RN Repro SG
A nurse is preforming a physical assessment of a newborn. Which of the following clinical finding should the nurse expect? 1. Heart rate 154/min 2. Axillary temperature 36° C (96.8° F) 3. Respiratory rate 58/min 4. Length 43 cm (16.9 in) 5. Weight 2,600 g (5 lb 12 oz)
1 3 5
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse preform the following actions? 1 Clean the newborns diaper area 2 Cleanse the skin around the newborns umbilical stump 3 Wash the newborns neck by lifting the newborns chin 4 Wash the newborns legs and feet 5 Wipe the newborns eyes from inner cants outward.
5 3 2 4 1
A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20g magnesium sulfate in 500mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr?
50 mL/hr
A nurse is a prenatal clinic is assessing a group of clients. Which of the following client should the nurse see first? A. A client who is at 11 weeks of gestation and reports abdominal cramping B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
A
A nurse is absorbing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? A. Lays the newborn across her lap and gently sways B. Places the newborn in the crib in a prone position C. Offers the newborn a pacifier dipped in formula D. Prepares a bottle of formula mixed with rice cereal
A
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? A. Abruptio placenta B. Placenta previa C. Preeclampsia D. Maternal bradycardia
A
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Report of visual disturbances B. Report of tingling of the fingers C. Report of urinary frequency D. Report of leg cramps
A
A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? A. Hypertension B. Hypothermia C. Constipation D. Muscle weakness
A
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? A. Substernal retractions B. Acrocyanosis C. Overlapping suture lines D. Head circumference 33 cm (13 in)
A
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? A. Minimal arm recoil B. Popliteal angle of 90° C. Creases over the entire foot sole D. Raised areolas with 3 to 4 mm buds
A
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? A. BUN 25 mg/dL B. Serum creatinine 0.8 mg/dL C. Urine output of 280 mL within 8 hr D. Urine negative for ketones
A
A nurse is caring for a client who is 24 seeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? A. Kleihauer-Betke test B. Progesterone serum level C. Lecithin/sphingomyelin (L/S) ratio D. Maternal Alpha-fetoprotein (AFP)
A
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client developed magnesium toxicity? A. Calcium gluconate B. Hydralazine C. Medroxyprogesterone acetate D. Methylergonovine
A
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic culture beliefs. Which of the following culture practices should the nurse include in the plan of care? A. Protect the client's head and feet from cold air. B. Bathe the client within 12 hr following birth. C. Ambulate the client within 24 hr following birth. D. Offer the client a glass of cold milk with her first meal.
A
A nurse is preforming a vaginal examination on a client who is in labor and observes the umbilical cord protruding. from the vagina. After calling for assistance, which of the following actions should the nurse take? A. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. B. Wrap the visible cord tightly with sterile, dry gauze. C. Apply oxygen to the client at 2 L/min via nasal cannula. D. Place the client in the lithotomy position and apply fundal pressure.
A
A nurse is providing teaching about non pharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following? A. Cold cabbage leaves B. Purified lanolin cream C. A snug-fitting support bra. D. Breast shells
A
A nurse is reviewing the prenatal laboratory results for a client who it at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? A. Hemoglobin 10 g/dL B. WBC count 10,000/mm3 C. Platelets 250,000/mm3 D. Fasting blood glucose 90 mg/dL
A
A nurse is transporting a newborn back to the patients room following a procedure. Which of the following actions should the nurse take? A. Verify that the parent's identification band matches the newborn's identification band. B. Scan the newborn's identification band to verify their identity. C. Check the newborn's security tag number to ensure it matches the newborn's medical record. D. Match the newborn's date and time of birth to the information in the parent's medical record.
A
A nurse is providing teaching to a client is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? A. "I can administer oxytocin 4 hours after the insertion of the medication." B. "You will need a full bladder prior to the insertion of the medication." C. "Remain in a side-lying position for 15 minutes after the medication is inserted."MY ANSWER D. "An antacid will be given 20 minutes prior to the insertion of the medication."
A Rationale: The nurse can administer oxytocin no sooner than 4 hours after the last dose of misoprostol. Oxytocin can be administered following misprostol for clients who have cervical ripening and have not begun labor.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plain to prepare the client for which of the following diagnostic tests? A. Biophysical profile B. Amniocentesis C. Cordocentesis D. Kleihauer-Betke test
A Rationale: A positive CST indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should he nurse expect? A. Reports increased urinary output B. Diaphoresis C. Reports blurred vision D. Shallow respirations
A Rationale: Increased urinary output, n/v, reports of thirst, abd. pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? A. Depression B. Polyuria C. Hypotension D. Urticaria (hives)
A Rationale: The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common AE of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? A. Late decelerations B. Moderate variability of the FHR C. Cessation of uterine dilation D. Prolonged active phase of labor
A Rationale: indicative of uteroplacental insufficiency. Therefore this is a CI for the administration of oxytocin and should be reported to the provider.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
A newborn who is 18 hr old and has an axillary temperature of 37.7 C (99.9 F) Rationale: an axillary temp greater than 99.5 is above the expected reference range for a newborn and can be an indication of sepsis.
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Fundal height 34 cm B. Report of decreased fetal movement C. Report of occasional ankle swelling D. BP 110/80 mm Hg
B
A nurse is caring for a client who is 38 weeks of gestation. Which of the following actions should the nurse take prior to apply an external transducer for fetal monitoring? A. Determine progression of dilatation and effacement. B. Perform Leopold maneuvers. C. Complete a sterile speculum exam. D. Prepare a Nitrazine paper test.
B
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? A. To estimate the fetal weight B. To locate a pocket of fluid C. To determine multiparity D. To prescreen for fetal anomalies
B
A nurse is caring for a prenatal client. who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? A. Administer antiviral medication. B. Schedule an ultrasound examination. C. Administer Haemophilus influenzae type b vaccine. D. Schedule an indirect Coombs' test.
B
A nurse is providing. teaching to a client about thee physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statement indicates an understanding of the teaching? A. "I will not gain more than 15 to 20 pounds during my pregnancy." B. "I will likely need to use alternative positions for sexual intercourse." C. "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." D. "I'm glad I have a light complexion and will not get any stretch marks."
B
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? A. Lochia serosa vaginal drainage B. Vaginal pressure C. Intermittent vaginal pain D. Yellow exudate vaginal drainage
B Rationale: the nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.
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? A. Administer aspirin for pain. B. Maintain the client on bed rest. C. Massage the affected leg every 12 hr. D. Apply cold compresses to the affected calf.
B Rationale: to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? Select all that apply. A. Yellow sclera B. Acrocyanosis C. Posterior fontanel larger than the anterior fontanel D. Positive Babinski reflex E. Two umbilical arteries visible
B D E
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the clients medical records, which of the following findings. should the nurse report to the provider? A. 1-hr glucose tolerance test B. Hematocrit C. Fundal height measurement D. Fetal heart rate (FHR) Blood pressure 130/78 mm Hg Respiratory rate 20/min Heart rate 90/min Hemoglobin 12 g/dL Hematocrit 34% 1-hr glucose tolerance test 120 mg/dL Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding Fetal heart rate 110/min
C
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? A. Blood pressure 136/88 mm Hg B. Report of insomnia C. Weight gain of 2.2 kg (4.8 lb) D. Report of Braxton Hicks contractions
C
A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medication should the nurse administer? A. Fentanyl B. Butorphanol C. Naloxone D. Meperidine
C
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestation should the nurse report to the provider? A. Acrocyanosis B. Transient strabismus C. Jaundice D. Caput succedaneum
C
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? A. Bruising over the buttocks B. Hard nodules on the roof of the mouth C. Petechiae over the head D. Bilateral periauricular papillomas
C
A nurse is caring for a client is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? A. Client reports nausea B. Urinary output of 40 mL/hr C. Respiratory rate 10/min D. Client reports feeling flushed
C
A nurse is caring for a client who is 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? A. Excessive bleeding B. Oligohydramnios C. Premature rupture of membranes D. Proteinuria
C
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. Decreased uterine contractions B. An increase in the client's hemoglobin levels C. A reduction in respiratory distress in the newborn D. Increased production of antibodies in the newborn
C
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 clients head to one side, which of the following actions should the nurse take immediately after the seizure? A. Monitor the FHR. B. Assess uterine activity. C. Administer oxygen via a nonrebreather mask. D. Start a bolus of IV fluids.
C
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a non stress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? A. Give the client orange juice. B. Elevate the client's legs. C. Have the client change position. D. Establish IV access.
C
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? A. Monitor the client's blood pressure every hour. B. Restrict the total hourly intake to 200 mL C. Monitor the FHR continuously. D. Administer protamine sulfate for manifestations of toxicity.
C
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? A. Feed the newborn 1 oz of water every 4 hr. B. Apply lotion to the newborn's skin three times per day. C. Remove all clothing from the newborn except the diaper. D. Discontinue therapy if the newborn develops a rash.
C
A nurse is providing education about family binding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7 years old child in accepting the new family member? A. Allow the sibling to hold the newborn during a bath. B. Make sure the sibling kisses the newborn each night. C. Obtain a gift from the newborn to present to the sibling. D. Switch the sibling's room with the nursery.
C
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? A. "My sister will be able to carry my baby from the nursery to my room when she arrives." B. "The nurse will match my wrist band to my baby's crib card when they bring him to me." C. "The person who comes to take my baby's pictures will be wearing a photo identification badge." D. "My baby doesn't need to wear the electronic security bracelet when he's in my room."
C
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following should the nurse include in the teaching? A. "Obtain an informed consent prior to obtaining the specimen." B. "Collect at least 1 milliliter of urine for the test." C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." D. "Premature newborns may have false negative tests due to immature development of liver enzymes."
C
A nurse in a providers office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following finding should the nurse identify as a risk factor for the development of preeclampsia? A. Singleton pregnancy B. BMI of 20 C. Maternal age 32 years D. Pregestational diabetes mellitus
D
A nurse is admitting a client states, "my water just broke". Which of the following interventions is the nurses priority? A. Perform Nitrazine testing. B. Assess the fluid. C. Check cervical dilation. D. Begin FHR monitoring.
D
A nurse is assessing a late preterm newborn. Which of the following manifestation is an indication of hypoglycemia? A. Hypertonia B. Increased feeding C. Hyperthermia D. Respiratory distress
D
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider ? A. A newborn who is 26 hr old and has erythema toxicum on his face B. A newborn who is 32 hr old and has not passed a meconium stool C. A newborn who is 12 hr old and has pink-tinged urine D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
D
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurses priority following the procedure? A. Check the client's temperature. B. Observe for uterine contractions. C. Administer Rho(D) immune globulin. D. Monitor the FHR.
D
A nurse is caring for a client who is at 22 weeks of gestation and its HIV positive. Which of the following actions should the nurse take? A. Administer penicillin G 2.4 million units IM to the client. B. Instruct the client to schedule an annual pelvic examination. C. Tell the client she will start medication for HIV immediately after delivery. D. Report the client's condition to the local health department
D
A nurse is preforming a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? A. Deep tendon reflexes 4+ B. Fundal height 14 cm C. Urine protein 2+ D. FHR 152/min
D
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? A. Apply a cool pack for 10 min to the heel prior to the puncture. B. Request a prescription for IM analgesic. C. Use a manual lance blade to pierce the skin. D. Place the newborn skin to skin on the mother's chest.
D
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? A. "I should increase my protein intake to 60 grams each day." B. "I should drink 2 liters of water each day." C. "I should increase my overall daily caloric intake by 300 calories." D. "I should take 600 micrograms of folic acid each day."
D
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non stress test. Which of the following instructions should the nurse include? A. "The test should take 10 to 15 minutes to complete." B. "You will lay in a supine position throughout the test." C. "You should not eat or drink for 2 hours before the test." D. "You should press the handheld button when you feel your baby move."
D
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? A. 2+ deep tendon reflexes B. Proteinuria of 200 mg in a 24-hr specimen C. Polyuria D. Blurred vision
D Rationale: The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? A. Check the client's capillary refill. B. Massage the client's fundus. C. Insert an indwelling urinary catheter for the client. D. Prepare the client for a blood transfusion.
b Rationale: uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the clients vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss.
A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? A. "You can resume sexual activity in 1 week." B. "You won't need to do Kegel exercises since you had a cesarean." C. "You can still become pregnant if you are breastfeeding." D. "You are safe to start adding sit-ups to your exercise routine in 2 weeks."
c Rationale: breastfeeding doesn't prevent ovulation. Therefore the client can become pregnant. Discuss contraception that is safe to use while breastfeeding.
