1. The nurse is planning care for a newborn client at term gestation who is large for gestational age.

PREBOARD 13

1.) The nurse is planning care for a newborn client at term gestation who is large for gestational age.Which of the following are appropriate interventions to include in the plan of care? Select all that apply.

• Assess newborn for birth-related injuries
• Discuss the need for feeding supplementation if symptoms of hypoglycaemia occur
• Encourage the mother to breastfeed the newborn every 2-3 hours
• Notify the health care provider if capillary blood glucose is <45 mg/dL (2.5 mmol/L)
• Perform capillary blood glucose checks prior to feedings

2.) The graduate nurse (GN) is caring for a laboring client with epidural anesthesia. After the client pushes for 3 hours during the second stage of labor, the health care provider (HCP) decides to use forceps to assist the client to deliver secondary to maternal exhaustion. Which action by the GN requires the nurse preceptor to intervene?

• Begins to apply fundal pressure when the HCP applies traction to forceps
• Drains the client’s bladder using a catheter before the placement of forceps
• Notes the exact time the forceps are applied on a card for documentation in the birth record
• Palpates for contractions and notifies the HCP when they are present

3.) The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply.

• Avoid intake of dairy products
• Drink large amounts of fluid with meals
• Eat several small meals each day
• Eliminate fried, fatty foods
• Lie down on the left side after meals

4.) The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply.

• “Do you feel like the contractions are getting stronger?”
• “Does anything you do make the pain better?”
• “Have you lost your mucous plug?”
• “How frequent are the contractions?”
• “Where do you feel the contraction pain most?”

5.) A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.

• Desire for adoption planning services
• Emotional response to the pregnancy
• Family/social support systems
• Nutritional habits and substance abuse
• Plan for finishing high school

6.) The nurse is planning care for a newborn client at term gestation who is large for gestational age.Which of the following are appropriate interventions to include in the plan of care? Select all that apply.

• Assess newborn for birth-related injuries
• Discuss the need for feeding supplementation if symptoms of hypoglycemia occur
• Encourage the mother to breastfeed the newborn every 2-3 hours
• Notify the health care provider if capillary blood glucose is <45 mg/dL (2.5 mmol/L)
• Perform capillary blood glucose checks prior to feedings

7.) A client indicates the desire to become pregnant. Which of the following are important preconception education topics for the nurse to provide? Select all that apply.

1.Aim for BMI of 18.5-24.9 kg/m 2

• Avoid alcohol consumption and tobacco products
• Ensure daily intake of 400 mcg of folic acid
• Obtain testing for rubella immunity
• Schedule dental wellness appointment

8.) The charge nurse is observing fetal heart rate (FHR) tracings of 4 clients who have just been admitted to labor and delivery triage. Which FHR pattern would be most concerning to the nurse?

9.) The nurse is reinforcing education to a group of clients that are pregnant or planning pregnancy.Which of the following client statements about alcohol use in pregnancy should concern the nurse?Select all that apply.

• “As long as I don’t binge drink, an occasional glass of wine is fine.”
• “I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now.”
• “If I drink alcohol, my baby may have withdrawal after birth but no permanent damage.”
• “It is important to stop drinking while I am trying to conceive.”
• “Third-trimester alcohol use is less harmful because the baby is fully developed.”

10.) A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate?

• Discontinue the oxytocin infusion prior to giving the medication
• Give the medication slowly during the peak of the next contraction
• Hold until contractions are occurring at least every 4 minutes for an hour
• Withdraw 5 mL of lactated Ringer from the IV tubing to dilute the medication

11.) The nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply.

• Burp during and after feeds
• Engage baby in active play after the feeding
• Feed baby in side-lying position
• Hold baby upright 20-30 minutes after each feeding
• Offer smaller but more frequent feeds
• Place baby on tummy after feeding.

12.) The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply.

• One artery and one vein in the umbilical cord
• Plantar creases up the entire sole
• Skin on the nose blanches to a yellowish hue
• Toes fan outward when the lateral sole surface is stroked
• White pearl-like cysts on gum margins

13.) A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client’s plan of care? Select all that apply.

• Assess deep tendon reflexes hourly
• Ensure availability of calcium gluconate
• Ensure bright lighting to prevent falls
• Have supplemental oxygen at bedside
• Limit visitors to minimize stimulation

14.) A client at 35 weeks gestation is admitted to the labor and delivery unit for severe pre-eclampsia.She is started on IV magnesium sulfate for seizure prophylaxis. Which of the following signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply.

• 0/4 patellar reflex
• Blood pressure of 156/84 mm Hg
• Client voiding 600 mL in 8 hours
• Respirations of 10/min
• Serum magnesium level off 8.0 mEq/L (4 mmol/L)

15.) A nurse is caring for a postpartum client who is breastfeeding and has been diagnosed with mastitis of the right breast. Which of the following instructions should the nurse include in client teaching? Select all that apply.

• Apply warm compresses to breast
• Discontinue breastfeeding until symptoms resolve
• Increase oral fluid intake
• Take ibuprofen as needed for pain
• Wear a tight-fitting bra as much as possible

16.) A nurse on the antepartum unit is caring for a pregnant client at 30 weeks gestation who was admitted with reports of vaginal bleeding. A diagnosis of placenta previa was confirmed by ultrasound.What should the nurse tell the client to anticipate? Select all that apply.

• Additional ultrasound around 36 weeks gestation
• Clearance for sexual activity if bleeding stops
• Discharge home if bleeding stops and fetal status is reassuring
• Scheduled caesarean birth before onset of labor
• Weekly vaginal examinations to assess for cervical change

17.) A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client received no prenatal care and reports being “about 7-8 months.” Which actions should the nurse anticipate? Select all that apply.

• Blood draw for type and screen
• Electronic fetal monitoring
• Initiation of 2 large-bore IV catheters
• Pad counts to assess bleeding
• Vaginal examination for cervical dilation

18.) The home health nurse assesses a child and suspects that the child is being abused. Wich of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply.

• “How would you describe your child’s usual behaviour at home?”
• “These bruises seem excessive and suspicious. How did they happen?”
• “What forms of discipline do you use with your child?”
• “When you are stressed, what coping mechanisms do you see?”
• “Who watches your child when you are at work?”

19.) An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?

• “I will refer you to the dietitian.”
• “It should take about 6-8 weeks before you see improvement in your symptoms.”
• “Tell me what you had to eat yesterday.”
• “You must not be following your diet.”

20.) The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris. Place the remaining steps in the correct order. All options must be used.

• Measure, mark, and lubricate tube
• Instruct client to extend neck back slightly
• Gently insert tube just past nasopharynx
• Ask client to flex head forward and swallow
• Advance tube to the marked point
• Verify tube placement and anchor

21.) The emergency department nurse cares for a client for a client with multiple bruises, a possible arm fracture, and a facial laceration. The client’s spouse is at the bedside and appears angry. Which action is the priority at this time?

• Call social services to assist the client in community resources for domestic violence victims
• Clean the facial laceration and prepare to assist the health care provider with suture placement
• Have the spouse leave the room so that the client can be spoken with and examined in private
• Place the arm in a shoulder sling for immobilization and prepare for an immediate x-ray

22.) The clinic nurse reinforces education about intimate partner violence for a group of graduate nurses.Which of the following are appropriate for the nurse to include? Select all that apply.

• “Intimate partner violence is most common in low-income families.”
• “Intimate partner violence is rare in same-sex patnerships.”
• “The abusive partner often demonstrates jealously and possessiveness.”
• “Victims may not leave due to financial concerns or fear of harm by the abuser.”
• “Violence against a female often intensifies during pregnancy.”

23.) The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room?

• 4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and inner

elbows

• 7-yr-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular rash
• 12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose
• 14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-

resistant staphylococcus aureus