
(Ch 21) A nurse is discussing risk factors for UTI with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (Multiple answers)
Epidural anesthesia. Urinary bladder catheterization. Frequent pelvic examinations. Hx of UTIs.
(Ch 23) A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. Is this finding characteristic of the following condition?
Epstein's pearls
(Ch 24) A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering?
Erythromycin
(Ch 24) A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss?
Evaporation
(Ch 22) A nurse is caring for a postpartum client who delivered their third infant 2 days ago. Which of the following could indicate postpartum depression? (Multiple answers)
Fatigue. Insomnia. Flat affect.
(Ch 6) A nurse reviews the findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (Multiple answers)
Fetal breathing movement. Fetal tone. Amniotic fluid volume.
(Ch 10) A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize which of the following are contraindications for using this medication? (Multiple answers)
Fetal distress. Vaginal bleeding. Cervical dilation greater than 6 cm.
(Ch 15) A nurse is caring for a client who has been in labor for 12 hrs with intact membranes. The nurse performs a vaginal examination to ensure which of the following before performing the amniotomy?
Fetal engagement
(Ch 11) A nurse is caring for a client having contractions every 8-min that are 30 to 40 seconds in duration. The client's cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station with an FHR of around 140 bpm. Which of the following stages and phases of labor is this client experiencing?
First stage, latent phase
(Ch 18) A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following actions should the nurse take?
Give the client time to express their feelings
(Ch 8) A nurse is caring for a client who is in labor. The nurse should identify which of the following infections can be treated during labor or immediately following birth? (Multiple answers)
Gonorrhea. Chlamydia. HIV. Group B streptococcus beta-hemolytic.
(Ch 3) A nurse is reviewing the health record of a client who is pregnant. The provider indicated that the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (Multiple answers)
Goodell's sign. Ballottement. Chadwick's sign.
(Ch 16) A nurse is caring for a client who is in active labor and reports severe back pain. During the assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress?
Hands and knees
(Ch 23) A nurse is completing a newborn assessment. In checking for the Moro reflex, the nurse should perform which of the following?
Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backwards
(Ch 2) A nurse is reviewing the medical record of a client who is to undergo hysterosalpingography. Which data alerts the nurse that the client is at risk for a complication related to this procedure? Vital Signs: 36.1 C (97 F) HR 60 bpm Hx & Physical: Employed as a radiology tech Allergy to shrimp Tonsillectomy at 18yrs old Laboratory Findings: Glucose 103 mg/dL Hgb 13.1 g/dL Total cholesterol 265 mg/dL Medications: Rosuvastatin Magnesium oxide Mafenide acetate
Hx and Physical
(Ch 7) A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea; vomiting; and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?
Hydatidiform mole
(Ch 26) A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindicated? (Multiple answers)
Hypospadias. Family hx of hemophilia. Epispadias.
(Ch 20) A nurse is caring for a client that is postpartum. The nurse should identify which of the following findings is an early indicator of hypovolemia caused by hemorrhage?
Increasing HR and decreasing BP
(Ch 11) A nurse is completing an admission assessment for a client who is 39-weeks gestation and reports fluid leaking from the vagina for 2 days. Which of the following conditions is the client at risk for developing?
Infection
(Ch 1) A nurse is teaching a client about the potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (Multiple answers)
Irregular vaginal bleeding. Weight gain. Nausea.
(Ch 3) A nurse is caring for a pregnant client and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery?
January 8th
(Ch 8) A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? (Multiple answers)
Joint pain. Malaise. Rash. Tender lymph nodes.
(Ch 10) A nurse is reviewing discharge teaching with a client who has a premature rupture of membranes at 26-weeks gestation. Which of the following instructions should the nurse include in the teaching?
Keep a daily record of fetal kick counts
(Ch 26) A nurse is reviewing the care of the umbilical cord with the parents of a newborn. Which of the following instructions should the nurse include in the teaching?
Keep the diaper folded below the cord
(Ch 25) A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide?
Keep the nipple full of formula throughout the feeding
(Ch 19) A nurse is providing discharge instructions to a postpartum client following a cesarean birth. The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest?
Kegel exercises
(Ch 27) A nurse is called to the birthing room to assess a newborn who has been born at 32-weeks gestation. The newborn's birth weight is 1100 g. Which of the following are expected findings in this newborn? (Multiple answers)
Lanugo. Weak grasp reflex. Translucent skin.
(Ch 6) A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity?
Lecithin/sphingomyelin (L/S) ratio
(Ch 14) A nurse is caring for a client in the 3rd stage of labor. Which of the following indicates placental separation? (Multiple answers)
Lengthening of the umbilical cord. Appearance of dark blood from the vagina. Fundus firm upon palpation.
(Ch 24) A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes?
Match the parent's identification band with the newborn's band
(Ch 20) A nurse is planning care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care?
Measure leg circumference
(Ch 16) A nurse is caring for a client who is at 42 weeks gestation and in active labor. Which of the following findings is the fetus at risk for developing?
Meconium aspiration
(Ch 17) A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. The pad is saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document?
Moderate lochia rubra
(Ch 13) A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes an FHR of 115 to 125 bpm with occasional increases up to 150 to 155 bpm that last for 25 seconds and have moderate variability. There is no slowing of the FHR from the baseline. The client is exhibiting manifestations of which of the following? (Multiple answers)
Moderate variability. FHR accelerations. Normal baseline FHR.
(Ch 5) A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which defects can occur in the fetus or neonate due to folic acid deficiency?
Neural tube defects
(Ch 27) A nurse is caring for a preterm newborn with respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following the administration of synthetic surfactant?
O2 saturation
(Ch 2) A nurse in an infertility clinic is providing care to clients who have been unable to conceive for 18 months. Which of the following data should the nurse assess? (Multiple answers)
Occupation. Menstrual hx. Childhood infectious diseases.
(Ch 15) A nurse is caring for a client who is at 42 weeks gestation and is having an ultrasound. For which of the following conditions should the nurse plan for an amnioinfusion? (Multiple answers)
Oligohydramnios. Fetal cord compression.
(Ch 5) A nurse is reviewing a new prescription for ion supplements with a client at 8 weeks of gestation and with iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with?
Orange juice
(Ch 13) A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?
Palpate the fundus of the uterus
(Ch 4) A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include? (Multiple answers)
Perform the pelvic rock exercise every day. Use proper body mechanics.
(Ch 12) A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling in the fingers. Which of the following actions should the nurse take?
Place an O2 mask over the client's nose and mouth, or having the client breath into a paper bag.
(Ch 25) A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? (Multiple answers)
Place used bottles in the dishwasher. Check the nipple for the appropriate flow of formula. Use tap water to dilute the concentrated formula.
(Ch 18) A nurse in the delivery room is planning to promote parent-infant bonding for the client who just delivered. Which of the following is the priority action by the nurse?
Position the neonate skin-to-skin on the client's chest
(Ch 22) A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and feeling of letdown. Which of the following conditions is associated with these manifestations?
Postpartum blues
(Ch 20) A nurse educator on a postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of newly licensed nurses. Which of the following factors should the nurse include in the teaching? (Multiple answers)
Precipitous delivery. Inversion of the uterus. Retained placental fragments.
(Ch 20) A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition?
Preeclampsia
(Ch 14) A nurse is caring for a client who is in the transitional phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse take?
Prepare for impending delivery
(Ch 16) A nurse is caring for a client who is in labor. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe?
Prolapsed umbilical cord
(Ch 18) A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?
Provide education about infant care when the parent is present
(Ch 12) A nurse is caring for a client in the second labor stage. The client's labor has been progressing, and a vaginal delivery is expected in 20 min. The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know which of the following types of regional anesthetic block is to be administered?
Pudendal
(Ch 16) A nurse is caring for a client in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications?
Reduced fetal O2 supply
(Ch 13) A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives more O2 when which of the following appears on the tracing?
Relaxation between uterine contractions
(Ch 7) A nurse is caring for a client experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with the condition?
Report of severe shoulder pain
(Ch 9) A nurse is administering magnesium sulfate IV for seizure prophylaxis to a client with severe preeclampsia. Which of the following indicates magnesium sulfate toxicity? (Multiple answers)
Respirations less than 12/min. Urinary output less than 25 mL/hr. Decreased level of consciousness.
(Ch 15) A nurse is caring for a client who had no prenatal care, is Rh-negative, and will undergo an external version at 38 weeks gestation. Which of the following medications should the nurse plan to administer prior to the version?
Rho(D) immune globulin
(Ch 12) A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological nursing interventions should the nurse recommend to the client?
Sacral counterpressure
(Ch 1) A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include?
Shortness of breath
(Ch 21) A nurse is caring for a client who has mastitis. Which of the following is the typical causative agent of mastitis?
Staphylococcus aureus
(Ch 27) A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn?
Sunken fontanels
(Ch 11) A nurse is caring for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I have had enough. I cannot do this anymore." Which of the following stages of labor is the client experiencing?
Transition phase
(Ch 11) A client calls a provider's office and reports having contractions for 2 hr that increased with activity and did not decrease with rest and hydration. The client denies leaking of vaginal fluid but did notice blood when wiping after voiding. Which of the following manifestations is the client experiencing?
True contractions
(Ch 10) A nurse is caring for a client who reports manifestations of preterm labor. Which of the following findings are risk factors for this condition? (Multiple answers)
UTI. Multifetal pregnancy. Diabetes mellitus. Uterine abnormalities.
(Ch 17) A nurse assesses a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions cause the uterine atony?
Urinary retention
(Ch 9) A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition?
Urine ketones present
(Ch 17) A nurse is providing education to a client who is 2 hrs postpartum and has a perineal laceration. Which of the following information should the nurse include? (Multiple answers)
Use a perineal squeeze bottle to cleanse the perineum. Apply a topical anesthetic cream or spray to the perineum. Apply cold or ice packs to the perineum.
(Ch 8) A nurse is admitting a client who is in labor and has HIV. Which interventions should the nurse identify as contraindications for this client? (Multiple answers)
Vacuum extractor. Forceps. Internal fetal monitoring.
(Ch 4) A nurse is caring for a pregnant client and reviewing manifestations of complications. The client should promptly report to the provider. Which of the following complications should the nurse include?
Vaginal bleeding
(Ch 25) A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicates an understanding of the teaching?
When latching on, the infant's nose, cheek, and chin are touching the breast
