The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?
A. Strict bed rest is required after the procedure.
B. Hospitalization is necessary for 24 hours after the procedure.
C. An informed consent needs to be signed before the procedure.
D. A fever is expected after the procedure because of the trauma to the abdomen.
C
The nurse has performed a nonstress test on pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding?
A. Normal
B. Abnormal
C. The need for further evaluation
D. That findings were difficult to interpret
A
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
A. Variability
B.Accelerations
C. Early decelerations
D. Variable decelerations
D
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client’s abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?
A. Identify the types of accelerations.
B. Assess the baseline fetal heart rate.
C. Determine the intensity of the contractions.
D .Determine the frequency of the contractions.
B
The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client’s primary physiological need at this time?
A. Ambulation
B. Rest between contractions
C. Change positions frequently
D. Consume oral food and fluids
B
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?
A.Length of 19 inches
B. Abnormal palmar creases
C. Birth weight of 6 lb, 14 oz 4.
D. Head circumference appropriate for gestational age
B
The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?
A. Protects the newborn’s eyes from possible infections acquired while hospitalized.
B. Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
C. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.
D. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.
D
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply
A. Avoid stimulation.
B. Decrease fluid intake.
C. Expose all of the newborn’s skin.
D. Monitor skin temperature closely.
E. Reposition the newborn every 2 hours.
F. Cover the newborn’s eyes with eye shields or patches.
D, E, F
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn?
A. Developmental delays because of excessive size
B. Maintaining safety because of low blood glucose levels
C. Choking because of impaired suck and swallow reflexes
D. Elevated body temperature because of excess fat and glycogen
B
The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide?
A. “Your newborn needs vitamin K to develop immunity.”
B. “The vitamin K will protect your newborn from being jaundiced.”
C. “Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel. “
D. “Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding.”
D
The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion?
A. Fatigue
B. Drowsiness
C. Uterine hyperstimulation
D. Early decelerations of the fetal heart rate
C
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?
A. The diet should include additional fluids.
B. Prenatal vitamins should be discontinued.
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary while breast-feeding.
A
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? Select all that apply.
A. “I should wear a bra that provides support.”
B. “Drinking alcohol can affect my milk supply.”
C. “The use of caffeine can decrease my milk supply.”
D. “I will start my estrogen birth control pills again as soon as I get home.”
E. “I know if my breasts get engorged I will limit my breast-feeding and supplement the baby.”
F. “I plan on having bottled water available in the refrigerator so I can get additional fluids easily.”
A, B, C, F
A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate?
A. Elevate the client’s legs.
B. Massage the fundus until it is firm.
C. Ask the client to turn on her left side.
D. Push on the uterus to assist in expressing clots.
B
The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.
A. Wear a supportive bra.
B. Rest during the acute phase.
C. Maintain a fluid intake of at least 3000 mL.
D. Continue to breast-feed if the breasts are not too sore.
E. Take the prescribed antibiotics until the soreness subsides.
F. Avoid decompression of the breasts by breast-feeding or breast pump.
A, B, C, D
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?
A. “I should breast-feed every 2 to 3 hours.”
B. “I should change the breast pads frequently.”
C. “I should wash my hands well before breast-feeding.”
D. “I should wash my nipples daily with soap and water.”
D
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action?
A. Record the findings.
B. Massage the fundus.
C. Notify the health care provider (HCP).
D. Place the client in Trendelenburg’s position.
C
The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?
A. Warming the crib pad
B. Closing the doors to the room
C. Drying the infant with a warm blanket
D. Turning on the overhead radiant warmer
C
The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse’s highest priority?
A. Turn on the apnea and cardiorespiratory monitors.
B. Connect the resuscitation bag to the oxygen outlet.
C. Set up the intravenous line with 5% dextrose in water.
D. Set the radiant warmer control temperature at 36.50 C (97.6° F).
B
The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome?
A. Tachypnea and retractions
B. Acrocyanosis and grunting
C. Hypotension and bradycardia
D. Presence of a barrel chest and acrocyanosis
A
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother?
A. Feed the newborn less frequently.
B. Continue to breast-feed every 2 to 4 hours.
C. Switch to bottle-feeding the infant for 2 weeks.
D. Stop breast-feeding and switch to bottle-feeding Permanently.
B
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?
A. “I should stay on the diabetic diet.”
B. “I should perform glucose monitoring at home.”
C. “I should avoid exercise because of the negative effects on insulin production.”
D. “I should be aware of any infections and report signs of infection immediately to my health care provider.”
C
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?
A. “I will watch for the evidence of the passage of tissue.”
B. “I will maintain strict bed rest throughout the remainder of the pregnancy.”
C. “I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad.”
D. “I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding.”
B
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
A. The contractions are regular.
B. The membranes have ruptured.
C. The cervix is dilated completely.
D. The client begins to expel clear vaginal fluid.
C
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?
A. Administer oxygen via face mask.
B. Place the mother in a supine position.
C. Increase the rate of the oxytocin (Pitocin) intravenous infusion.
D. Document the findings and continue to monitor the fetal patterns.
A
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?
A. Hemoglobin of 11 g/dL
B. Fetal heart rate of 180 beats/minute
C. Maternal pulse rate of 85 beats/minute
D. White blood cell count of 12,000 cells/mm3
B
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?
A. Notify the health care provider (HCP).
B. Continue monitoring the fetal heart rate.
C. Encourage the client to continue pushing with each contraction.
D. Instruct the client’s coach to continue to encourage breathing techniques.
A
The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?
A. Notify the health care provider of the findings.
B. Reposition the mother and check the monitor for changes in the fetal tracing.
C. Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen.
D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
D
Which assessment finding following an amniotomy should be conducted first?
A. Cervical dilation
B. Bladder distention
C. Fetal heart rate pattern
D. Maternal blood pressure
C
The nurse is assisting a client undergoing induction of labor at 41 weeks’ gestation. The client’s contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?
A. Notify the health care provider.
B. Discontinue the infusion of oxytocin (Pitocin).
C. Place oxygen on at 8 to 10 L/minute via face mask.
D. Contact the client’s primary support person(s) if not currently present.
B
The nurse is reviewing the health care provider’s (HCP’s) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?
A. Monitor fetal heart rate continuously.
B. Monitor maternal vital signs frequently.
C. Perform a vaginal examination every shift.
D. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.
C
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?
A. Slow the intravenous flow rate.
B. Place the client in a high Fowler’s position.
C. Continue the oxytocin (Pitocin) drip if infusing.
D. Administer oxygen, 8 to 10 L/minute, via face mask.
D
The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?
A. Gently push the cord into the vagina.
B. Place the client in Trendelenburg’s position.
C. Find the closest telephone and page the health care provider stat.
D. Call the delivery room to notify the staff that the client will be transported immediately.
B
During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat?
1
Liver and raisins
Cheese and broccoli
3
Eggs and lean meats
4
Whole-wheat breads and cereals
cheese and broccoli
need calcium
A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?
1Oxygen
2Naloxone
3Calcium gluconate
4Suction equipment
calcium gluconate
The antagonist of magnesium sulfate is calcium gluconate. Oxygen is ineffective if the action of magnesium is not reversed. Naloxone is unnecessary; it is an opioid antagonist. Suction equipment may be necessary if the client has excessive secretions after a seizure. The priority intervention is trying to prevent a seizure.
A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client?
1increased blood pressure and pulse
2Reduction of pain in the perineal area
3Gradual cervical dilation as labor progresses
4Decreased frequency and duration of contractions
decreased frequency and duration of contractions
Terbutaline sulfate (Brethine) is a β-mimetic that acts on the smooth muscles of the uterus to reduce contractility, which in turn inhibits dilation and the frequency and duration of contractions. Although terbutaline may increase blood pressure and pulse, this is a side, not a therapeutic, effect requiring frequent assessments. Terbutaline is not an analgesic. It should stop cervical dilation rather than increase it.
greenish amniotic fluid indicates
meconium in amniotic fluid and dr should be notified immediately
pt on magnesium sulfide, what base line assessment is needed
repsiration rate
LOC is also affected but do not need a baseline
hydatidiform mole
causes extra large utereus
lepolds maneuver on patient with placental previa expects
high floating, presenting part
A client’s membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. What does the nurse suspect as the cause of this change?
1Fetal acidosis
2Prolapsed cord
3Head compression
4uteroplacental insufficiency
prolapsed cord
This variable pattern with bradycardia is an ominous sign; it is indicative of cord compression, which can result in fetal hypoxia. Immediate intervention is required. Fetal acidosis occurs with uteroplacental insufficiency, not in response to a prolapsed cord. Early decelerations are associated with head compression and are benign. Late decelerations and tachycardia are associated with uteroplacental insufficiency, not a prolapsed cord.
heart burn while pregnant
don’t take antacids with sodium
A 36-year-old woman comes to the emergency department complaining of severe abdominal cramping and heavy bleeding. She informs the nurse that she is 10 weeks pregnant. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of miscarriage is the client experiencing?
1Missed
2Complete
3Inevitable
4Threatened
inevitable
Miscarriage is inevitable because the cervical os has opened, heavy bleeding is occurring, and tissue is present with the bleeding. In a missed miscarriage, the fetus has died but the products of conception are retained in utero for as long as several weeks. There may be no bleeding or cramping, and the os is closed. In a complete miscarriage all fetal tissue has already passed and the cervix is closed; there may be slight bleeding. Symptoms of a threatened miscarriage include spotting and a closed cervical os. There may be mild cramping.
blood in urine in catheter back during c-section indicates
incisional nick in the bladder
risk for hypotonic uterine dystocia
twin gestation
placental previa
when the placenta covers the opening of the cervix
most likely to have it is a 30y/0m g6p5
signs of a ruptured tubal pregnancy occur when
6 weeks into pregnancy
this is when the fallopian tube is no longer able to get any larger
megaloblastic anemia in pregnancy
can cause neural tube defects
mother needs to be started on folic acid supplements asap
vaginal hematoma
pain is severe and vagina feels full and heavy
classification of magnesium sulfate
CNS depressant
pt. receiving lovenox for DVT, what sign is most concerning
dyspnea
when a patient is on magnesium sulfate
keep room dark and quiet
Taking-in Phase —
For the first day or two after the birth, new mothers need extra food and rest. Cesarean mothers need even more rest. All new mothers also need “mothering” themselves so they can successfully mother their new babies. New fathers also may have difficulty adjusting to parenting. Partners can make a special effort to support each other during this big change in their lives.
Taking-hold Phase —
During this phase, parents focus on learning to care for their new baby. Temporary mood swings and feelings of vulnerability on the part of the new mother are not uncommon. Each partner may feel neglected as they become more involved with the baby, overlooking their partner’s needs or feelings.
Letting-go Phase —
The couple will continue their relationship that they had before the birth of the baby. The older brothers and sisters get to know the baby at this time.
magnesium sulfate and the importance of deep tendon reflexes
indicates respiratory depression
nursinging intervention for pt. with placental previa
document amount of bleeding
after internal fetal heart monitor placement dr listens to fetal heart rate for 1 full minute to monitor
uterine cord prolapse
risk factor for abruptio placentae
hypertension
positive Contraction stress test indicates
Late decelerations of the fetal heart rate are occurring with each contraction.
also uteroplacental insufficiency
A nurse administers two serial intramuscular injections of betamethasone (Celestone) to a woman at 32 weeks’ gestation who has been admitted in preterm labor. The nurse knows that this medication is given to:
stimulate surfactant production.
Corticosteroids stimulate surfactant production; they also have been shown to reduce the incidence of intraventricular hemorrhage. Betamethasone (Celestone) does not affect the labor process, increase placental perfusion, or affect the intensity of contractions.
low lying placenta in third trimester puts mom at risk for
painless vaginal bleeding
pt. with pre-eclampsia is admitted, after vitals are taken what is next priority
checking pt. reflexes
chorionic villi sampling when can it be done
10 weeks and no later than 12 weeks
magnesium sulfate: how to know when you have reached therapeutic level
deep tendon reflexes +2
what to assess before administration of magnesium sulfate
patellar reflexes and urinary output
threatened abortion
vaginal spotting, abdominal cramping, closed cervix
vertex postion
proper for delivery
risk when undergoing IVF
tubal pregnancy
mom with mitral valve stenosis, ,what symptom indicates cardiac difficulties
syncope for exertion
what contraindicates pitocin
herpes infection
patient with eclampsia, when does risk for seizure decrease
48 hours postpartum
folic acid in patient with sickle cell is important for
compensating for a rapid turnover of red blood cells
what is a danger sign for a mom with history of preterm mulit gestational neonatal deaths
pelvic pressure
type 1 diabetes in pregnancy puts mom at risk for
hypertensive states
what assessments are priority for pt with diagnosed abruptio placentae
fundal height, vital sighs, skin color, urine output, FHR
for patient with abuse what is priority action of the nurse
develop a safety plan
sign of preclampsia other than high blood pressure
weight gain of 6 pounds in 1 month
priority nursing intervention for pt admitted with abdominal pain and vaginal bleeding
administer oxygen
normal l/s ratio
2.0-2.5; shows fetal lung maturity
creatinine
should be between 0.4-0.9. if higher indicates kidney problems
reason for increased pain in abruptio placentae
concealed hemorrhage
multiple UTI’s can cause what
preterm birth
what kind of epidural is used for a pt with class 1 heart disease
epidural regional
increase alpha fetoprotein indicates
spin bifid a or other neural turn defects
new born baby eyes cross eyed
normal for first 6 months as they are trying to foucs
a preterm infant and maintaing body heat
they do not have enough brown fat available to provide heat
the key factors to a baby survival rate in the neonatal period
gestational age and birth weight
erbs palsy in newborn
upper and lower nerves are stretched
caused by injury to brachial plexus
signs of hypoglycemia in newborn
high-pitched cry, jitteriness, and irregular respirations
silverson anderson score means
indications if respiratory distress
0=no respiratory distress
less than or equal to 7 means impending respiratory failure
red tinged mucus in the diaper of a female new born
is normal reaction to mothers hormones
necrotizing enterocolitis (NEC): what will nurse expect to find as a complication
Increased amount of residual gastric volume from earlier feedings
when newborn has a meningocele priority nursing intervention is
covering sac with sterile moist gauze
giving o2 to a infant can cause what
retinopathy of prematurity
PKU test will not be done until
the baby has enough milk for the test to be accurate
circumoral pallor can indicate
a cardiac problem
when newborn is small for gestational age priority nursing intervention is
to perform glucose test reading
when newborns head circumference is 4cm smaller than chest circumference
the infants head size is smaller than average
when newborn has necrotizing enterocolitis (NEC) it is important to
measure the abdominal girth frequently
exstrophy
effects the bladder and can cause separation of pubic bones
when a newborn is receiving oxygen via hood the nurse is responsible to
keep a hat on the infants head
when pregnant with twins mom is at higher risk for hemorrhage due to
uterine atony
medication to strop pre-term labor
a beta-adrenergic (has tocolytic agents)
pt. arrives at high risk unit for delivery with abdominal pain and vaginal bleeding what does nurse do
adminster oxygen
when fetus makes a rapid decent the nurse worries about
fetal head trauma
primigravida in labor, priority nursing assessment is to
monitor FHR
positive CST result means
the function of the placenta has diminished
sitz baths
promote vasodilation
most spontaneous abortions occur due to
embryonic defects
what to avoid for a pt who is breastfeeding with PKU
amino acids
safest position for mom with prolapsed cord
trandlenburg
hypertension in pregnancy puts mom at risk for
abruptio placentae
premature rupture of membranes can lead to
cord prolapse
corticosteriods are given to moms 24-34 weeks for
lung development
2022 Hesi Maternity OB Exam Version 2 Test Questions & Answers (A+ grade) 1 The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse documents in the medical record? A Caput succedaneum B Hydrocephalus C Cephalhematoma D Microcephaly 2 A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse assessment reveals approximately 30ML of bright red vaginal bleeding.
Fetal rate of 130 – 140 beats per minute, no contractions and no complaints of pain what is the most likely cause of these client’s bleeding. A Abruptio Placenta B Placenta Previa C Normal bloody show indicting induction of labor D A ruptured blood vessel in the vaginal vault. 3 A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. which assessment warrants immediate intervention by the nurse. A Fetal Heart rate 60 beats per minute B Ruptured amniotic membrane C onset of uterine contractions
D leaking amniotic fluid. 4 A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. the nurse should recognize the clients is prohibiting symptoms of which condition? A Genital Warts B Syphilis C Herpes Simplex Virus D German Measles 5 The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor which maternity description is most important in preventing this fetus from developing respiratory distress syndrome. A Ampicillin 1 gram IV push q8h B Betamethasone 12 mg deep IM
C Terbutaline 0.25 mg subcutaneously q 15 minutes X 3 D Butorphanol tartrate 1mg IV push q2h PRN. 6 A 16 year old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She’s not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan? A Allow liberal family visitation B Keep an airway at the bedside C Assess temperature every hour D Monitor blood pressure, pulse, and respiration every 4 hours. 7 At 12 hours after the birth of a healthy infant the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. which action should nurse take?
A Check the suprapubic area for distention. B Inform the client to take a warm sitz bath C Inspect clients perineal and rectal areas D Apply a fresh pad and check in 1 hour. 8 If primigravida at 36 weeks gestation who is RH negative experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider? A Fetal heart rate at 162 beats /minute B Mild contractions every 10 minutes. C Trace of protein in the urine
D. Positive fetal hemoglobin testing 9 In The Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old infant as a gestational age of 42 weeks. Based on this finding which intervention is most important for the nurse to implement. A Provide blow by oxygen B Provide a capillary blood glucose C draw arterial blood gases D Apply a pulse oximeter to the foot. 10 A new mother who is a lacto-ovo vegetarian plans to breast feed her infant. which information should the nurse provide prior to discharge.
A Continue prenatal vitamins with B12 While breastfeeding B Avoid using Lanolin-based nipple cream or ointment. C Offer iron fortified supplemental formula daily. D Weigh the baby weekly to evaluate the newborns growth. 11 What should be the primary focus of nursing care in the transitional phase of Labor for a client who anticipates an unmedicated delivery. A Assessing the strength of uterine contractions B Re-evaluate the need for medication C Remind her to push 3 times with each contraction. D Assessing her to maintain control.
12 A care provider prescribes a maintenance dose of magnesium sulfate 2 grams per hour intravenously for clients with preeclampsia. The IV bag contains magnesium sulfate 20 grams how much in ml/Hr. should a nurse program the infusion pump enter numerical value only. if the IV bag is 1000 ml the answer is 100 ml per hour 13 *A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contraction 5 minutes apart while the client is in the bathroom changing into a hospital gown the nurse hears the noise of a baby what should the nurse take first? A Push the call light for help B Inspect the clients perineum C Notify a health care provider D Turn on the infant warmer
14 The nurse is caring for a multiparous client who is 8 centimeters dilated 100% effaced and the fetal head is at 0 station. The clients is shivering and states extreme discomfort with the urge to bear down. which intervention should the nurse implement? A Administer IV pain medication B Perform a vaginal exam C Reposition to side lying D Encourage pushing with each contraction. 15 Following a traumatic delivery an infant receives an initial Apgar score of 3. which intervention is most important for the nurse to implement. A Page the pediatrician STAT B Continue resuscitative efforts C Repeat the Apgar assessment in 5 minutes
D Inform the parents of the infant’s condition. 16 A 3-hour old male infants hands and feet as cyanotic, and has an axillary temperature of 96.5 degrees Fahrenheit 35.8 degrees centigrade a respiratory rate of 40 breaths per minute and a heart rate of 165 beats per minute what nursing action should nurse implement. A Administer oxygen by mouth at 2L/min B Gradually warm the infant under a radiant heat source. C Notify the pediatrician of the infant’s vital signs D Perform a heel-stick to maintain blood glucose level 17 A new born nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a new born admission. What action should the nurse take to ensure adequate installation of the client. A Instill a thin ribbon into each lower conjunctival sac
B Occlude the inner canthus after retracting the eyelids C Mummy wrap the infant before instilling the ointment D Stabilize the instilling hand on the neonate’s head 18 The nurse notes on the fetal monitor that a laboring client has a variable deceleration. which action should the nurse implement first. A Turn off the oxytocin infusion B Assess cervical dilation C Change the client’s position D Administer oxygen via facemask 19 The nurse places one hand above the symphysis while massaging the fundus of a multiparous client who’s uterine tone is boggy 15 minutes after delivering a 7 pounds 10 ounces 3220 grams infant which information should the nurse try to provide the client about those finding.
A The uterus should be firm to prevent an intrauterine infection B Both the lower uterine segment and the fundus must be massaged C A firm uterus prevents the endometrial lining from being sloughed D Clots may form inside a boggy uterus and needs to be expelled 20 A newborn assessment reveals spina bifida occulta. Which maternity factors should nurse identify as having the greatest impact on the development of this newborn complication. A Short interval pregnancy B Folic acid deficiency C Preeclampsia D Tobacco use
21 A primigravida client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is lactated ringer’s 1,000 ml with oxytocin 20 units. The nurse should program the machine to deliver how many ML per hour. Answer: 12 ml per hour will give 4 mu per minute. Dose/Available stock xQuantity (4mu/20,000 mu)x1000 ml=0.2 ml x 60 min = 12 ml A client who delivered a healthy newborn an hour ago asked the nurse when can she go home. Which information is most important for the nurse to provide the client. A After the baby no longer demonstrates acrocyanosis. B After the vitamin K injection is given to the baby. C When ambulating to avoid does not cause dizziness. D When there is no significant vaginal bleeding.
22 A 17 year old client gave birth 12 hours ago she states that she doesn’t know how to care for her baby. To promote parent infant attachment behaviors which intervention should the nurse implement. A Ask if she has help to care for the baby at home. B Provide a video on newborn safety and care. C Explored the basis of fears with the client. D Encourage rooming in while in the hospital. 23 A pregnant client mentions in a history that she changes cats litter box daily. Which test should the nurse anticipate the health care provider to prescribe. A Biophysical profile. B Fern test. C Amniocentesis. D Torch screening.
24 The nurse is receiving report for a laboring client who arrived in the emergency center which ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client his admitted to the labor and delivery suite? A Begin a pad count. B Prepare to start an IV. C Take the clients temperature. D Monitor amniotic fluid for meconium. 25 Four client at full term present to the labor and delivery unit at the same time. which client should a nurse access first. A Multipara with contractions occurring every three minutes. B Multiple scheduled for non stress test and biophysical profile.
C Primipara with vaginal show and leaking membranes. D Primipara with burning on urination and urinary frequency. 26 The nurse is preparing to administer phytonadione to a newborn. Which statement makes made by the parents indicates understanding why the nurse is administering this medication. A Improve insufficient dietary intake. B Stimulates the immune system C Help an immature liver. D Prevent hemorrhagic disorders. 27 The nurse is planning discharge teaching for four mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?
A A primiparous woman who has recently migrated to the US with a spouse. B A multiparous client who lives with her husband and his family members. C A multiparous female with a large family living in a community. D A primiparous adolescent living at home with their parents and significant other. 28 On the first postpartum day the nurse examines the breast of a new mother. Which condition is the nurse most likely to find. A Firm larger and very tender to touch. B Slightly firm with immediate let-down response. C Soft with no change from before delivery. D Filling and secreting colostrum.
29 A client at 31 weeks gestation with a fundal height measurement of 25 c is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide. A Assessment for congenital anomalies. B Recalculation of gestational age. C Evaluation of fetal growth. D Determination of fetal presentation. 30 A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7 pounds infant 4 hours ago by cesarean delivery. Which nursing problem has the highest priority? A Risk for injury related to uterine atony. B Ineffective breastfeeding related to fatigue. C Acute pain related to abdominal incision.
D Impaired parenting related to inexperience. 31 Examination reveals that the laboring clients cervix is dilated to 2 centimeters, 70% effaced with the presenting part at -2 station the client tells the nurse I need my epidural now, this hurts, the nurses response to the client is based on which information. A The client will need to be catheterized before the epidural can be administered. B Administering an epidural at this point would slow down labor process. C The client should be dilated to at least 8 centimeters before receiving an epidural. D The baby needs to be at a zero station before an epidural can be administered. 32 The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right she tells the nurse, “Now my daughter is not getting enough to eat” which response would be best for the nurse to make.
A Feed your baby hourly until you feel confident that your child is receiving enough milk. B Don’t worry soon your milk will come in and you will feel how full your breasts are. C Since you are so concerned you should probably supplement breastfeeding with formula. D If your baby’s urine is straw colored, she’s getting enough milk. 33 A client in the first trimester of pregnancy calls the prenatal clinic to report she’s nauseated, and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? select all that applies. A Come to the clinic today. B Drink a full glass of tea with each iron tablet. C Increase the consumption of milk while taking iron. D Changes in color and consistency of stool are normal. E Take iron supplement at bedtime.
34 A primiparous woman presents in labor with the following labs. hemoglobin 10.9 g/dl (109 g/dl) Hematocrit 29% (0.29) hepatitis surface antigen positive, Group B Streptococcus positive and rubella non-immune. which intervention should the nurse implement? A Transfuse 2 units packs red blood cells. B Give measles mumps rubella vaccine 0.5 ML. C Administer ampicillin 2 grams intravenously. D Inject hepatitis B immune globulin 0.5 milliliters. 35 A mother spontaneously delivers a newborn infant in the taxicab while on the way to the hospital the emergency room nurse reported the mother as active herpes (H5V III) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery? A Documents the temperature on the flow sheet.
B Place the newborn in the isolation area of the nursery. C Obtain blood specimen for serum glucose level. D Administer the vitamin K injection. 36 The health care provider prescribes 10 units per liters of oxytocin via IV drip to augment a client’s labor because she’s experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin. A Contraction duration of 100 seconds. B For contractions in 10 minutes. C Uterus is soft. D early deceleration of fetal heart rate. 37 A client who is 24 weeks gestation arrives to the clinic reporting swollen hands. On examination the nurse notes the clients as had a rapid weight gain over six weeks. which action should a nurse implements next?
A Review previous blood pressures in the chart. B Obtain the clients blood pressure. C Observe and time the client’s contractions. Examined the client for pedal edema. D examine the client for pedal edema 38 * the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 41 respirations per minute. He has a loud cry with stimulation, good muscle tone and his color is ———-. What Apgar score should the nurse assign? 39. A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first? A increase the intravenous fluid to 150ML/hr. B Call the health care provider. C Encourage the client to void.
D Administer ibuprofen 800 milligrams by mouth. 40 The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of eight pounds 3629 grams at 36 weeks gestation. This amniocentesis is being performed to obtain which information A Presence of a neural tube defect. B Chromosomal abnormalities. C Gender of the fetus. D Fetal lung maturity. 41 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 per minute and contraction occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time.
A Membranes are intact. B 2+ pitting edema in lower extremities. C Contractions decrease with walking. D Cervical dilation is 1 centimeter. 42 A newborn assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication? A Tobacco use. B Folic acid deficiency. C Short interval pregnancy. C Preeclampsia. 43 A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the health care provider. A A pattern of fetal late decelerations. B Fetal heart rate accelerations with fetal movement.
C Absence of uterine contractions within 20 minutes. D Spontaneous rupture of membranes. 44 A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take. A Assess bowel sounds. B Continue to monitor. C Assist with intubation. D Rub the infant’s back. 45 client tells the nurse that she thinks she’s pregnant. Which signs or symptoms provide the best indication that the client is pregnant. A Morning sickness. B Breast tenderness.
C Amenorrhea. D Hegar’s sign. 46 A newborns head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 centimeters). The nurse notes that this infant has no molding, and it was a bridge presentation delivered by cesarean section. What action should the nurse take based on this data. A No action needs to be taken, it is normal for an infant born by caesarean section to have a small head circumference. B Notify the pediatrician immediately. These signs 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. 47 A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is priority nursing action for this client? A Assess the blood pressure for hypertension. B Gently massage fundus every four hours.
C Observe for signs of uterine hemorrhage. D Encourage direct contacts with the infant. 48 A client with 26 weeks gestation was informed this morning that she has an elevated alpha fetal protein (AFP) level. After the health care provider leaves the room, the client asks what she should do next. What information should the nurse provide. A Reassured the client that the AFP results are likely to be a false reading. B Explain that his sonogram should be scheduled for definitive results. C Inform her that a repeat alpha fetoprotein AFP should be evaluated. D Discuss options for intrauterine surgical correction of congenital defects. 49 A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. which assessment finding warrants immediate intervention by the nurse? A Dizziness while standing B Sinus tachycardia
C Lower Back pain D Absent Patellar reflexes.