A client who had her first baby 3 months ago & is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?
A. After ceasing breastfeeding, the diaphragm should be resized.
B. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated.
C. If no more than 20 pounds was gained during pregnancy, the diaphragm is safe to use.
D. Use an alternate form of contraceptive until a new diaphragm is obtained.
D. Use an alternate form of contraceptive until a new diaphragm is obtained.
The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge …
A. Ensure that they have the pediatric clinic’s phone number.
B. Provide the results of the infant’s hearing test to the parents.
C. Request a return demonstration of a diaper change.
D. Evaluate infant feeding technique prior to discharge.
D. Evaluate infant feeding technique prior to discharge.
A 30-year-old primigravida delivers a 9-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?
A. Gently massage the fundus every 4 hours.
B. Observe for signs of uterine hemorrhage.
C. Encourage direct contact with the infant.
D. Assess the blood pressure for hypertension.
A. Gently massage the fundus every 4 hours.
D. Prepare for a cesarean section.
The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessments for which condition has the highest priority?
A. Hyperbilirubinemia
B. Polycythemia
C. Hyperthermia
D. Hypoglycemia
While assessing a 40-week gestation primigravida in active labor, the client’s membranes rupture spontaneously and the nurse notices that the amniotic fluid is meconium stained. Which additional finding is most important for the nurse to report to the healthcare provider?
A. Maternal blood pressure of 130/85 mmHg.
B. Fetal heart rate of 100 to 110 bpm.
C. Vaginal exam reveals a cervix 6cm dilated.
D. Contractions occurring every 2-3 minutes.
A. Maternal blood pressure of 130/85 mmHg.
The nurse is caring for a 35-week gestation infant delivered by cesarean section 2 hours ago. The nurse observes the infant’s respiratory rate is 72 breaths/minute with nasal flaring, grunting, and retractions. The nurse should recognize these findings indicate which complication?
A. Persistent pulmonary hypertension of the newborn.
B. Transient tachypnea of the newborn.
C. Meconium aspiration syndrome.
D. Bronchopulmonary dysplasia.
B. Transient tachypnea of the newborn.
A primipara client at 42 weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75 second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20 second duration. What intervention should the nurse implement?
A. Notify nursery about the client’s response.
B. Check for clonus in both feet.
C. Stop oxygen per cannula.
D. Restart oxytocin infusion rate per protocol.
D. Restart oxytocin infusion rate per protocol.
At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. What action would the nurse take first?
A. Ensure preoperative lab results are available.
B. Inform the anesthesia care provider.
C. Start prescribed IV with Lactated Ringer’s.
D. Contact the client’s obstetrician.
B. Inform the anesthesia care provider.
The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologists arrival on the unit, which action should the nurse perform?
A. Cleanse the spinal injection site.
B. Place procedure equipment at bedside.
C. Apply an abdominal binder.
D. Insert an indwelling Foley catheter.
B. Place procedure equipment at bedside.
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 10-15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?
A. Contractions decrease with walking.
B. 2+ pitting edema in lower extremities.
C. Cervical dilations is 1cm.
D. Membranes are intact.
A. Contractions decrease with walking.
A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
A. Administer misoprostol every 2hrs.
B. Ambulate the client after administration of misoprostol.
C. Start oxytocin infusion immediately.
D. Begin oxytocin 4hrs after misoprostol is given.
D. Begin oxytocin 4hrs after misoprostol is given.
The nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is important for the nurse to take?
A. Explain reasons consent for an infant autopsy is needed.
B. Encourage the mother to hold and spend time with her baby.
C. Determine if the mother desires a visit from her clergy.
D. Create a memory box of baby’s footprints and photographs.
B. Encourage the mother to hold and spend time with her baby.
Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mmHg and heart rate is 130 bpm. Which action should the nurse implement first?
A. Palpate the abdomen for contractions.
B. Tilt the backboard sideways to displace the uterus laterally.
C. Obtain a blood sample for complete blood count.
D. Infuse 1,000 mL normal saline using a large bare IV.
B. Tilt the backboard sideways to displace the uterus laterally.
A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?
A. “That is called caput succedaneum. It will have to be drained.”
B. “That is called caput succedaneum. It will absorb and cause no problems.”
C. “That is called a cephalhematoma. It will cause no problems.”
D. “That is called a cephalhematoma. It can cause jaundice as it is absorbed.”
B. “That is called caput succedaneum. It will absorb and cause no problems.”
A client at 35 weeks gestation complains of a “pain whenever the baby moves”. On assessment, the nurse notes the client’s temperature to be 101.2F with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of which condition?
A. Round ligament strain.
B. Viral infection
C. Abruptio placenta
D. Chorioamnionitis
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivers a 7-pound infant 12 hours ago is reporting a severe headache. The client blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/minute, heart rate is 74 bpm, and temperature is 98.6F. The client’s fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?
A. Notify the healthcare provider of the assessment findings.
B. Obtain a STAT hemoglobin and hematocrit.
C. Assign a practical nurse (PN) to reassess the client’s vital signs.
D. Determine if the client received anesthesia during delivery.
A. Notify the healthcare provider of the assessment findings.
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. Stimulate the immune system.
C. Prevent hemorrhagic disorders.
D. Help an immature liver.
C. Prevent hemorrhagic disorders.
A 16 year old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan?
A. Assess temperature every hour.
B. Monitor blood pressure, pulse, and respirations every 4 hours.
C. Keep an airway at the bedside.
D. Allow family visitation
C. Keep an airway at the bedside.
A pregnant client presents to the antepartum clinic complaining of brownish vaginal bleeding. The nurse notes that she has a greatly enlarges uterus and is complaining of severe nausea. The client reports that her period was “about 2 and a half months ago”. Vital signs are: temperature 98.7F, pulse rate 70bpm, rr 18, and bp 190/110 mmHg. Based on these findings, what laboratory value should the nurse review?
A. HcG values.
B. Hematocrit.
C. Vaginal secretions culture.
D. Glucose in the urine.
C. Change the client’s position.
Upon admission to the nursery, the nurse places a newborn supine under a radiant warmer, an external heat source. What intervention should the nurse implement to ensure safe thermoregulation?
A. Wrap the infant in two blankets and place the radiant warmer on low.
B. Dry the newborn’s scalp and place a stockinet cap on the head.
C. Move temperature probe over the ribs when turning to a lateral position.
D. Place temperature probe on the abdomen in line with the radiant heat source.
D. Place temperature probe on the abdomen in line with the radiant heat source.
At 6 weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?
A. Early postpartum, within 72hrs of delivery.
B. Immediately, at 6-weeks gestation, to protect this fetus.
C. After the client reaches 20-weeks gestation.
D. After the client stops breastfeeding.
A. Early postpartum, within 72 hours of delivery.
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of testing provides the greatest degree of accuracy?
A. Visualization of implantation by vaginal ultrasound.
B. Presence of amenorrhea for 2 months.
C. Maternal blood serum tests positive for alpha-fetoprotein.
D. Complaints of feeling tired all of the time.
A. Visualization of implantation by vaginal ultrasound.
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 multiparous client who lives with her husband and his family members.
B. A primiparous woman who has recently immigrated to the U.S. with her spouse.
C. A multiparous female with a large family living in the community.
D. A primiparous adolescent living at home with her parents and significant other.
B. A primiparous woman who has recently immigrated to the U.S. with her spouse.
Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first?
A. Increase oxytocin IV infusion.
B. Have the client empty her bladder.
C. Perform fundal massage until firm.
D. Inspect the perineum for lacerations.
C. Perform fundal massage until firm.
A new mother who is breastfeeding her 4-week-old infant and 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. Counsel her to increase her caloric intake.
C. Advise the client to breastfeed more frequently.
D. Schedule an appointment for the client with the diabetic nurse educator.
A. Inform her that a decreased need for insulin occurs while breastfeeding.
A newborn’s head circumference is 12inches and his chest measurement is 13 inches. 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 need be taken. It is normal for an infant born by Cesarean section to have a small head circumference.
B. Notify the pediatrician immediately. These findings support the possibility of hydrocephalus.
C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
D. Record the findings on the chart. They are within normal limits.
C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3cm. The nurse’s assessment findings and electronic fetal monitoring(EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribed and oxytocin drip. Which data is most important for the nurse to monitor?
A. Preparation for emergency cesarean birth.
B. Client’s hourly blood pressure.
C. Checking the perineum for bulging.
D. Intensity, interval, and length of contractions.
D. Intensity, interval, and length of contractions.
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. Reassure the client that the AFP results are likely to be a false reading.
B. Explain that a sonogram should be scheduled for definitive results.
C. Discuss options for intrauterine surgical correction of congenital defects.
D. Inform her that a repeat alpha-fetoprotein(AFP) should be elevated
B. Explain that a sonogram should be scheduled for definitive results.
The nurse is caring for a client following an emergency cesarean delivery under general anesthesia. Which assessment finding occurring in the first 8 hours after deliver is most critical and requires immediate intervention?
A. Mild nausea and anorexia.
B. Respiratory rate of 12bpm.
C. A positive Homan’s sign.
D. Uterine atony.
The nurse’s assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
A. Assess the infant’s blood glucose level.
B. Nipple feed 1oz 5% glucose in water.
C. Place the infant in a side-lying position.
D. Position a radiant warmer over the crib.
A. Assess the infant’s blood glucose level.
A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the records and observes there has been a rapid weight gain over 6 weeks. Which action should the nurse implement next?
A. Ask for a 24 hour diet recall.
B. Obtain a blood pressure.
C. Inspect for pedal edema.
D. Listen to fetal heart rate.
The nurse is conducting a home health visit of a client who delivered 3 weeks ago and is formula feeding the infant. Which observations should the nurse find most concerning?
A. The client notes infant feeds every 2-3 hours and voids 5-6 times per day.
B. The client is in pajama’s and infant is freshly bathed.
C. Used bottles are in the kitchen and infant is in a swing.
D. The clients eyes are red from crying and infant is fussing in the crib.
D. The clients eyes are red from crying and infant is fussing in the crib.
The nurse is caring for a client whos is 10 weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?
A. Measure vital signs.
B. Recommend bed rest.
C. Collect urine sample urinalysis.
D. Obtain human chronic gonadotropin levels.
D. Obtain human chronic gonadotropin levels.
D. The growing uterus is putting pressure on the bladder.
C. Assess the infant’s blood glucose level
B. Begin humidified oxygen via hood
C. Count the heart rate for at least one full minute
B. Explore the mother’s concerns about the infant receiving an injection of vitamin K
A. Avoid alcohol because it is excreted in breast milk
Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?
D. Encourage early initiation of breast of formula feeding
D. The heart develops in the third to fifth weeks after conception
B. The fetus in utero is capable of hearing and does respond to the mother’s voice
B. The fetus can respond to sound by 24-weeks gestation
C. Secretes both estrogen and progesterone
A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and is not sleeping well. The client’s physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results?
B. Using an anticonvulsant for epilepsy
B. Make sure to include adequate folic acid in the diet
A. “Protein helps the fetus grow while I am pregnant.”
D. Abstinence is strongly recommended throughout the pregnancy
B. The pregnancy should progress normally and be considered low risk
D. Medical backup should be available quickly in case of complications
B. Help her breathe into a paper bag
D. Document the findings in the client record
B. Assess the fetal heart rate and pattern
Which action should the nurse implement caring for a newborn immediately after birth?
A. Keep the newborn’s airway clear
What action should the nurse implement when caring for a newborn receiving phototherapy?
B. Place an eyeshield over the eyes
Which finding indicates to the nurse that a 4 day old infant is receiving adequate breast milk?
B. Saturates 6 to 8 diapers per day
D. Report uterine cramping or low backache
C. Degree of glycemic control during pregnancy
C. Monitor for premature ventricular contractions
C. Changes in fetal heart rate patterns
B. Intensity of contractions is 130 mmHg
C. Place the client in the knee-chest position
D. The fetal heart rate is 180 bpm without variability
C. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia
D. Swaddle the infant snugly and hold tightly
The father of a newborn tells the nurse, “My son just died.” how should the nurse respond?
A. “I am sorry for your loss.”
C. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia
D. The pinpoint spots are benign and disappear within 48 hours
D. One fetal movement noted in an hour
A. Tetanus
C. Diphtheria
E. Hepatitis B
C. A large body surface area favors heat loss to the environment
B. Observe the mother for other attachment behaviors
D. Report findings to the healthcare provider
What nursing action should be implemented when intermittently gavage-feeding a preterm infant?
A. Allow formula to flow by gravity
D. Oral sucrose and nonnutritive sucking
D. Evaluate the newborn’s color and respirations
What action should the nurse implement with the family when an infant is born with anencephaly?
B. Prepare the family to explore ways to cope with the imminent death of the infant
C. Observe interactions of family members with the newborn and each other
A client in labor receives an epidural block. What intervention should the nurse implement first?
C. Apply counter pressure against the sacrum
C. Ask the client to describe why she thinks she is in labor
B. Exhibit interest in learning more about infant care
B. Continue breastfeeding every 2 hours
C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy
Which client finding should the nurse document as a positive sign of pregnancy?
D. Fetal heart tones (FHT) heard with a doppler
A. Determine the firmness of the fundus
C. Document the finding as erythema toxicum
C. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects
B. Eat more green, leafy vegetables
D. The weight gain is acceptable for the number of weeks pregnant
D. Respiratory rate of 11 breaths/minute
Which procedure evaluates the effect of fetal movement on fetal heart activity?
A. Give 10 liters of oxygen via face mask
D. Notify the healthcare provider
C. “I am sorry for your loss. Do you want to talk about it?”
C. Other parts of her body have injuries that are in different stages of healing
C. Determine fetal heart rate and maternal vital signs
B. Visualize the perineum for bulging
A. Pregnancy induced hypertension
A. Fetal well being with labor progression
Which nursing intervention is the priority during the fourth stage of labor?
C. Place the client in a side-lying position
D. Spray with warm water from front to back using a squeeze bottle
D. Primigravida mother who is Rh-negative
A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4000 grams. The client’s funud is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the fundus, the fundus remains difficult to locate and the rubra lochia remains heavy. What action should the nurse implement next?
B. Notify the healthcare provider
B. Inform the client to continue breastfeeding
D. Gently rub the infant’s feet or back
C. Assess for abdominal distention
What action should the nurse implement to prevent conductive heat loss in a newborn?
B. Put a blanket on the scale when weighing the infant
D. Document the finding in the client record
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?
a. Check the hematocrit results.
b. Administer pain medication.
c. Increase the rate of IV fluids.
d. Monitor client for contractions.
c. increase the rate of IV fluids
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask wen she could use a home pregnancy test to diagnose pregnancy. Which response is best?
a. a home pregnancy test can be used right after your first missed period
b. these tests are most accurate after you have missed your second period
c. home pregnancy tests often give false positives and should not be trusted
d. the test can provide accurate information when used right after ovulation
a. a home pregnancy test can be used right after your first missed period
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:
a. shortness of breath
b. joint pain
c. a persistent cold
d. organmegaly
c. a persistent cold
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60. What action should the nurse take?
a. notify the healthcare provider or anesthesiologist
b. continue to assess the blood pressure q5min
c. place the woman in a lateral position
d. turn off continuous epidural
c. place the woman in a lateral position
In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant’s fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the
a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week
b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the week
c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the second week
d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month
d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month
A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client’s care?
a. patellar reflex 4+
b. blood pressure 158/80
c. four hour urine output 240 ml
d. respiration 12/minute
a. patellar reflex 4+
A 4 week old premature infant has been receiving epoetin alfa for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective?
a. slowly increasing urine output over the last week
b. respiratory rate changes from the 40s to the 60s
c. changes in apical heart rate from the 180 to the 140s
d. change in indirect bilirubin from 12 mg/dl to 8 mg/dl
c. changes in apical rate from the 180s to the 140s
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele’s rule, what is the estimated date of delivery?
a. April 25, 2007
b. May 9, 2007
c. May 29, 2007
d. June 2, 2007
b. May 9, 2007
The nurse is performing a AGA on a full-term newborn during the first hour of transition using the Dubowitz scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate is SGA? (Select all that apply.)
a. admission weight of 4 lbs 15 oz
b. head to heel length of 17 in
c. frontal occipital circumference of 12.5 in
d. skin smooth with visible veins and abundant vernix
e. anterior plantar crease and smooth heel surfaces
f. full flexion of all extremities in resting supine position
a, b, c
The nurse assess a client admitted to the labor and delivery unit and obtains the following data: BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
a. insert a fetal monitor
b. assess for cervical changes q1H
c. monitor bleeding from IV sites
d. perform Leopold’s maneuvers
c. monitor for bleeding from IV sites
Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assess an apical heart rate of 80 bpm and respirations 20. What action should the nurse perform next?
a. initiate positive pressure ventilation
b. intervene after one minute APGAR is assessed
c. initiate CPR on the infant
d. assess the infant’s blood glucose level
a. initiate positive pressure ventilation
A client with no prenatal care arrives at the labor unit screaming, “The baby is coming!” The nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain?
a. gravidity and parity
b. time and amount of last oral intake
c. date of last normal menstrual period
d. frequency and intensity of contractions
c. date of last normal menstrual period
A mutigravida client at 41 weeks gestation present in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?
a. biophysical profile
b. ultrasound for fetal abnormalities
c. maternal serum alpha-fetoprotein screening
d. percutaneous umbilical blood sampling
a. biophysical profile
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
a. raise the foot of the bed
b. assess for vaginal bleeding
c. evaluate the fetal heart rate
d. take the client’s blood pressure
a. raise the foot of the bed
A client at 28 weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
a. come to the clinic today for an ultrasound
b. go immediately to the emergency room
c. lie on your left side for about one hour and see if the bleeding stops
d. bring a urine specimen to the lab tomorrow to determine if you have a UTI
a. come to the clinic today for an ultrasound
Which nursing intervention is helpful in relieving “afterpains”?
a. using relaxation breathing techniques
b. using a breast pump
c. massaging the abdomen
d. giving oxytocic medications
a. using relaxation breathing techniques
The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurses should know that ovulation usually occurs
a. two weeks before menstruation
b. immediately after menstruation
c. immediately before menstruation
d. three weeks before menstruation
a. two weeks before menstruation
A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurses’s response should be based on what information?
a. males inherit the disorder with a greater frequency than females
b. each pregnancy carries a 50% chance of inheriting the disorder
c. the disorder occurs in 25% of pregnancies
d. all children will be carriers of the disorder
b. each pregnancy carries 50% chance of inheriting the disorder
The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?
a. yellowish tinge to the skin
b. Babinski reflex present bilaterally
c. pink papular rash on the face
d. Moro reflex noted after a loud noise
a. yellowish tinge to the skin
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?
a. elevate lower legs while resting
b. increase caloric intake by 200 to 300 calories per day
c. increase water intake to 8 full glasses per day
d. take prescribed multivitamin and mineral supplements
d. take prescribed multivitamin and mineral supplements
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
a. blood glucose level of 45
b. blood pressure of 82/45
c. non-bulging anterior fontanel
d. central cyanosis when crying
d. central cyanosis when crying
A 28 year old client in active labor complains of cramps in her leg. What intervention should the nurse implement?
a. massage the calf and foot
b. extend the leg and dorsiflex the foot
c. lower the leg off the side of the bed
d. elevate the leg above the heart
b. extend the leg and dorsiflex the foot
A new mother asks the nurse “How do I know that my daughter is getting enough breast milk?” Which explanation should the nurse provide?
a. weigh the baby daily and if she is gaining weight she is eating enough
b. your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day
c. offer the baby extra bottle milk after her feeding and see if she is still hungry
d. if you’re concerned you might consider bottle feeding so that you can monitor her intake
b. your milk is sufficient if the bay is voiding pale straw-colored urine 6 to 10 times a day
On admission to the prenatal clinic, a 23 year old woman tells the nurse that her last menstrual period began on February 15 that previously her periods were regular. Her pregnancy test is positive. This client’s expected date of delivery
a. November 22
b. November 8
c. December 22
d. October 22
a. November 22
An off-duty finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
a. provide as much privacy as possible for the woman
b. use a thread to tie off the umbilical cord
c. put the newborn to breast
d. reassure the husband and try to keep him calm
c. put the newborn to breast
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
a. a higher rate of congenital abnormalities
b. respiratory distres
c. lower birth weights
d. lower APGAR scores
c. lower birth weights
A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She sure has a funny looking head.” Which response by the nurse is best?
a. this is not an unusual shaped head especially for a first baby
b. that is normal the head will return to a round shape within 7 to 10 days
c. it may look funny to you but newborn babies are often born with heads like your baby’s
d. your pelvis was too small so the baby’s head had to adjust to the birth canal
b. that is normal the head will return to a round shape within 7 to 10 days
After each feeding, a 3 day old newborn is spitting up large amounts of newborn formula, a nonfat cow’s milk formula. The pediatric healthcare provider changes the neonates’s formula to Similac. What information should the nurse provide to the mother about the newly prescribed formula?
a. Enfamil formula is demineralized whey formula that is needed with diarrhea
b. The new formula is a coconut milk formula used with babies with impaired fat absorption
c. the new formula is a casein protein source that is low in phenylalanine
d. similac is a soy based formula that contains sucrose
d. similac is a soy based formula that contains sucrose
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse’s response is based on what knowledge?
a. iron absorption is decreased in the GI tract during pregnancy
b. it is difficult to consume 18 mg of additional iron by diet alone
c. iron is needed to prevent megaloblastic anemia in the last trimester
d. supplementary iron is more efficiently utilized during pregnancy
b. it is difficult to consume 18 mg of additional iron by diet alone
When explaining postpartum blues to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (select all that apply)
a. panic attacks
b. tearfulness
c. decreased need for sleep
d. mood swings
e. disinterest in the infant
b, d
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
a. recognize this is a common reaction in new mothers
b. ask the mother why she won’t look at the infant
c. observe the mother for other attachment behaviors
d. examine the newborn’s eyes for the ability to focus
c. observe the mother for other attachment behaviors
A couple concerned because the woman has not been able to conceive is referred to a HCP for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent?
a. shoulder pain
b. leg cramps
c. back pain
d. abdominal pain
a. shoulder pain
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the cline is lying in a 6 in diameter pool of blood. Which action should the nurse implement next?
a. obtain a blood pressure
b. inspect the perineum for lacerations
c. cleanse the perineum
d. palpate the firmness of the fundus
d. palpate the firmness of the fundus
A 38 week primigravida who works as a secretary and sits at a computer 8 hrs each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling blood in the lower extremities?
a. avoid constrictive clothing
b. move every hour
c. wear support stockings
d. reduce salt in her diet
b. move every hour
The total bilirubin level of a 36 hour breastfeeding newborn is 14 mg/dl. Based on this finding which intervention should the nurse implement?
a. feed the newborn sterile water hourly
b. assess the newborn’s blood glucose level
c. provide phototherapy for 30 mins q8h
d. encourage the mother to breastfeed frequently
c. encourage the mother to breastfeed frequently
A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first?
a. notify the pediatrician immediately
b. position the infant on the right side
c. suction the infant’s nares then the oral cavity
d. check the infant’s oxygen saturation rate
d. check the infant’s oxygen saturation rate
28 year old client in active labor complains of cramps in her leg.What intervention should the nurse implement.
A. massage the calf and foot
B. extend the leg and dorsiflex the foot
C. lower the leg off the side of the bed
D. elevate the leg above the heart.
B. Extend the leg and dorsiflex the foot.
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling finger and dizziness. What action should the nurse take?
a. administer o2 by face mask
b. notify the HCP for the client’s syndrome
c. have the client breathe into her cupped hands
d. check the client’s BP and fetal HR/
c. have the client breathe into her cupped hands.
When assessing a client who is at 12 week gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
A. at 16 weeks gestation
B.at 20 weeks gestation
C. at 24 weeks gestation
D. at 30 weeks gestation
D. At 30 weeks gestation.
In developing a teaching plan for expectant parents the nurse plans to include formation about when the parents can expect the infants fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the
A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month
D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month
A 42 week gestational client is receiving an intravenous infusion of oxytocin(Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for with pattern of contractions?
A. transition labor with contractions every 2 mins, lasting 90 seconds each.
B. early labor with contractions every 5 min, lasting 40 seconds each.
C. Active labor with contractions every 31 mins, lasting 60 seconds each.
D. Active labor with contraction every 2 to 3 mins, lasting 70 to 80 seconds each.
A. transition labor with contractions every 2 mins, lasting 90 seconds each.
What action should the nurse implement to decrease the client’s risk for hemorrhage after c-section.
A. Monitor urinary output via an indwelling catheter.
B. assess the abdominal dressings for drainage.
C. Give the Ringer’s lactated infusion at 125ml
D. Check the firmness of the uterus every 15mins.
D. Check the firmness of the uterus every 15mins.
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
A. blood glucose level of 45mg/dl
B. blood pressure of 82/45 mmHG
C. Non bulging anterior fontanel
D. central cyanosis when crying
D. central cyanosis when crying
The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?
A. yellowish tinge to the skin
B. babinski reflex present bilaterally
C. pink papular rash on the face
D. moro reflex noted after a loud noise
A. yellowish tinge to the skin
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated a
nd the client is lying in a 6inch diameter pool of blood.
A. Cleanse the perineum
B. obtain a BP
C. palpate the firmness of the fundus
D; inspect the perineum for lacerations
C. palpate the firmness of the fundus
A 40 week gestation primigravida client is being induced with an ocytocin secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?
A. Discontinue the oxytocin infusion
B. place the client in a semi-fowler’s position
C. inform the healthcare provider
D. apply firm pressure to sacral area
D. apply firm pressure to sacral area
A client with gestational htn is an active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse available for signs of potential toxicity?
A. oxytocin
B. calcium gluconate
C. terbutaline
D. naloxone 9
B. calcium gluconate
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate.
A. dark,red vaginal bleeding
B. lower back pain
C. premature rupture of membranes
D. increased uterine irritability
E. bilateral pitting edema
F. Rigid abdomen
A. dark,red vaginal bleeding
D. increased uterine irritability
F. Rigid abdomen
A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately.
A.heart rate of 100 beats min
B. variable fetal HR
C. Onset of uterine contractions
D. Burning on urination
Onset of uterine contractions.
A multigravida client arrives at the L&D unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal HR is between 140 and 150 beats/min. What action should the nurse implement next?
A. complete sterile vag exam
B. take maternal temp every 2 hrs
C. Prepare for an immediate cesarean bitrh
D. Obtain sterile suction equipment
A. complete sterile vag exam
Immediately after birth a newborn infant is suctioned, dried and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical HR of 80 beats/minute and respirations of 20 breaths/min. What action should be performed next?
A. Initiate positive pressure ventilation
B . Intervene after one min Apgar is assessed.
C. Initiate CPR on the infant
D. Assess the infant’s blood glucose level
A. Initiate positive pressure ventilation
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing hx, the client indicates that she has delivered premature twins, one full term baby and has had no abortions. Which GTPAL should the nurse document in this client’s record?
A. 3-1-2-0-3
B. 4-1-2-0-3
C. 2-1-2-1-2
D. 3-1-1-0-3
D. 3-1-1-0-3
The healthcare provider prescribes terbutaline for a client in preterm labor. Before initating this prescription, it is most important for the nurse to assess the client for which of condition.
A. gestational diabetes
B. Elevated BP
C. UTI
D> Swelling in lower extremities
A. gestational diabetes
A 4 week old premature infant has been receiving epoetin alfa for the last 3 weeks. WHich assessment finding indicates to the nurse that the drug is effective.
A.slowly increasing urinary output over the last week
B.rr changes from 40s to the 60s
C. changes in apical HR from the 180 to the 140
D.Change in indirect bilirubin from 12mg/dl to 8mg/dl.
C. changes in apica HR from the 180 to the 140
The nurse should explain to a 30 year old gravid client that alpha fetoprotein testing is recommended for which purpose?
A.detect cardiovascular disorders
B.screen for neural tube defects
c .monitor the placental functioning
d. assess for maternal pre-eclampsia
B.screen for neural tube defects
During labor, the nurse determine that a full term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions.
- Reposition the client
- Provide O2 via face mask
- Increase IV fluid
- Call the healthcare provider
A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?
A.Bathe the infant with an antimicrobial soap.
B.Measure the head and chest circumference.
C. Obtain the infant’s footprints.
D. Administer vitamin K (AquaMEPHYTON).
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?A. Check the hematocrit results.
B. Administer pain medication.
C.Increase the rate of IV fluids.
D.Monitor client for contractions.
C.Increase the rate of IV fluids.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
A.Wear support stockings.
B. Reduce salt in her diet.
C. Move about every hour.
D. Avoid constrictive clothing.
…
Client teaching is an important part of the maternity nurse’s role. Which factor has the greatest influence on successful teaching of the gravid client?
A. The client’s readiness to learn.
B. The client’s educational background.
C. The order in which the information is presented.
.DThe extent to which the pregnancy was planned.
A. The client’s readiness to learn.
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
A. lower Apgar scores.
B. lower birth weights.
C. respiratory distress.
D. a higher rate of congenital anomalies.
Move about every hour.
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best?
A. home pregnancy test can be used right after your first missed period.
B.These tests are most accurate after you have missed your second period.
C. Home pregnancy tests often give false positives and should not be trusted.
D . The test can provide accurate information when used right after ovulation.
A. A home pregnancy test can be used right after your first missed period.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?
A. Drowsiness and bradycardia.
B. Depressed reflexes and increased respirations.
C. Tachycardia and a feeling of nervousness.
D. A flushed, warm feeling and a dry mouth
C. Tachycardia and a feeling of nervousness.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
A. Wear a cotton bra.
B. Increase nursing time gradually.
C.Correctly place the infant on the breast.
D.Manually express a small amount of milk before nursing.
C.Correctly place the infant on the breast.
A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?
a. Length of labor and method of delivery
b. Infant’s condition at birth and treatment received.
C. Feeding method chosen by the parents.
D. History of drugs given to the mother during labor.
B. Infant’s condition at birth and treatment received.
In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant’s fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the
A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
B.anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
C.anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
A.At 16-weeks gestation.
B.At 20-weeks gestation.
C.At 24-weeks gestation.
D.At 30-weeks gestation.
D.At 30-weeks gestation.
The nurse should encourage the laboring client to begin pushing when
A.there is only an anterior or posterior lip of cervix left.
B.the client describes the need to have a bowel movement.
C.the cervix is completely dilated.
D.the cervix is completely effaced.
C.the cervix is completely dilated.
The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs
A.two weeks before menstruation.
B.immediately after menstruation.
immediately before menstruation.
C. immediately before menstruation.
D. three weeks before menstruation.
A.two weeks before menstruation.
The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?
A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part.
B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
C.Urine specimens for glucose and protein must be obtained at certain intervals throughout labor.
D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.
B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement?
A. Massage the calf and foot.
B. Extend the leg and dorsiflex the foot
C. Lower the leg off the side of the bed.
D. Elevate the leg above the heart.
B. Extend the leg and dorsiflex the foot
When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?
A.Milia are red marks made by forceps and will disappear within 7 to 10 days.
B.Meconium is the first stool and is usually yellow gold in color.
C.Vernix is a white, cheesy substance, predominantly located in the skin folds.
D.Pseudostrabismus found in newborns is treated by minor surgery.
C.Vernix is a white, cheesy substance, predominantly located in the skin folds.
A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She sure has a funny looking head.” Which response by the nurse is best?
A.This is not an unusual shaped head, especially for a first baby.
B.It may look funny to you, but newborn babies are often born with heads like your baby’s.
C. That is normal; the head will return to a round shape within 7 to 10 days.
D.Your pelvis was too small, so the baby’s head had to adjust to the birth canal.
C. That is normal; the head will return to a round shape within 7 to 10 days.
An expectant father tells the nurse he fears that his wife “is losing her mind.” He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
B.Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed.
C. Ask him to observe his wife’s behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.
D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.
A new mother asks the nurse, “How do I know that my daughter is getting enough breast milk?” Which explanation should the nurse provide?
A.Weigh the baby daily, and if she is gaining weight, she is eating enough.
B.Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.
C.Offer the baby extra bottle milk after her feeding, and see if she is still hungry.
D.If you’re concerned, you might consider bottle feeding so that you can monitor her intake.
B.Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.
After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow’s milk formula. The pediatric healthcare provider changes the neonate’s formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula?
A.The new formula is a coconut milk formula used with babies with impaired fat absorption.
B.Enfamil® Formula is a demineralized whey formula that is needed with diarrhea.
C. The new formula is a casein protein source that is low in phenylalanine.
D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.
D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
A. Encourage the mother to provide total care for her infant.
B. Provide privacy so the mother can develop a relationship with the infant.
C. Encourage the father to provide most of the infant’s care during hospitalization.
D.Meet the mother’s physical needs and demonstrate warmth toward the infant.
D.Meet the mother’s physical needs and demonstrate warmth toward the infant.
Which nursing intervention is most helpful in relieving postpartum uterine contractions or “afterpains?”
A. Lying prone with a pillow on the abdomen.
B. Using a breast pump.
C. Massaging the abdomen.
D. Giving oxytocic medications.
A. Lying prone with a pillow on the abdomen.
hich maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
a. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
b. Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips.
c. Her arms and hands receive the infant and she then cuddles the infant to her own body.
She eagerly reaches for the infant and then holds the infant close to her own body.
b. Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client’s expected date of delivery (EDD) is
a.November 22.
b.November 8.
c.December 22.
d.October 22.
a.November 22.
The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman’s next fertile period is
a.January 14-15.
b.January 22-23.
c.January 30-31.
d.February 6-7.
c. January 30-31.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?
A. 4+ reflexes.
B.Urinary output of 50 ml per hour.
C.A decrease in respiratory rate from 24 to 16.
D. A decreased body temperature.
C.A decrease in respiratory rate from 24 to 16.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60. What action should the nurse take?
A. Notify the healthcare provider or anesthesiologist immediately.
B.Continue to assess the blood pressure q5 minutes.
C.Place the woman in a lateral position.
D.Turn off the continuous epidural.
C.Place the woman in a lateral position.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency room.
C.Lie on your left side for about one hour and see if the bleeding stops.
D.Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.
A.Come to the clinic today for an ultrasound.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
A.Use a thread to tie off the umbilical cord.
B.Provide as much privacy as possible for the woman.
C.Reassure the husband and try to keep him calm.
D.Put the newborn to breast
D.Put the newborn to breast
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, “Why must I stay in bed all the time?” Which response is best for the nurse to provide this client?
A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
B.We want your baby to be healthy, and this is the only way we can make sure that will happen.
C.I know you’re upset. Would you like to talk about some things you could do while in bed?
D.Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.
A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first?
A.Notify the pediatrician immediately.
B.Suction the infant’s nares, then the oral cavity.
C.Check the infant’s oxygen saturation rate.
D.Position the infant on the right side.
C.Check the infant’s oxygen saturation rate.
Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child, but I would like to try with this baby.” Which intervention is best for the nurse to implement first?
A.Assess the husband’s feelings about his wife’s decision to breastfeed their baby.
B.Ask the client to describe why she was unsuccessful with breastfeeding her last child.
C.Encourage the client to develop a positive attitude about breastfeeding to help ensure success.
D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?
A.Two vessels: one artery and one vein.
B.Two vessels: two arteries and no veins.
C.Three vessels: two arteries and one vein.
D.Three vessels: two veins and one artery
C.Three vessels: two arteries and one vein.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
A. Between the time the temperature falls and rises.
B. Between 36 and 48 hours after the temperature rises.
C. When the temperature falls and remains low for 36 hours.
D. Within 72 hours before the temperature falls.
A. Between the time the temperature falls and rises.
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
A.Edema, basilar rales, and an irregular pulse.
B. Increased urinary output and tachycardia.
C.Shortness of breath, bradycardia, and hypertension.
D.Regular heart rate and hypertension.
A.Edema, basilar rales, and an irregular pulse.
client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
A. Raise the foot of the bed.
B.Assess for vaginal bleeding.
C.Evaluate the fetal heart rate.
D.Take the client’s blood pressure.
A. Raise the foot of the bed.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement?
A.Provide phototherapy for 30 minutes q8h.
B. Feed the newborn sterile water hourly.
C.Encourage the mother to breastfeed frequently.
D.Assess the newborn’s blood glucose level.
C.Encourage the mother to breastfeed frequently.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
A.Deep tendon reflexes 2+.
B.Blood pressure 140/90.
C.Respiratory rate 18/minute.
D.Urine output 90 ml/4 hours.
D.Urine output 90 ml/4 hours.
30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks’ gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug?
A. Maternal blood pressure and respirations.
B.Maternal and fetal heart rates.
C.Hourly urinary output.
D.Deep tendon reflexes.
B.Maternal and fetal heart rates.
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?
A.Grief related to her perceptions about the loss of this child.
B.Relief of ambivalent feelings experienced with this pregnancy.
C.Shock because she may not have realized that she was pregnant.
D. Guilt because she had not followed her healthcare provider’s instructions.
A.Grief related to her perceptions about the loss of this child.
The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class?
A.Begin as soon as your baby is born to establish a four-hour feeding schedule.
B.Resting helps with milk production. Ask that your baby be fed at night in the nursery.
C.Feed your baby every 2 to 3 hours or on demand, whichever comes first.
D. Do not allow your baby to nurse any longer than the prescribed number of minutes.
C.Feed your baby every 2 to 3 hours or on demand, whichever comes first.
A new mother is afraid to touch her baby’s head for fear of hurting the “large soft spot.” Which explanation should the nurse give to this anxious client?
A.Some care is required when touching the large soft area on top of your baby’s head until the bones fuse together.
B.That’s just an ‘old wives’ tale’ so don’t worry, you can’t harm your baby’s head by touching the soft spot.
C.The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby.
D.There’s a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.
D.There’s a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent?
A.Back pain
B.Abdominal pain.
C.Shoulder pain.
D. Leg cramps.
C.Shoulder pain.
client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse’s response is based on what knowledge?
A. Supplementary iron is more efficiently utilized during pregnancy.
B. It is difficult to consume 18 mg of additional iron by diet alone.
C. Iron absorption is decreased in the GI tract during pregnancy.
D. Iron is needed to prevent megaloblastic anemia in the last trimester.
B. It is difficult to consume 18 mg of additional iron by diet alone.
Which nursing intervention is helpful in relieving “afterpains” (postpartum uterine contractions)?
A.Using relaxation breathing techniques.
B.Using a breast pump.
C.Massaging the abdomen.
D.Giving oxytocic medications.
A.Using relaxation breathing techniques.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
A.Provide oral hydration.
B.Have a complete blood count (CBC) drawn.
C.Obtain a specimen for urine analysis.
D.Place the client on strict bedrest.
C.Obtain a specimen for urine analysis.
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.)
A.Admission weight of 4 pounds, 15 ounces (2244 grams)
B.Head to heel length of 17 inches (42.5 cm).
C.Frontal occipital circumference of 12.5 inches (31.25 cm).
D.Skin smooth with visible veins and abundant vernix.
E.Anterior plantar crease and smooth heel surfaces.
F. Full flexion of all extremities in resting supine position.
A.Admission weight of 4 pounds, 15 ounces (2244 grams)
B.Head to heel length of 17 inches (42.5 cm).
C.Frontal occipital circumference of 12.5 inches (31.25 cm).
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?
A.Elevate lower legs while resting.
b.Increase caloric intake by 200 to 300 calories per day.
c.Increase water intake to 8 full glasses per day.
d.Take prescribed multivitamin and mineral supplements.
D. Take prescribed multivitamin and mineral supplements.
A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited?
a. Choking, coughing, and cyanosis.
b. Projectile vomiting and cyanosis.
c. Apneic spells and grunting.
d. organomegaly.
a. Choking, coughing, and cyanosis.
The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant?
a.Herpes.
b.Staphylococcus
c.Gonorrhea.
d. Syphilis.
c.Gonorrhea.
A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider?
a.Cervical dilation of 5 cm with 90% effacement.
b.White blood cell count of 12,000/mm3.
c.Hemoglobin of 12 mg/dl and hematocrit of 38%.
d.A platelet count of 67,000/mm3.
d.A platelet count of 67,000/mm3.
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?
a. Describe diet changes that can improve the management of her diabetes.
b.Inform the client that oral hypoglycemic agents are teratogenic during pregnancy.
c. Demonstrate self-administration of insulin.
d. Evaluate the client’s ability to do glucose monitoring.
a. Describe diet changes that can improve the management of her diabetes.
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement?
a.Notify the healthcare provider.
b.Move the newborn to an isolation nursery.
c.Document the finding in the infant’s record.
d.Obtain a culture of the vesicles.
c.Document the finding in the infant’s record.
the nurse is planning preconception care for a new female client. Which information should the nurse provide the client?
a.Discuss various contraceptive methods to use until pregnancy is desired.
b.Provide written or verbal information about prenatal care.
c.Ask the client about risk factors associated with complications of pregnancy.
d.Encourage healthy lifestyles for families desiring pregnancy.
d.Encourage healthy lifestyles for families desiring pregnancy.
The nurse is calculating the estimated date of confinement (EDC) using Nägele’s rule for a client whose last menstrual period started on December 1. Which date is most accurate?
a.August 1.
b.August 10.
c.September 3.
d.September 8.
d.September 8.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?
a.Herbs are a cornerstone of good health to include in your treatment.
b.Touch is also therapeutic in relieving discomfort and anxiety.
c.Your healthcare provider should direct treatment options for herbal therapy.
d.It is important that you want to take part in your care.
d.It is important that you want to take part in your care.
The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching?
a.Cuddles the baby close to her.
b.Rocks and soothes the infant in her arms.
c.Places the infant prone in the bassinet.
d. Wraps the baby in a warm blanket after bathing.
c.Places the infant prone in the bassinet.
A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse’s response should be based on what information?
a.Males inherit the disorder with a greater frequency than females.
b.Each pregnancy carries a 50% chance of inheriting the disorder.
c.The disorder occurs in 25% of pregnancies.
d.All children will be carriers of the disorder.
b.Each pregnancy carries a 50% chance of inheriting the disorder.
A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, “My son is so jealous of my daughter, I don’t know how I’ll ever manage both children when I get home.” How should the nurse respond?
a.Tell the older child that he is a big boy now and should love his new sister.
b.Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him.
c.Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn.
d.Regression in behaviors in the older child is a typical reaction so he needs attention at this time.
…
When explaining “postpartum blues” to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.)
a.Mood swings.
b.Panic attacks.
c.Tearfulness
d.Decreased need for sleep.
e. Disinterest in the infant
a.Mood swings.
c.Tearfulness
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?
a.Dehydration.
b.Hyperstimulation.
c. Galactorrhea.
d.Fetal tachycardia.
b.Hyperstimulation.
While breastfeeding, a new mother strokes the top of her baby’s head and asks the nurse about the baby’s swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother?
a.The infant should be positioned to reduce the swelling.
b.The swelling is a subperiosteal collection of blood.
c.The pediatrician will aspirate the blood if it gets larger.
d.The scalp edema will subside in a few days after birth.
d.The scalp edema will subside in a few days after birth.
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
a.Ask the mother why she won’t look at the infant.
b.Observe the mother for other attachment behaviors.
c.Examine the newborn’s eyes for the ability to focus.
d.Recognize this as a common reaction in new mothers.
b.Observe the mother for other attachment behaviors.
A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client?
a.Refer the client to a social worker to arrange for home care.
b.Recommend perinatal care from an obstetrician, not a nurse-midwife.
c.Teach the client why keeping prenatal care appointments is important.
d.Advise the client that neonatal intensive care may be needed.
c.Teach the client why keeping prenatal care appointments is important.
tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?
a.Your current dose of Insulin should be maintained throughout your pregnancy.
b.Maintain blood sugar levels in a constant range within normal limits during pregnancy.
c.The course and outcome of your pregnancy is not an achievable goal with diabetes.
d.Expect an increase in insulin dosages by 5 units/week during the first trimester.
b.Maintain blood sugar levels in a constant range within normal limits during pregnancy.
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next?
a.Cleanse the perineum.
b.Obtain a blood pressure.
c.Palpate the firmness of the fundus
d. Inspect the perineum for lacerations.
c.Palpate the firmness of the fundus
the nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?
a.Yellowish tinge to the skin.
b. Babinski reflex present bilaterally.
c.Pink papular rash on the face.
d.Moro reflex noted after a loud noise.
a.Yellowish tinge to the skin.
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
a.Blood glucose level of 45 mg/dl.
b. Blood pressure of 82/45 mmHg.
c.Non-bulging anterior fontanel.
d.Central cyanosis when crying.
d.Central cyanosis when crying.
What action should the nurse implement to decrease the client’s risk for hemorrhage after a cesarean section?
a.Monitor urinary output via an indwelling catheter.
b.Assess the abdominal dressings for drainage.
c.Give the Ringer’s Lactated infusion at 125 ml/hr.
d.Check the firmness of the uterus every 15 minutes.
d.Check the firmness of the uterus every 15 minutes.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
a.Transition labor with contractions every 2 minutes, lasting 90 seconds each.
b.Early labor with contractions every 5 minutes, lasting 40 seconds each.
c.Active labor with contractions every 31 minutes, lasting 60 seconds each.
d.Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each.
a.Transition labor with contractions every 2 minutes, lasting 90 seconds each.
A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately?
a.Heart rate of 100 beats/minute.
b.Variable fetal heart rate.
c.Onset of uterine contractions.
d.Burning on urination.
c.Onset of uterine contractions.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?
a.Biophysical profile (BPP). t
b.Ultrasound for fetal anomalies.
c.Maternal serum alpha-fetoprotein (AF) screening
d.Percutaneous umbilical blood sampling (PUBS).
a.Biophysical profile (BPP).
When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?
A. thrombophlebitis
B. pregnancy induced hypertension
C. pressure on blood vessels from the enlarging uterus
D. the force of gravity pulling down on the uterus
C – Explanation
Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.
Which of the following would cause a false-positive result on a pregnancy test?
A. The test was performed less than 10 days after an abortion
B. The test was performed too early or too late in the
pregnancy
C. The urine sample was stored too long at room
temperature
D. A spontaneous abortion or a missed abortion is
impending
A – Explanation
A false-positive reaction can occur if the
pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results.
During a lecture on reproduction, a student nurse asks the instructor what determines the sex of a fetus. Accurate information in response to this question would be:
A. “The sex of the fetus is not determined until the eighth week of gestation.”
B. “The fertilization of the zygote is the point at which sex is determined.”
C. “Males have one less pair of chromosomes than females.”
D. “Sex is determined by the chromosomes contributed by the ovum.”
B. Explanation
The sex of the fetus is determined at the point that the sperm fertilizes the ovum to form the zygote. Sex is ultimately determined by the chromosome contributed by the sperm.
Pediazole is a suspension medication that contains 200 mg erythromycin and 600 mg sulfisoxazole per 5 mL. The physician orders Pediazole 4 mL PO every 12 hours. How many mg of sulfisoxazole is this client receiving in a 24-hour period?
A. 160 mg
B. 320 mg
C. 480 mg
D. 960 mg
D. Explanation
600 mg/ 5 mL = x mg/ 4 mL
2400 = 5x
x= 2400/5
x= 480 mg per dose x 2 = 960 mg in 24 hours.
A primigravida patient who is 12 weeks pregnant visits a helath promotion program in the community pertaining to the pregnancy care. A group of nursing student is educating the public about measures to prevent discomfort of pregnancy. The primigravida patient asks one of the student about measures on how to prevent heartburn she is experiencing throughout the day. Select all the necessary measures to prevent the primigravia patient’s complaint.
A. Eating small, frequent meals and avoiding fatty and spicy food
B. Eating high fiber foods and increase drinking fluids
C. Drinking milk between milk
D. Arranging frequent rest periods throughout the day
E. Sitting upright for 30 minutes after a meal
F. Engaging in regular exercise
A, C, E
The nurse identifies substance abuse behaviors exhibited by a pregnant client during an initial prenatal screening. While promoting a therapeutic and accepting environment, the care managment by the nurse would be MOST appropriate if focused on which of the following?
A. Discouraging substance use during pregnancy
B. Termination of the pregnancy at an early stage
C. Eliminating substance use during pregnancy
D. Setting boundaries with the client in regards to substance use
C.
Explanation
Use of substances during pregnancy can lead to severe fetal or neonatal abnormalities, complications, and death. The primary goal of nursing care should be prevention or elimination of substance use during pregnancy.
This is a dark streak down the midline of the abdomen that may appear as the uterus is enlarging. The LPN correctly describes this to the pregnant woman as?
LINEA NIGRA
Cervical softening and uterine souffle are classified as which of the following?
A. diagnostic signs
B. presumptive signs
C. probable signs
D. positive signs
C.
Explanation
Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.
A client at 36 weeks’ gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?
A. The ultrasound will help to locate the placenta
B. The ultrasound identifies blood flow through the umbilical cord
C. The test will determine where to insert the needle
D. The ultrasound locates a pool of amniotic fluid
B.
Explanation
Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.
A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply.
A. Allows for fetal movement
B. Is a measure of kidney function
C. Surrounds, cushions, and protects the fetus
D. Maintains the body temperature of the fetus
E. Prevents large particles such as bacteria from passing to the fetus
F. Provides an exchange of nutrients and waste products between the mother and the fetus
A, B, C, D
A 25-year-old client with diabetes type I visits the clinic to discuss her and her husband’s desire to start a family. This diabetic client
A. should be discouraged from becoming pregnant
B. has a greater risk of complications during pregnancy
C. should be informed about treatment for infertility
D. will be able to carry out a completely normal pregnancy
B.
Explanation
Clients with DM are at greater risk for developing maternal and fetal complications during pregnancy.
Q.12) A nurse is collecting data during the admission asessment of a client who is pregnant with twins. The client also has 5 year old child. The nurse would document which gravida and para status on this client?
A. G1P1
B. G2P1
C. G2P2
D. G3P2
B
During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?
A. post partum phase
B. first trimester
C. second trimester
D. third trimester
B
Explanation
First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.
Family centered nursing care for women and newborn focuses on which of the following?
A. Assisting individuals and families achieve their optimal health
B. Diagnosing and treating problems promptly
C. Preventing further complications from developing
D. Conducting nursing research to evaluate clinical skills
A
The hormone responsible for the development of the ovum during the menstrual cycle is?
A. estrogen
B. progesterone
C. follicle stimulating hormone (Correct Answer)
D. leutenizing hormone (Your Answer)
C
A client LMP began July 5. Her EDD should be which of the following?
A. January 2
B. March 28
C. April 12
D. October 12
C
Explanation
To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.
A client is pregnant with her third child. Medical history of the client indicates a previous precipitate labor and birth. Which of the following interventions would NOT be expected during labor of the present pregnancy?
A. Use of magnesium sulfate
B. Close monitoring of the fetus for hypoxia
C. The nurse stays at the bedside constantly or as much as possible
D. amnioinfusion will be performed
D
Explanation
Amnioinfusion is instillation of fluid into the amniotic sac within the uterus to treat oligohydraminios. This is not done to prevent precipitate labor and birth.
Which of the following prenatal laboratory test values would the nurse consider as significant?
A. Hematocrit 33.5%
B. Rubella titer less than 1:8
C. White blood cells 8,000/mm3
D. One hour glucose challenge test 110 g/dL
B
Explanation
A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.
During which of the following phase of the menstrual cycle is it ideal for implantation of a fertilized egg to occur?
A. ischemic phase
B. mentrual phase
C. proliferative phase
D. secretory phase
D
The LPN is preparing to administer Solu-medrol 40 mg mixed in 150 mL of sodium chloride via intravenous piggyback. The medication is to be administered over 30 minutes. Using the tubing with a drop factor of 15 ggts/mL, what would the LPN calculate the rate to be in drops per minute?
A. 40
B. 50
C. 75
D. 150
C
The nurse knows that there are psychological maternal changes that occurs during pregnancy in a primigravida patient. Select all the normal psychological maternal changes that happens throughout pregnancy.
A. Ambivalence
B. Breast tenderness
C. Emotional lability
D. Body image changes
E. Bonding or relationship with the fetus
F. Nausea and vomiting
G. Syncope
H. Urinary frequency
A, C, D, E
Which of the following represents the average amount of weight gained during pregnancy?
A. 12 to 2 lbs
B. 15 to 25 lbs
C. 25 to 35 lbs
D. 25 to 40 lbs
C
Explanation
The average amount of weight gained during pregnancy is 25 to 35 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.
A 36 weeks gestation pregnant woman is complaining of urinary urgency and frequency. The nurse explained that the enlarging fetus is pressing the bladder which causes frequent urination. This is normally occuring during the first and third trimesters of pregnancy. The nurse advices the patient to do the following measures to prevent urinary frequency. Select all the necessary measures that the nurse can provide to the patient.
A. Drink 2 quarts of fluid during the day
B. Engaging in a regular exercise
C. Performing Kegel exercises
D. Soaking in a warm sitz bath
E. Limiting fluid intake during the evening
A, C, E
The LPN has initiated the administration of vancomycin via IV piggyback . In which of the following situations should the nurse recognize that the client may be experiencing a fatal reaction to this medication?
A. The client start coughing
B. The client complains of pain at the intravenous catheter insertion site
C. The nurse hears the client snoring from the hall
D. The nurse notices the client’s neck and chest is bright red
D
Explanation
While administering vancomycin the LPN should know to monitor the client carefully for the development of Red Man Syndrome or anaphylactic shock. The common side effects of this medicine are pruritus, flushing and erythema to the head, neck, and upper body.
Ativan 0.5 mg IM every 1 hour as needed is prescribed for a client experiencing delirium tremens. The medication vial reads 2mg/mL of solution. How many mL should the LPN draw into the syringe for single dose administration?
Possible correct answers:
0.25 mL0.25mL0.25ml0.25 ml
Explanation
2mg/mL= 0.5mg/xmL
2x=0.5
x=0.5/2
x=0.25 mL
Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?
A. increased plasma HCG levels
B. decreased intestinal motility
C. decrease gastric acidity
D. elevated estrogen levels
C
Explanation
During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.
According to Diane, her LMP is November 15, 2002, using the Naegle’s rule what is her EDC?
A. August 23, 2003
B. August 18, 2003
C. July 22, 2003
D. February 22, 2003
A
Which of the following would the nurse identify as a presumptive sign of pregnancy?
A. Hegar sign
B. Nausea and vomiting
C. skin pigmentation changes
D. positive serum pregnancy test
B
Explanation
resumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.
The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The LPN should tell the patient that she can expect to feel the fetus move at which time?
A. Between 10 and 12 weeks’ gestation
B. Between 16 and 20 weeks’ gestation
C. Between 21 and 23 weeks’ gestation
D. Between 24 and 26 weeks’ gestation
B
Explanation
A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.
A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond?
A. “Yes, it produces no adverse effect.”
B. “No, it can initiate premature uterine contractions.”
C. “No, it can promote sodium retention.”
D. “No, it can lead to increased absorption of fat-soluble vitamins.”
B
Explanation
Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased.
31) During the prenatal visit, the client states that she has been experiencing heartburn frequently. The LPN provides instruction on the cause and prevention of heartburn. When she ask to verbalize understanding of the information, which of the following statements by the client indicates further instruction may be necessary?
A. “The sphincter that normally prevents stomach contents from going back up into the esophagus is relaxed.”
B. “I should try to avoid drinking fluids while I’m eating.”
C. “Eating six or seven small meals a day may help my symptoms.”
D. “I’ll eat enough to ensure that I am full at every meal.”
D
Explanation
It suggests that the instruction might need to be reinforced on preventing stomach distention.
A. The client’s readiness to learn
C. Tachycardia and a feeling of nervousness
C. correctly place the infant on the breast
B. Infant’s condition at birth and treatment received.
D. anterior fontanel closes at 12-18 mos and the posterior fontanel by the end of the second month.
The nurse should encourage the laboring client to begin pushing when
C. the cervix is completely dilated
A. two weeks before menstruation.
C. have the client breath into her cupped hands
C. Vernix is a white, cheesy substance, predominately located in the skin folds.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks.
B. “your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times a day.
C. That is normal, the head will return to a round shape within 7-10 days.
D. Meet the mother’s physical needs and demonstrate warmth toward the infant.
A. Lying prone with a pillow on the abdomen
C. a decrease in RR from 24 to 16.
C. place the woman in a lateral position.
A. Come to the clinic today for an ultrasound.
A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
C. Check the infant’s oxygen saturation rate.
D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
A. Between the time the temp falls and rises.
D. Take prescribed multivitamin and mineral supplements.
A. Edema, basilar rales, and an irregular pulse.
A. Describe diet changes that can improve the management of her diabetes.
C. Encourage the mother to breast-feed frequently.
D. Urine output 90 ml/4 hours.
B. maternal and fetal heart rates
A. choking, coughing, and cyanosis.
A. Grief related to her perceptions about the loss of this child.
C. Feed your baby every 2 to 3 hours or on demand, whichever comes first.
The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?
C. 3 vessels: 2 arteries and a vein.
B. It is difficult to consume 18 mg of additional iron by diet alone.
A. a home pregnancy test can be used right after your first missed period.
B. the infant’s condition at birth and treatment received.
B. Extend the leg and dorsiflex the foot.
A client 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
C. obtain a specimen for urine analysis
C. changes in apical heart rate from the 180s to the 140s
C. date of last normal menstrual period.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
C. monitor bleeding from IV sites.
A. initiate positive pressure ventilation.
D. a 40-week primagravida who presents at 100% effacement, 3 cm dilation, and a -1 station.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, “What if I start having red bleeding after it changes?” What should the nurse instruct the client to do?
A. Reduce activity level and notify healthcare provider.
One hour after giving birth to an 8-pound infant, a client’s lochia rubra has increased from small to large and her fundus is boggy despite massage. The client’s pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?
D. Call the healthcare provider to question the prescription.
D. Do you have a history of rheumatic fever?
D. They use lubricants with each sexual encounter to decrease friction.
After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow’s milk formula. The pediatric healthcare provider changes the neonate’s formula to Similac Soy Isomil Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula?
D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose.
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard scale. Based on this assessment, the nurse determines that the neonate has a maturity rating at 40-weeks. What findings should the nurse identify to determine if the neonate is SGA?
D. Ask the client if she has felt any fetal movement.
A. Bathe the infant with antimicrobial soap.
A. Have the client empty her bladder.
D. It is important that you want to take part in your care.
D. Encourage healthy lifestyles for families during pregnancy.
D. A platelet count of 67,000/mm3.
A. apply cold compresses to both breasts for comfort.
C. Document the finding in the newborns record.
C. places the infant prone in the bassinet.
B. each pregnancy carries a 50% chance of inheriting the disorder.
B. screen for neural tube defects.
B. observe for an asymmetrical Moro reflex.
C. teach the client why keeping prenatal care appointments is important.
B. maintain blond sugar levels in a constant range WNL during pregnancy.
A. complete a sterile vaginal exam.
D. the scalp edema will subside in a few days after birth.
C. onset of uterine contractions
A. dark red vaginal bleeding
D. increased uterine irritability.
F. a rigid abdomen.
D. apply firm pressure to the sacral area.
A. transition labor with contraction every 2 min, lasting 90 seconds each.
What action should the nurse implement to decrease the client’s risk for hemorrhage after a C/S?
D. check the firmness of the uterus Q15 min.
Which assessment finding should the nursery nurse report to the ped healthcare provider?
D. central cyanosis when crying
A. yellowish tinge to the skin
C. palpate the firmness of the fundus
C. a sterile glove
D. an aminhook
F. lubricant
At 14-weeks gestation, a client arrives at the Er complaining of a dull pain in the RLQ. The nurse obtains a blood sample and initiates and IV. 30 minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. assessment findings include diaphoresis HR 120, BP 86/48. What action should the nurse implement ?
C. a sterile glove
D. amniotic hook
F. a doppler
During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?
A. Encourage her to pant between contractions and blow with contractions.
B. Coach her to take a deep cleansing breath and then refocus.
C. Instruct her to pant three times and then exhale through pursed lips.
D. Have her cup both hands over her nose and mouth while breathing.
D. Have her cup both hands over her nose and mouth while breathing.
The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse?
A. Remove all ice from the client’s room.
B. Ask the client what foods she might consider eating.
C. Remind the client that what she eats affects her baby.
D. Notify the health care provider.
D. Notify the health care provider.
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, “What type of disease causes infections in babies that can be prevented by using this ointment?” Which response by the nurse is accurate?
A. Herpes
B. Trichomonas
C. Gonorrhea
D. Syphilis
The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.)
A. Pain in the lower back that radiates to abdomen
B. Contractions decreased in frequency with ambulation
C. Progressive cervical dilation and effacement
D. Discomfort localized in the abdomen
E. Regular and rhythmic painful contractions
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?
A. Administer oxygen by facemask.
B. Notify the health care provider of the client’s symptoms.
C. Have the client breathe into her cupped hands.
D. Check the client’s blood pressure and fetal heart rate.
C. Have the client breathe into her cupped hands.
The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation
A. Two weeks before menstruation
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
A. Use thread to tie off the umbilical cord.
B. Provide privacy for the woman.
C. Reassure the husband and keep him calm.
D. Put the newborn to the breast immediately.
D. Put the newborn to the breast immediately.
A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She sure has a funny-looking head.” Which response by the nurse is best?
A. “This is not an unusually shaped head, especially for a first baby.”
B. “It may look odd, but newborn babies are often born with heads like that.”
C. “That is normal. The head will return to a round shape within 7 to 10 days.”
D. “Your pelvis was too small, so the head had to adjust to the birth canal.”
C. “That is normal. The head will return to a round shape within 7 to 10 days.”
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?
A. Avoid alcohol because it is excreted in breast milk.
B. Eat a high-roughage diet to help prevent constipation.
C. Increase caloric intake by approximately 500 cal/day.
D. Increase fluid intake to at least 3 quarts each day.
A. Avoid alcohol because it is excreted in breast milk.
When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation?
A. Milia are red marks made by forceps and will disappear within 7 to 10 days.
B. Meconium is the first stool and is usually yellow gold in color.
C. Vernix is a white cheesy substance, predominantly located in the skin folds.
D. Pseudostrabismus found in newborns is treated by minor surgery.
C. Vernix is a white cheesy substance, predominantly located in the skin folds.
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record?
A. Gravida 1, para 0
B. Gravida 1, para 1
C. Gravida 2, para 0
D. Gravida 2, para 1
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate?
A. Drowsiness and paroxysmal bradycardia
B. Depressed reflexes and increased respirations
C. Tachycardia and a feeling of nervousness
D. A flushed warm feeling and dry mouth
C. Tachycardia and a feeling of nervousness
A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted?
A. If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect.
B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect.
C. If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies.
D. If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.
Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child, but I would like to try with this baby.” Which intervention should the nurse implement first?
A. Assess the husband’s feelings about his wife’s decision to breastfeed their baby.
B. Ask the woman to describe why she was unsuccessful with breastfeeding her last child.
C. Encourage the woman to develop a positive attitude about breastfeeding to help ensure success.
D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line?
A. Cephalhematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage
A. Cephalhematoma, which is caused by forceps trauma
In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant’s fontanels to close. Which statement is accurate regarding the timing of closure of an infant’s fontanels that should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week.
C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B. Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
D. She eagerly reaches for the infant and then holds the infant close to her own body.
Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)
A. Increased heartburn that is not relieved with doses of antacids
B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
C. Shoes and rings that are too tight because of peripheral edema in extremities
D. Decrease in ability for the client to sleep for more than 2 hours at a time
E. Chronic headache that has been lingering for a week behind the client’s eyes
A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse’s response?
A. Telling the client and her partner that the labor process is often unpredictable
B. Informing the client that this means she will give birth sooner than expected
C. Asking the client and her partner if they would like the nurse to stay in the room
D. Affirming that the fetal heart rate is remaining within normal limits
C. Asking the client and her partner if they would like the nurse to stay in the room
A new mother asks the nurse, “How do I know that my daughter is getting enough breast milk?” Which explanation is appropriate?
A. “Weigh the baby daily, and if she is gaining weight, she is getting enough to eat.”
B. “Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day.”
C. “Offer the baby extra bottled milk after her feeding and see if she still seems hungry.”
D “If you’re concerned, you might consider bottle feeding so that you can monitor intake.”
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately?
A. Notify the health care provider or anesthesiologist.
B. Continue to assess the blood pressure every 5 minutes.
C. Place the client in a lateral position.
D. Turn off the continuous epidural.
C. Place the client in a lateral position.
One hour following a normal vaginal delivery, a newborn infant boy’s axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy’s hands shake. Which intervention should the nurse implement first?
A. Stimulate the infant to cry.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D. Obtain a serum glucose level.
D. Obtain a serum glucose level.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C. Breastfeed on the unaffected breast only until the mastitis subsides.
D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?
A. Cyanosis of the hands and feet
B. Skin color that is slightly jaundiced
C. Tiny white papules on the nose or chin
D. Red patches on the cheeks and trunk
B. Skin color that is slightly jaundiced
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?
A. Wear a cotton bra with nonbinding support.
B. Increase nursing time gradually over several days.
C. Ensure that the baby is positioned correctly for latching on.
D. Manually express a small amount of milk before nursing.
C. Ensure that the baby is positioned correctly for latching on.
A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide?
A. Most infants of HIV-positive women will continue to test positive for HIV antibodies.
B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease.
C. Medication taken during pregnancy to reduce the mother’s viral load ensures that the infant is HIV-negative.
D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.
During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother?
A. Lower Apgar score recorded at delivery
B. Lower initial weight documented at birth
C. Higher oxygen use to stimulate breathing
D. Higher prevalence of congenital anomalies
B. Lower initial weight documented at birth
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?
A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking.
B. Hold the infant’s head firmly against the breast until he latches onto the nipple.
C. Encourage the mother to stop feeding for a few minutes and comfort the infant.
D. Provide formula for the infant until he becomes calm, and then offer the breast again.
C. Encourage the mother to stop feeding for a few minutes and comfort the infant.
A mother expresses fear about changing the infant’s diaper after circumcision. What information should the nurse include in the teaching plan?
A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B. Wash off the yellow exudate on the glans once every day to prevent infection.
C. Place petroleum ointment around the glans with each diaper change and cleansing.
D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.
C. Place petroleum ointment around the glans with each diaper change and cleansing.
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?
A. Turn the client to her side.
B. Begin oxygen by nasal cannula at 2 L/min.
C. Place the client in a slight Trendelenburg position.
D. Assess for cervical dilation.
C. Place the client in a slight Trendelenburg position.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal distention
C. Impaired bowel motility related to pain medication and immobility
D. Fatigue related to cesarean delivery and physical care demands of infant
C. Impaired bowel motility related to pain medication and immobility
An expectant father tells the nurse he fears that his wife “is losing her mind.” He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father?
A. Suggest that his wife seek professional counseling to deal with her symptoms.
B. Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D. Reassure him that normal maternal-fetal bonding is occurring.
D. Reassure him that normal maternal-fetal bonding is occurring.
The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign?
A. 3
B. 4
C. 5
D. 8
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
A. At 16 weeks of gestation
B. At 20 weeks of gestation
C. At 24 weeks of gestation
D. At 30 weeks of gestation
Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?
A. “Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”
B. “Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk.”
C. “I can start smoking cigarettes while breastfeeding because it will not affect my breast milk.”
D. “When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings.”
A. “Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client’s next fertile period occur?
A. January 14 to 15
B. January 22 to 23
C. January 29 to 30
D. February 6 to 7
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
A. Come to the clinic today for an ultrasound.
B. Go immediately to the emergency department.
C. Lie on your left side for about 1 hour and see if the bleeding stops.
D. Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).
A. Come to the clinic today for an ultrasound.
Client teaching is an important part of the perinatal nurse’s role. Which factor has the greatest influence on successful teaching of the pregnant client?
A. The client’s investment in what is being taught
B. The couple’s highest levels of education
C. The order in which the information is presented
D. The extent to which the pregnancy was planned
A. The client’s investment in what is being taught
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take?
A. Reapply the external transducer.
B. Insert the intrauterine pressure catheter.
C. Discontinue the oxytocin infusion.
D. Continue to monitor labor progress.
D. Continue to monitor labor progress.
The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, “I don’t know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!” Which adjustment phase should the nurse determine the client is experiencing?
A. Taking-in phase
B. Postpartum blues
C. Attachment difficulty
D. Letting-go phase
A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?
A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now, and if it is seriously elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a histamine blocking agent.
C. Take your blood pressure now, and if it is seriously elevated, go to the hospital.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?
A. Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing.
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant’s discharge teaching plan?
A. Observe the parents applying a Pavlik harness.
B. Provide a referral for an orthopedic surgeon.
C. Schedule a physical therapy follow-up home visit.
D. Teach the parents to check for hip joint mobility.
A. Observe the parents applying a Pavlik harness.
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?
A. Avoid using the breast pump.
B. Breastfeed the infant every 2 hours.
C. Reduce fluid intake for 24 hours.
D. Skip feedings to let the sore breasts rest.
B. Breastfeed the infant every 2 hours.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn’s umbilical cord care at home?
A. Wash the cord frequently with mild soap and water.
B. Cover the cord with a sterile dressing.
C. Allow the cord to air-dry as much as possible.
D. Apply baby lotion after the baby’s daily bath.
C. Allow the cord to air-dry as much as possible.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take?
A. Instruct the client to go to the emergency room.
B. Recommend vaginal douching.
C. Explain this is a normal finding.
D. Determine if ovulation has occurred.
C. Explain this is a normal finding.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement?
A. Place a wedge under the client’s left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin (Pitocin) infusion.
D. Increase the rate of the oxytocin (Pitocin) infusion.
An expectant father tells the nurse he fears that his wife is “losing her mind.” He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring.
D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are not necessary because the behaviors displayed are normal.
C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the development of amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk
B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing.
C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return. Option A would increase venous return from varicose veins in the lower extremities but would be of little help with swelling. Option B might be helpful with generalized edema but is not specific for edematous lower extremities. Option D does not address venous return, and there is no indication in the question that constrictive clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage
A.Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn’s umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby’s daily bath
C.Allow the cord to air-dry as much as possible.
Rationale:Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant’s diaper after circumcision. What information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth
C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing.
C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby’s body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer.
A new mother asks the nurse, “How do I know that my daughter is getting enough breast milk?” Which explanation is appropriate?
A.”Weigh the baby daily, and if she is gaining weight, she is getting enough to eat.”
B.”Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day.”
C.”Offer the baby extra bottled milk after her feeding and see if she still seems hungry.”
D.”If you’re concerned, you might consider bottle feeding so that you can monitor intake.”
B.”Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day.”
Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious. Option C causes nipple confusion and diminishes the mother’s milk production. Option D does not address the client’s question.
The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions
Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?
A.”Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”
B.”Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk.”
C.”I can start smoking cigarettes while breastfeeding because it will not affect my breast milk.”
D.”When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings.
A.”Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings.
A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She sure has a funny-looking head.” Which response by the nurse is best?
A.”This is not an unusually shaped head, especially for a first baby.”
B.”It may look odd, but newborn babies are often born with heads like that.”
C.”That is normal. The head will return to a round shape within 7 to 10 days.”
D.”Your pelvis was too small, so the head had to adjust to the birth canal.”
C.”That is normal. The head will return to a round shape within 7 to 10 days.”
Rationale: Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken “don’t worry” is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother’s fault.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately?
A.Notify the health care provider or anesthesiologist.
B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural.
C.Place the client in a lateral position.
Rationale: The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice. Option D may also be warranted, but such action is based on hospital protocol.
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day.
A.Avoid alcohol because it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant. Options B, C, and D should also be included in diet teaching for a breastfeeding mother; however, because these do not involve safety of the infant, they do not have the same degree of importance as option A.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).
A.Come to the clinic today for an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus. If those symptoms were described, option B would be appropriate. Option C does not address the cause of the symptoms. The client is not describing symptoms of a UTI.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement?
A.Place a wedge under the client’s left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion.
B.Determine cervical dilation and effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and immobility
D.Fatigue related to cesarean delivery and physical care demands of infant
C.Impaired bowel motility related to pain medication and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility.
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client’s next fertile period occur?
A.January 14 to 15
B.January 22 to 23
C.January 29 to 30
D.February 6 to 7
C.January 29 to 30
Rationale: This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant’s fontanels to close. Which statement is accurate regarding the timing of closure of an infant’s fontanels that should be included in this teaching plan?
A.The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week.
B.The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week.
C.The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month.
D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month
D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month
Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination. Options A, B, and C are incorrect.
B.Breastfeed the infant every 2 hours.
Rationale: The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. If the infant does not feed adequately and empty the breast, using a breast pump helps extract the milk and relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping feedings may cause further engorgement and discomfort.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
A.Use thread to tie off the umbilical cord.
B.Provide privacy for the woman.
C.Reassure the husband and keep him calm.
D.Put the newborn to the breast immediately.
D.Put the newborn to the breast immediately.
Rationale: Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.
The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, “I don’t know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!” Which adjustment phase should the nurse determine the client is experiencing?
A.Taking-in phase
B.Postpartum blues
C.Attachment difficulty
D.Letting-go phase
B.Postpartum blues
Rationale: During the postpartum period, when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues, which peaks around the fifth postpartum day. The taking-in phase is the period following birth when the mother focuses on her own psychological needs; typically, this period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a normal physical and emotional response. The letting-go phase is when the mother sees the child as a separate individual.
A.Cramping with bright red spotting
C.Lack of tenderness of the breast
E.Increased right-side flank pain
Rationale: Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client’s menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant’s discharge teaching plan?
A.Observe the parents applying a Pavlik harness.
B.Provide a referral for an orthopedic surgeon.
C.Schedule a physical therapy follow-up home visit.
D.Teach the parents to check for hip joint mobility.
A.Observe the parents applying a Pavlik harness.
Rationale: It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment often negates the need for surgery, and option B is not indicated until approximately 6 months of age. Option C is not indicated for hip dysplasia. It is best for the pediatrician to monitor hip joint mobility, and teaching the parents to perform this technique is likely to increase their anxiety.
Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)
A.Increased heartburn that is not relieved with doses of antacids
B.Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
C.Shoes and rings that are too tight because of peripheral edema in extremities
D.Decrease in ability for the client to sleep for more than 2 hours at a time
E.Chronic headache that has been lingering for a week behind the client’s eyes
A.Increased heartburn that is not relieved with doses of antacids
E.Chronic headache that has been lingering for a week behind the client’s eyes
Rationale: Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.
Client teaching is an important part of the perinatal nurse’s role. Which factor has the greatest influence on successful teaching of the pregnant client?
A.The client’s investment in what is being taught
B.The couple’s highest levels of education
C.The order in which the information is presented
D.The extent to which the pregnancy was planned
A.The client’s investment in what is being taught
Rationale: When teaching any client, readiness to learn is related to how much the client has invested in what is being taught or how important the materials are to the client’s particular life. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery but is probably very ready to learn about ways to relieve morning sickness. Options B and C are factors that may influence learning but are not as influential as option A. Even if a pregnancy is planned and very desirable, the client must be ready to learn the content presented.
When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation?
A.Milia are red marks made by forceps and will disappear within 7 to 10 days.
B.Meconium is the first stool and is usually yellow gold in color.
C.Vernix is a white cheesy substance, predominantly located in the skin folds.
D.Pseudostrabismus found in newborns is treated by minor surgery.
C.Vernix is a white cheesy substance, predominantly located in the skin folds.
Rationale:
Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?
A.Turn the client to her side.
B.Begin oxygen by nasal cannula at 2 L/min.
C.Place the client in a slight Trendelenburg position.
D.Assess for cervical dilation.
C. Place the client in a slight Trendelenburg position.
Rationale:The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.
A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide?
A.Most infants of HIV-positive women will continue to test positive for HIV antibodies.
B.Infants who have HIV-positive mothers carry the virus and will eventually develop the disease.
C.Medication taken during pregnancy to reduce the mother’s viral load ensures that the infant is HIV-negative.
D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.
D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.
Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant’s blood. Passive HIV antibodies disappear in the infant within 18 months of age. Option B is inaccurate. Although administration of HIV medication during pregnancy can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will not become manifest in the infant.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?
A.Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking.
B.Hold the infant’s head firmly against the breast until he latches onto the nipple.
C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
D.Provide formula for the infant until he becomes calm, and then offer the breast again.
C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Options A and D would cause nipple confusion. Option B would only cause the infant to be more resistant, resulting in the mother and infant becoming more frustrated.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take?
A.Instruct the client to go to the emergency room.
B.Recommend vaginal douching.
C.Explain this is a normal finding.
D.Determine if ovulation has occurred.
A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?
A.Lie on your left side and call 911 for emergency assistance.
B.Take an antacid and call back if the pain has not subsided.
C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
D.See your health care provider to obtain a prescription for a histamine blocking agent.
C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
Rationale: Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in option A. Options B and D ignore the threat to client safety posed by a significant increase in blood pressure.
The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
A.Two weeks before menstruation
B.Immediately after menstruation
C.Immediately before menstruation
D.Three weeks before menstruation
A.Two weeks before menstruation
Rationale:Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. Options B, C, and D are incorrect.
A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse’s response?
A.Telling the client and her partner that the labor process is often unpredictable
B.Informing the client that this means she will give birth sooner than expected
C.Asking the client and her partner if they would like the nurse to stay in the room
D.Affirming that the fetal heart rate is remaining within normal limits
C.Asking the client and her partner if they would like the nurse to stay in the room
Rationale: Offering to remain with the client and her partner offers support without providing false reassurance. The length of labor is not always predictable, but options A and B do not offer the client the support that is needed at this time. Option D may be reassuring regarding the fetal heart rate but does not provide the client the emotional support she needs at this time during the labor process.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
A.At 16 weeks of gestation
B.At 20 weeks of gestation
C.At 24 weeks of gestation
D.At 30 weeks of gestation
D.At 30 weeks of gestation
Rationale: Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. Option D is closest to the time when parents would be ready for such classes. Options A, B, and C are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take?
A.Reapply the external transducer.
B.Insert the intrauterine pressure catheter.
C.Discontinue the oxytocin infusion.
D.Continue to monitor labor progress
D.Continue to monitor labor progress
Rationale: The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client’s record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time.
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?
A.Administer oxygen by facemask.
B.Notify the health care provider of the client’s symptoms.
C.Have the client breathe into her cupped hands.
D.Check the client’s blood pressure and fetal heart rate.
C.Have the client breathe into her cupped hands.
Rationale:
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. Option A is inappropriate because the carbon dioxide level is low, not the oxygen level. Options B and D are not specific for this situation.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
A.She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B.Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips.
C.Her arms and hands receive the infant and she then cuddles the infant to her own body.
D.She eagerly reaches for the infant and then holds the infant close to her own body.
B.Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips.
Rationale:Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in option B during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record?
A.Gravida 1, para 0
B.Gravida 1, para 1
C.Gravida 2, para 0
D.Gravida 2, para 1
C.Gravida 2, para 0
Rationale: This is the client’s second pregnancy or second gravid event, so option C is correct. The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not take into account the current pregnancy, nor does option B, which also counts the miscarriage as a “para,” an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child, but I would like to try with this baby.” Which intervention should the nurse implement first?
A.Assess the husband’s feelings about his wife’s decision to breastfeed their baby.
B.Ask the woman to describe why she was unsuccessful with breastfeeding her last child.
C.Encourage the woman to develop a positive attitude about breastfeeding to help ensure success.
D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
Rationale: Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery. Options A and B might provide interesting data, but gathering this information is not as important as providing support and instructions to the new mother. Although option C is also true, this response by the nurse might seem judgmental to a new mother.
A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted?
A.If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect.
B.If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect.
C.If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies.
D.If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.
B.If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect.
Rationale:Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.
During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?
A.Encourage her to pant between contractions and blow with contractions.
B.Coach her to take a deep cleansing breath and then refocus.
C.Instruct her to pant three times and then exhale through pursed lips.
D.Have her cup both hands over her nose and mouth while breathing.
D.Have her cup both hands over her nose and mouth while breathing.
Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose so that she can rebreathe carbon dioxide. Options A, B, and C do not help restore carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper bag.
One hour following a normal vaginal delivery, a newborn infant boy’s axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy’s hands shake. Which intervention should the nurse implement first?
A.Stimulate the infant to cry.
B.Wrap the infant in warm blankets.
C.Feed the infant formula.
D.Obtain a serum glucose level.
D.Obtain a serum glucose level.
Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.
During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother?
A.Lower Apgar score recorded at delivery
B.Lower initial weight documented at birth
C.Higher oxygen use to stimulate breathing
D.Higher prevalence of congenital anomalies
B.Lower initial weight documented at birth
Rationale:Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy. Options A, C, and D have not been clearly associated with smoking during pregnancy, but there is a strong correlation between smoking and lower birth weights.
The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign?
A.3
B.4
C.5
D.8
C.5
Rationale: The Silverman-Anderson index is an assessment scale that scores a newborn’s respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options A, B, and D are not accurate.
The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse?
A.Remove all ice from the client’s room.
B.Ask the client what foods she might consider eating.
C.Remind the client that what she eats affects her baby.
D.Notify the health care provider.
D.Notify the health care provider.
Rationale: The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. Option A is overreacting and may be perceived as punishment by the client. Option B allows the dietary department to customize the client’s tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. Option C is judgmental and blocks further communication.
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, “What type of disease causes infections in babies that can be prevented by using this ointment?” Which response by the nurse is accurate?
A.Herpes
B.Trichomonas
C.Gonorrhea
D.Syphilis
C.Gonorrhea
Rationale: Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not effective against option A, B, or D.
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?
a. Ccmplete a sterile vaginal exam
b. Take maternal temperature every 2 hours
c. Prepare for an immediate cesarean birth
d. Obtain sterile suction equipment
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
a. Provide oral hydration
b. Have a complete blood count (CBC) drawn
c. Obtain a specimen for urine analysis
d. Place the client on strict bedrest
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
a. edema, basilar rales, and an irregular pulse
b. Increased urinary output, and tachycardia
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate, and hypertension
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefor, the best time for intercourse to ensure conception?
a. Between the time the temperature falls and rises
b. Between 36 and 48 hours after the temperature rises
c. When the temperature falls and remains low for 36 hours
d. Within 72 hours before the temperature falls
a. Between the time the temperature falls and rises
In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?
a. Herbs are a corner stone of good health to include in your treatment
b. Touch is also therapeutic in relieving discomfort and anxiety
c. Your healthcare provider should direct treatment options for herbal therapy
d. It is important that you want to take part in your care
The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her menstrual period was January *. The nurse correctly calculates that the woman’s next fertile period is
a. January 14-15
b. January 22-23
c. January 30-31
d. February 6-7
c. January 30-31
This woman can expect her next period to begin 36 days from the first day of her last menstrual period – the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31 (C).
c. the cervix is completely dilated
Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated (A, B, and D), the cervix can become edematous and may never completely dilate, necessitating an operative delivery. Many primigravidas begin active labor 100% effaced and then proceed to dilate.
One hour after giving birth to an 8-pound infant, a client’s lochia rubra has increased from small to large and her fundus is boggy despite massage. The client’s pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM x 1. What action should the nurse take immediately?
a. Give the medication as prescribed and monitor for efficacy
b. Encourage the client to breastfeed rather than bottle feed
c. Have the client empty her bladder and massage the fundus
d. Call the healthcare provider to question the prescription
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply)
a. Dark, red vaginal bleeding
b. Lower back pain
c. Premature rupture of membranes
d. Increased uterine irritability
e. Bilateral pitting edema
f. A rigid abdomen
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
a. Insert an internal fetal monitor
b. Assess for cervical changes q1h
c. Monitor bleeding from IV sites
d. Perform Leopold’s maneuvers
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse’s response is based on what knowledge?
a. Supplementary iron is more efficiently utilized during pregnancy
b. It it difficult to consume 18 mg of additional iron by diet alone
c. Iron absorption is decreased in the GI tract during pregnancy
d. Iron is needed to prevent megaloblastic anemia in the last trimester
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
a. Transition labor with contractions every 2 minutes, lasting 90 seconds each
a. Early labor with contractions every 5 minutes, lasting 40 seconds each
c. Active labor with contractions every 31 minutes, lasting 60 seconds each
d. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
a. She eagerly reaches for the infant, undresses the infants, and examines the infant completely
b. Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips
c. Her arms and hands receive the infant and she then cuddles the infant to her own body
d. She eagerly reaches for the infant and then holds the infant close to her own body
Client teaching is an important part of the maternity nurse’s role. Which factor has the greatest influence on successful teaching on the gravid client?
a. The client’s readiness to learn
b. The client’s educational background
c. The order in which the information is presented
d. The extent to which the pregnancy was planned
1. Reposition the Client
2. Provide oxygen via face mask
3. Increase IV fluid
4. Call the healthcare provider
To stabilize the fetus, intrauterine resuscitation is the first priority, and to enhance the fetal blood supply, the laboring client should be repositioned (1) to displace the gravid uterus and improve fetal perfusion. Secondly, to optimize oxygenation of the circulatory blood volume, oxygen via face mask (2) should be applied to the mother. Next, the IV fluids should be increased (3) to expand the maternal circulating blood volume. Then, the primary healthcare provider should be notified (4) for additional interventions to resolve the fetal stress.
c. Gonorrhea
Erythromycin ointment is instilled into the lower conjunctive of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia (C). The infant may be exposed to these bacteria when passing the birth canal.
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
a. Elicit positive scarf sign on the affected side
b. Observe for an asymmetrical Moro (startle) reflex
c. Watch for swelling of fingers on the affected side
d. Note paralysis of affected extremity and muscles
b. Observe for an asymmetrical Moro (startle) reflex
The most common neonatal birth trauma due to vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fracture clavicle should be suspected is an infant has limited use of the affected arm malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important is most important for the nurse to provide this client?
a. Elevate lower legs while resting
b. Increase caloric intake by 200 to 300 calories per day
c. Increase water intake to 8 full glasses per day
d. Take prescribed multivitamin and mineral supplements
The total bilirubin level of a 36-hour, breastfeeding newborns is 14 mg/dl. Based on this finding, which intervention should the nurse implement?
a. Provide phototherapy for 30 minutes q8h
b. Feed the newborn sterile water hourly
c. Encourage the mother to breastfeed frequently
d. Assess the newborn’s blood glucose level
c. Encourage the mother to breastfeed frequently
The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant’s bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin (C).
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
a. Encourage the mother to provide total care for her infant
b. Provide privacy so the mother can develop a relationship with the infant
c. Encourage the father to provide most of the infant’s care during hospitalization
d. Meet the mother’s physical needs and demonstrate warmth toward the infant
d. Meet the mother’s physical needs and demonstrate warmth toward the infant
It is most important to meet the mother’s requirement for attention to her needs so that she can begin infant care-taking (D). Nurse theorist Reva Rubin describes the initial postpartal period as the “taking-in phase,” which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn.
a. Raise the foot of the bed
These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the silent is in a lateral position are also appropriate interventions.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, “What if I start having red bleeding after it changes?” What should the nurse instruct the client to do?
a. Reduce activity level and notify the healthcare provider
b. Go to bed and assume a knee-chest position
c. Massage the uterus and go to the emergency room
d. Do not worry as this is a normal occurrence
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, “Why must I stay in bed all the time?” Which response is best for the nurse to provide this client?
a. Complete bedrest decreases oxygen needs and demands on the heart muscle
b. We want your baby to be healthy, and this is the only way we can make sure that will happen again
c. I know you’re upset. Would you like to talk about somethings you could so while in bed?
d. Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicated that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client’s record?
a. 3-1-2-0-3
b. 4-1-2-0-3
c. 2-1-2-1-2
d. 3-1-1-0-3
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?
a. Which symptom did you experience first?
b. Are you eating large amounts of salty foods?
c. Have you visited a foreign country recently?
d. Do you have a history of rheumatic fever?
d. Do you have a history of rheumatic fever?
Clients with a history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about the client’s health history is priority.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
a. Deep tendon reflexes 2+
b. Blood pressure 140/90
c. Respiratory rate 18/minute
d. Urine output 90 ml/4 hours
Client teaching is an important part of the maternity nurse’s role. Which factor has the greatest influence on successful teaching of the gravid client?
A. The client’s readiness to learn
B. The client’s educational background
C. The order in which the information is presented
D. The extent to which the pregnancy is planned
A. The client’s readiness to learn
A 38-week primagravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
A. Wear support stockings
B. Reduce salt in her diet
C. Move about every hour
D. Avoid constrictive clothing
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
A. lower Apgar scores
B. lower birth weights
C. respiratory distress
D. a higher rate of congenital anomalies
A 26-year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg SQ to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?
A. drowsiness and bradycardia
B. depressed reflexes and increased respirations
C. tachycardia and a feeling of nervousness
D. a flushed, warm feeling and a dry mouth
C. tachycardia and a feeling of nervousness
C. correctly place the infant on the breast
A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?
A. length of labor and method of delivery
B. infant’s condition at birth and treatment received
C. feeding method chosen by the parents
D. history of drugs given to the mother during labor
B. infant’s condition at birth and treatment received
In developing a teaching plan for expectant parents, the nurse plans to including information about when the parents can expect the infant’s fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the
A. anterior fontanel closes at 2-4 months and the posterior by the end of the first week
B. anterior fontanel closes at 5-7 months and the posterior by the end of the second week
C. anterior fontanel closes at 8-11 months and the posterior by the end of the first month
D. anterior fontanel closes at 12-18 months and the posterior by the end of the second month.
D. anterior fontanel closes at 12-18 months and the posterior by the end of the second month.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
A. at 16 weeks gestation
B. at 20 weeks gestation
C. at 24 weeks gestation
D. at 30 weeks gestation
C. the cervix is completely dilated
A. two weeks before menstruation
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
A. administer oxygen by face mask
B. notify the healthcare provider of the client’s symptoms
C. have the client breathe into her cupped hands
D. check the client’s blood pressure and fetal heart rate
C. Have the client breathe into her cupped hands.
When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?
A. Milia are red marks made by forceps and will disappear within 7-10 days
B. Meconium is the first stool and is usually yellow gold in color
C. Vernix is a white, cheesy substance, predominantly located in the skin folds
D. Pseudostrabismus found in newborns is treated by minor surgery.
C. Vernix is a white, cheesy substance, predominantly located in the skin fold
Twenty four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line in a newborn variation known as
A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks
B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications
C. molding, caused by pressure during labor and will disappear within 2 to 3 days
D. a subdural hematoma which can result in lifelong damage
A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks
An expectant father tells the nurse he fears that his wife “is losing her mind.” He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed.
C. Ask him to observe his wife’s behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.
A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She sure has a funny looking head” Which response by the nurse is best?
A. “This is not an unusual shaped head, especially for a first baby.”
B. “It may look funny to you, but newborn babies are often born with heads like your baby’s.”
C. “That is normal, the head will return to a round shape within 7 to 10 days.”
D. “Your pelvis was too small, so the baby’s head had to adjust to the birth canal.”
C. “That is normal, the head will return to a round shape within 7 to 10 days.”
A new mother asks the nurse, “How do I know that my daughter is getting enough breast milk?” Which explanation will the nurse provide?
A. “weigh the baby daily, and if she is gaining weight, she is eating enough.”
B. “your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times/day.”
C. “Offer the baby extra bottle milk after her feeding and see if she is still hungry.”
D. “If you’re concerned, you might consider bottle feeding so that you can monitor her intake.”
B. “your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times/day.”
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
A. encourage the mother to provide total care for her infant
B. provide privacy so the mother can develop a relationship with the infant.
C. encourage the father to provide most of the infant’s care during hospitalization.
D. Meet the mother’s physical needs and demonstrate warmth toward the infant.
D. Meet the mother’s physical needs and demonstrate warmth toward the infant.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that that woman’s fallopian tubes are patient?
A. back pain
B. abdominal pain
C. shoulder pain
D. leg cramps
A. lying prone with a pillow on the abdomen
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
A. she eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B. Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips
C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
D. She eagerly reaches for the infant and then holds the infant close to her own body
On admission to the prenatal clinic, a 23-year old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client’s expected date of delivery (EDD) would be
A. November 22
B. November 8
C. December 22
D. October 22
The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman’s next fertile period will be
A. January 14-15
B. January 22-23
C. January 30-31
D. February 6-7
B. January 30-31. This woman can expect her next period to begin 36 days from the first day of her last menstrual period – the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, began on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31.
A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved?
A. 4+ reflexes
B. urinary output of 50 mL per hour
C. a decrease in respiratory rate from 24 to 16
D. a decreased body temperature
C. a decrease in respiratory rate from 24 to 16
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client’s blood pressure drops from 120/80 to 90/60. What action will the nurse take?
A. notify the healthcare provider or anesthesiologist immediately.
B. continue to assess the blood pressure q5 minutes
C. place the woman in a lateral position
D. turn off the continuous epidural
C. place the woman in a lateral position. The nurse should immediately turn the woman to a lateral position, place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases ,the anesthesiologist/healthcare provider should be notified immediately. Turning off the continuous epidural may also be warranted, but such action is based on hospital protocol.
A client at 28 weeks gestation calls the antepartal clinical and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
A. come to the clinic today for an ultrasound
B. go immediately to the emergency room
C. lie on your left side for about one hour and see if the bleeding stops
D. bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection
A. come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound.
An off-duty nurse finds a woman in a supermarket parking lot delivery an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
A. use a thread to tie off the umbilical cord.
B. provide as much privacy as possible for the woman.
C. reassure the husband and try to keep him calm
D. put the newborn to breast.
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, “Why must I stay in bed all the time?” Which response is best for the nurse to provide the client?
A. “Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.”
B. “We want your baby to be healthy, and this is the only way we can make sure that will happen.”
C. “I know you’re upset. Would you like to talk about some things you could do while in bed.”
D. “Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.”
A. “Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.”
C. Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, and infection caused by gonorrhea, and including conjunctivitis,, an infection caused by chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.
A newborn infant is brought to the nursery from the bathing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first?
A. notify the pediatrician
B. suction the infant’s nares, then the oral cavity
C. check the infant’s oxygen saturation rate
D. position the infant on the right side.
C. check the infant’s oxygen saturation rate
Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child, but I would like to try with this baby.” Which intervention is best for the nurse to implement first?
A. Assess the husband’s feelings about his wife’s decision to breastfeed their baby
B. Ask the client to describe why she was unsuccessful with breastfeeding her last child
C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success
D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
A. between the time the temperature falls and rises
B. between 36 and 48 hours after the temperature rises
C. when the temperature falls and remains low for 36 hours
D. within 72 hours before the temperature falls
A. between the time the temperature falls and rises
A woman who had a miscarriage 6 months ago became pregnant. Which instruction is most important for the nurse to provide this client?
A. Elevate lower legs while resting
B. increase caloric intake by 200-300 calories per day
C. increase water intake to 8 full glasses per day
D. take prescribed multivitamin and mineral supplements
take prescribed multivitamin and mineral supplements
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of the greatest concern?
A. edema, basilar rates, and an irregular pulse
B. increased urinary output and tachycardia
C. shortness of breath, bradycardia, and hypertension
D. regular heart rate and hypertension
A. edema, basilar rates, and an irregular pulse
A woman with type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?
A. Describe diet changes that can improve the management of her diabetes
B. inform the client that oral hypoglycemic agents are teratogenic during pregnancy
C. Demonstrate self-administration of insulin
D. evaluate the client’s ability to do glucose monitoring
A. describe diet changes that can improve the management of her diabetes
The total bilirubin level of a 36 hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement?
A. provide phototherapy for 30 minutes q8h
B. feed the newborn sterile water hourly
C. encourage the mother to breastfeed frequently
D. assess the newborn’s blood glucose level
C. encourage the mother to breastfeed frequently
A 35-year old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity?
A. deep tendon reflexes 2+
B. blood pressure 140/90
C. respiratory rate 18/min
D. urine output 90 mL/4 hours
A 30 year old gravida, 2 para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug?
A. maternal blood pressure and respirations
B. maternal and fetal heart rates
C. hourly urinary output
D. deep tendon reflexes
B. maternal and fetal heart rates
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?
A. choking, coughing, and cyanosis
B. projectile vomiting and cyanosis
C. apneic spells and grunting
D. scaphoid abdomen and anorexia
A. choking, coughing and cyanosis
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks gestation. What type of emotional response should the nurse anticipate?
A. grief related to her perceptions about the loss of this child
B. Relief of ambivalent feelings experienced with this pregnancy
C. Shock because she may not have realized that she was pregnant
D. guilt because she had not followed her healthcare provider’s instructions
A. grief related to her perceptions about the loss of this child
The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class?
A. begin as soon as your baby is born to establish a four-hour feeding schedule
B. resting helps with milk production. Ask that your baby be fed at night in the nursery
C. feed your baby every 2 to 3 hours or on demand, whichever comes first.
D. do not allow your baby to nurse any longer than the prescribed number of minutes
C. feed your baby every 2-3 hours or on demand, whichever comes first
C. three vessels: two arteries and one vein
A new mother is afraid to touch her baby’s head for fear of hurting the “large soft spot”. Which explanation should the nurse give to this anxious client?
A. “Some care is required when touching the large soft area on top of your baby’s head until the bones fuse together.”
B. “That’s just an ‘old wives’ tale’ so don’t worry, you can’t harm your baby’s head by touching the soft spot.
C. “The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby.”
D. “There’s a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.”
The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?
A. emptying the bladder during delivery is difficult because of the position of the presenting fetal part.
B. An over-distending bladder could be traumatized during labor, as well as prolong the progress of labor
C. urine specimens for glucose and protein must be obtained at certain intervals throughout labor.
D. frequent voiding minimizes the need for catheterization which increases the chance of bladder infection
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse’s response is based on what knowledge?
A. supplementary iron is more efficiently utilized during pregnancy
B. it is difficult to consume 18 mg of additional iron by diet alone.
C. iron absorption is decreased in the GI tract during pregnancy
D. iron is needed to prevent megaloblastic anemia in the last trimester
B. it is difficult to consume 18 mg of additional iron by diet alone.
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate?
A. “A home pregnancy test can be used right after your first missed period.”
B. “These tests are most accurate after you have missed your second period.”
C. “Home pregnancy tests often give false positives and should not be trusted.”
D. “The test can provide accurate information when used right after ovulation.”
A. “A home pregnancy test can be used right after your first missed period.”
A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?
A. the length of labor and method of delivery
B. the infant’s condition at birth and treatment received
C. the feeding method chosen by the parents
D. the history of drugs given to the mother during labor
B. the infant’s condition at birth and treatment received
B. extend the leg and dorsiflex the foot. “Toes to the nose”
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick and high. Based on this data, which intervention should the nurse implement first?
A. provide oral hydration
B. have a complete blood count (CBC) drawn
C. obtain a specimen for urine analysis
D. place the client on strict bedrest
A 4 week old premature infant has been receiving epoetin alfa (Epogen) for the last 3 weeks. Which assessment finding indicates to the nurse that the drug is effective?
A. slowly increasing urinary output over the last week
B. respiratory rate changes from the 40s to the 60s.
C. changes in apical heart rate from the 180s to the 140s
D. change in indirect bilirubin from 12 mg/dl to 8 mg/dl
A. slowly increasing urinary output over the last week
The healthcare provider prescribes terbutalne (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?
A. gestational diabetes
B. elevated blood pressure
C. urinary tract infection
D. swelling in lower extremities
A client with no prenatal care arrives at the labor unit screaming, “the baby is coming!” The nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain?
A. gravidity and parity
B. time and amount of last oral intake
C. date of last normal menstrual period
D. frequency and intensity of contractions
C. date of last normal menstrual period
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
A. insert an internal fetal monitor
B. assess for cervical changes q1h
C. monitor for bleeding from IV sites
D. perform Leopold’s maneuvers
Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 bpm and respirations of 20 breaths/min. What action should the nurse perform next?
A. initiate positive pressure ventilation
B. intervene after the one minute Apgar is assessed
C. initiate CPR on the infant
D. assess the infant’s blood glucose level
The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure?
A. a gravida 6, para 5 who is 38 years of age an in early labor
B. a 37 week primigravida who presents at 100% effacement, 3 cm cervical dilation and a -1 station.
C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to post dates
D. A 40-wk primigravida who is at 6 cm dilation and the presenting part is not engaged
The nurse is providing discharge for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink to white. The client asks, “What if I start having red bleeding after it changes?” What should the nurse instruct the client to do?
A. reduce activity level and notify the healthcare provider
B. go to bed and assume a knee-chest position
C. massage the uterus and go to the emergency room
d. do not worry as this is a normal occurance
A. reduce activity level and notify the healthcare provider
One hour after giving birth to an 8 pound infant, a client’s lochia rubra has increased from small to large and her fundus is boggy despite massage. The client’s pulse is 84 bpm and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM x 1. What action should the nurse take immediately?
A. give the medication as prescribed and monitor for efficacy
B. encourage the client to breast feed rather than bottle feed
C. have the client empty her bladder and then massage the fundus
D. call the healthcare provider to question the prescription
A client at 32 weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue and a moist cough. Which question is most important for the nurse to ask this client?
A. “Which symptom did you experience first?”
B. “Are you eating large amounts of salty foods?”
C. “Have you visited a foreign country recently?”
D. “Do you have a history of rheumatic fever?”
D. “Do you have a history of rheumatic fever?” Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client’s health history is a priority.
A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple’s ability to conceive a child?
A. Exercise regimen of both partners includes running 4 miles each morning
B. history of having sexual intercourse 2-3x/wk.
C. The woman’s menstrual period occurs every 35 days
D. They use lubricants with each sexual encounter to decrease friction
After each feeding, a 3-day old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow’s milk formula. The pediatric healthcare provider changes the neonate’s formula to Similac Soy Isomil Formula, a soy protein isolate based on infant formula. What information should the nurse provide to the mother about the newly prescribed formula?
A. The new formula is a coconut milk formula used with babies with impaired fat absorption
B. Enfamil Formula is a demineralized whey formula that is needed with diarrhea
C. the new formula is a casein protein source that is low in pheynylalanine.
D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose.
D. Similac Soy Isomil Formula is a soy-based formula that contains sucrose. The nurse should explain that the newborn’s feeding intolerance may be related to the lactose found in cow’s milk formula and is being replaced with the soy-based formula that contains sucrose which is well-tolerated in infants with milk allergies and lactose intolerances
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? Select all that apply
A. admission weight of 4 pounds, 15 ounces (2244 grams)
B. head to heel length of 17 inches (42.5 cm)
C. Frontal occipital circumference of 12.5 in (31.25 cm)
D. Skin smooth with visible veins and abundant vernix
E. Anterior plantar crease and smooth heel surfaces
F. Full flexion of all extremities in resting supine position
A. admission weight of 4 pounds, 15 ounces (2244 grams)
B. head to heel length of 17 inches (42.5 cm)
C. Frontal occipital circumference of 12.5 in (31.25 cm). The normal full-term appropriate for gestational age (AGA) newborn should fall between the measurement ranges of weight 6-9 pounds, length 19-21 inches, FOC 13-14 inches. This neonate’s parameters plot below the 10% percentile, which indicate that the infant is SGA.
The nurse is assessing a client who is having a non-stress test (NST) at 41 weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occuring. What action should the nurse take?
A. check the client for urinary bladder distension
B. notify the healthcare provider of the nonreactive results
C. have the mother stimulate the fetus to move
D. ask the client if she has felt any fetal movement
D. ask the client if she has felt any fetal movement. An NST is used to determine fetal well-being and is often implemented when postmaturity is suspected. A ‘reactive’ NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus’ own movement, and is “nonreacctive” if no FHR acceleration occurs in response to fetal movement. The client should empty her bladder before starting the test, but bladder distention does not impede fetal movement. The client should be quizzed about fetal movement before determining that the NST is nonreactive. If no movement has occurred in the last 20-30 minutes, it is likely that the fetus is sleeping. Providing the mother with orange juice often wakes the infant, and then the NST should be conducted again.
A. have the client empty her bladder
A client who is in the second trimester tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?
A. “Herbs are a cornerstone of good health to include in your treatment.”
B. “Touch is also therapeutic in relieving discomfort and anxiety.”
C. “Your healthcare provider should direct treatment options for herbal therapy.”
D. “It is important that you want to take part in your care.”
D. “It is important that you want to take part in your care.”
The nurse is planning preconception care for a new female client. Which information should the nurse provide to the client?
A. discuss various contraceptive methods to use until pregnancy is desired
B. provide written or verbal information about prenatal care
C. ask the client about risk factors associated with complications of pregnancy
D. encourage healthy lifestyles for families desiring pregancy
D. encourage healthy lifestyles for families desiring pregancy
A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider?
A. cervical dilation of 5 cm with 90% effacement
B. WBC of 12,000/mm3
C. hemoglobin of 12 mg/dl and hematocrit of 38%.
D. a platelet count of 67,000/mm3
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?
A. apply cold compresses to both breasts for comfort.
B. instruct the client to run warm water on her breasts
C. wear a loose-fitting bra to prevent nipple irritation
D. express small amounts of milk to relieve pressure
A. apply cold compresses to both breasts for comfort.
A 30-year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, “My son is so jealous of my daughter. I don’t know who I’ll ever manage both children when I get home.” How should the nurse respond?
A. “Tell the older child that he is a big boy now and should love his new sister.”
B. “Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him.”
C. “Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the newborn.”
D. “Regression in behaviors in the older child is a typical reaction so he needs attention at this time.”
D. “Regression in behaviors in the older child is a typical reaction so he needs attention at this time.” Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep habits, as a method of seeking attention so the parents should distribute their attention between the children and include the preschooler during infant care.
A 24-hour old newborn has a pink papular rash with vesicles superimposed on the thorax, back and abdomen. What action should the nurse implement?
A. notify the healthcare provider
B. move the newborn to an isolation nursery
C. document the finding in the infant’s record
D. obtain a culture of the vesicles
The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching?
A. cuddles the baby close to her
B. rocks and soothes the infant in her arms
C. places the infant prone in the bassinet
D. wraps the baby in a warm blanket after bathing
A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to the infant. The nurse’s response should be based on what information?
A. males inherit the disorder with a greater frequency than females
B. each pregnancy carries a 50% chance of inheriting the disorder
C. the disorder occurs in 25% of pregnancies
D. all children will be carriers of the disorder
B. each pregnancy carries a 50% chance of inheriting the disorder
B. screen for neural tube defects
The nurse identifies crepitus when examining the chest of the newborn who was delivered vaginally. Which further assessment should the nurse perform?
A. elicit a positive scarf sign on the affected side
B. observe for an asymmetrical Moro (startle) reflex
C. Watch for swelling of fingers on the affected side
D. Note paralysis of affected extremity and muscles
B. observe for an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if the infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
A 23 year old client who is receiving Medicaid is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client?
A. refer the client to a social worker to arrange for home care
B. recommend prenatal care from an obstetrician, not a nurse midwife
C. teach the client why keeping prenatal care appointments is important
D. Advise the client that neonatal intensive care may be needed
C. teach the client why keeping prenatal care appointments is important
A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?
A. “Your current dose of insulin should be maintained throughout your pregnancy.”
B. “Maintain blood sugar levels in a constant range within normal limits during pregnancy.”
C. “The course and outcome of your pregnancy is not an achievable goal with diabetes.”
D. “Expect an increase in insulin dosages by 5 units/wk during the first trimester.”
B. “Maintain blood sugar levels in a constant range within normal limits during pregnancy.”
A multigravida client at 41 weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?
A. biophysical profile (BPP)
B. ultrasound for fetal anomalies
C. maternal serum alpha-fetoprotein (AF) screening
D. percutaneous umbilical blood sampling (PUBS)
A. biophysical profile (BPP). This test provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client’s gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to the aging placenta.
A multigravida client arrives at the labor and delivery unit and tells the nurse that her “bag of water” has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140-150 bpm. What action should the nurse implement next?
A. complete a sterile vaginal exam
B. take maternal temperature every 2 hours
C. prepare for an immediate cesarean birth
D. obtain sterile suction equipment
While breastfeeding, a new mother strokes the top of her baby’s head and asks the nurse about the baby’s swollen scalp. The nurse responds that the swelling is caput succadeaneum. Which additional information should the nurse provide this new mother?
A. the infant should be positioned to reduce the swelling
B. the swelling is a subperiosteal collection of blood
C. the pediatrician will aspirate the blood if it gets larger
D. the scalp edema will subside in a few days after birth.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply)
A. dark, red vaginal bleeding
B. lower back pain
C. premature rupture of the membranes
D. increased uterine irritability
E. bilateral pitting edema
F. a rigid abdomen
A. dark, red vaginal bleeding
D. increased uterine irritability
A 40 week gestation primigravada client is being induced with an oxytocin (pitocin) secondary infusion and complains pain in her lower back. Which intervention should the nurse implement?
A. discontinue the oxytocin (Pitocin) infusion
B. place the client in a semi-Fowler’s position
C. inform the healthcare provider
D. apply firm pressure on the sacral area.
D. apply firm pressure on the sacral area
A 42 week gestational client is receiving an intraenous infusion of oxytocin (pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?
A. transition labor with contractions every 2 minutes, lasting 90 seconds each.
B. early labor with contractions every 5 minutes, lasting 40 seconds each
C. Active labor with contractions every 31 minutes, lasting 60 seconds each
D. Active labor with contractions every 2-3 minutes, lasting 70-80 seconds each
What action should the nurse implement to decrease the client’s risk for hemorrhage after a cesarean section?
A. monitor urinary output via an indwelling catheter
B. assess the abdominal dressings for drainage
C. give the Ringer’s lactated infusion at 125 ml/hr.
D. check the firmness of the uterus every 15 minutes
The nurse is assessing a 3 day old infant with a cephaloheatoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?
A. Yellowish tinge to the skin
B. Babinski reflex present bilaterally
C. pink papular rash on the face
D. Moro reflex noted after a loud noise
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6 inch diameter pool of blood. Which action should the nurse implement next?
A. cleanse the perineum
B. obtain a blood pressure
C. palpate the firmness of the fundus
D. inspect the perineum for lacerations.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in the client’s record?
A. 31203
B. 41203
C. 21212
D. 31103
C. a sterile glove
D. an amnihook
F. lubricant
At 14 weeks gestation, a client arrives at the emergency center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 bpm, and a blood pressure of 86/48. Which action should the nurse implement next?
A. check the hematocrit results
B. administer pain medication
C. increase the rate of IV fluids
D. monitor client for contractions
C. increase the rate of IV fluids. The client is demonstrating symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at approximately 14 weeks gestation when embryonic growth expands the fallopian tube causing its rupture and can result in hemorrhage and hypovolemic shock. Increasing the IV infusion rate provides intravascular fluid to maintain blood pressure.
C. a sterile glove
D. an amniotic hook
F. a Doppler
A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg SQ. Which assessment is the highest priority for the nurse to monitor during the adminstration of this drug?
A. maternal blood pressure and respirations
B. maternal and fetal heart rates
C. hourly urinary output
D. deep tendon reflexes
B. maternal and fetal heart rates
A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
A. 3+ deep tendon reflexes and hyperclonus
B. periorbital edema, flashing lights, and aura
C. epigastric pain in the third trimester
D. recent decreased urinary output