2023 HESI MATERNITY OB EXAM VERSION 1 LATEST ALL 55 QUESTIONS AND CORRECT ANSWERS |ALREADY GRADED A+ (SCORE 1292)

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

A 38-week primagravida who works as a secretary and sits at a computer 8 hours a 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?
C. Move about every hour

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
C. correctly place the infant on the breast

A full term infant is transferred to the nursery from L & D. Which information is most important for the nurse to receive when planning immediate care for the newborn?
B. Infant’s condition at birth and treatment received.

When assessing a client who is 12-weeks gestation, the nurse recommends the she and her husband consider attending childbirth preparation classes.
What is the best time for the couple to attend these classes?
D. At 30 weeks gestation.

The nurse should encourage the laboring client to begin pushing when
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.

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?
C. have the client breath into her cupped hands

When preparing a newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?
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.

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 the expectant father?
D. Let him know that these behaviors are part of normal maternal/fetal bonding which occurs once the mother feels fetal movement.

A new mother asks the nurse, “How do I know my daughter is getting enough breast milk? Which explanation will the nurse provide?
B. “your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times a day.

A new mother who has just had her first baby says to the nurse, “I saw the baby in the recovery room. She has a funny looking head”. Which response by the nurse is the best?
C. That is normal, the head will return to a round shape within 7-10 days.

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 the mother to bond with her newborn 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 the woman’s fallopian tubes are patent?
C. shoulder pain

Which nursing intervention is most helpful in relieving postpartum uterine contractions or “afterpains?”
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?
B. Her arms and hands receive the infant and she ten 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

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates the woman’s next fertile period will be
C. January 30-31

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?
C. place the woman in a lateral position.

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 the best for the nurse to provide this client?
A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.

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?
C. Gonorrhea

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satifactorily but appears dusky. What action should the nurse take first?
C. Check the infant’s oxygen saturation rate.

The nurse is teaching a woman how to use her basal body temp 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 temp falls and rises.

A woman who had a miscarriage 6 mos ago becomes pregnant. Which instruction is most important for the nurse to provide this client?
D. Take prescribed multivitamin and mineral supplements.

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
C. a persistent cold

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.

A client receiving epidural anesthesia begins to experience nausea and become pale and clammy. What intention should the nurse implement first?
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?
C. Encourage the mother to breast-feed frequently.

A 35-year-old primagravida client with severe preeclampia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity?
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 am IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of the drug?
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.

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 nurser anticipate?
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 int the class?
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.

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?
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 encourage 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?
B. An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor.

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?
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.

A full-term infant is transferred to the nursery from L & D. Which information is most important for the nurses to receive when planning immediate care for the newborn?
B. the infant’s condition at birth and treatment received.

A client in active labor complains of cramps in her leg. What intervention should the nurse implement?
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

A client in active labor is admitted with preeclampsia. Which is assessment finding is most significant in planning this client’s care?
A. Patellar reflex 4+

A 4-week old premature infant has been receiving epoetin alfa for the last 3 weeks. Which assessment finding indicated to the nurse that the drug is effective?
C. changes in apical heart rate from the 180s to the 140s

The healthcare provider prescribes terbulatine (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

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 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain?
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.

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 BPM. What action should the nurse perform next?
A. initiate positive pressure ventilation.

The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure?
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.

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
C. epigastric pain

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 the client?
D. Do you have a history of rheumatic fever?

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?
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?
A. admission weight of 4 lbs.
B. Head to heel length of 17 inches.
C. frontal occipital circumference of 12.5 inches.

The nurse is assessing a client who is having a NST at 41-weeks gestation. The nurse determines that the client is not having contractions, the FHR baseline is 144 bpm, and no FHR accels are occurring. What action should the nurse take?
D. Ask the client if she has felt any fetal movement.

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 antimicrobial soap.

A pregnant client tells the nurse that the first day of her LMP was 8/2/06. Based on Nagele’s rule, what is the estimated date of delivery?
B. 5/9/07

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?
A. Have the client empty her bladder.

A client who is in the 2nd trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?
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?
D. Encourage healthy lifestyles for families during pregnancy.

A primagravida 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 to the nurse to report to the healthcare provider?
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.

A 30-year old multiparous woman who has a 3-y/o and a newborn 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?
D. “regression in behaviors in the older child is a typical reaction so he needs attention at this time”.

A 24-hour old newborn has pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement?
C. Document the finding in the newborns record.

The nurse observes a new mother is rooming in and caring for her newborn infant. What observation indicates the need for further teaching?
C. places the infant prone in the bassinet.

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 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?
B. each pregnancy carries a 50% chance of inheriting the disorder.

The nurse should explain toa 30 y/o gravid client that alpha fetoprotein testing is recommended for which purpose?
B. screen for neural tube defects.

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
B. observe for an asymmetrical Moro reflex.

A primagravida at 40 weeks gestation is receiving oxytocin (Pitocin) to augment labor. What adverse effect should the nurse monitor for during infusion of Pitocin?
B. hyperstimulation

A 23 y/o client who is receiving Medicaid benefits is pregnant with her 1st child. Based on knowledge of the stats r/t infant mortality, which plan should the nurse implement w/this client?
C. teach the client why keeping prenatal care appointments is important.

A female client w/insulin dependent diabetes arrives at the clinic seeking a plan to get pregnant in approx 6 mos. 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?
B. maintain blond sugar levels in a constant range WNL during pregnancy.

A multigravida client arrives at the L & D unit and tells the nurse tht her “bag of water” has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the FHR is between 140 -150 BPM. What action should the nurse implement next?
A. complete a sterile vaginal exam.

A multigravida at 41-weeks gestation presents in the L & D after a NST indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about eh fetal status?
A. a BPP

A client is admitted w/the diagnosis of total placenta previa. Which finding is is most important for the nurse to report to the healthcare provider immediately?
C. onset of uterine contractions

A healthcare provider informs the charge nurse of L & D that a client is coming to the unit w/suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate?
A. dark red vaginal bleeding
D. increased uterine irritability.
F. a rigid abdomen.

A client with gestational hypertension is in active labor and receiving an infusion of mag sulfate. Which drug should the nurse have available for signs of potential toxicity?
B. calcium gluconate

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?
D. apply firm pressure to the sacral area.

A 42-week gestational client is receiving an IV infusion of oxytocin (Pitocin) to augment early labor. The nurse should d/c the oxytocin infusion for which pattern of contractions?
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

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

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?
C. palpate the firmness of the fundus

The nurse is calculating the EDC using Nagel’s rule for a client whose LMP started on 12/1. Which date is most accurate?
D. 9/8

A pregnant women 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. What GTPAL should the nurse document in this client’s record?
D. 3-1-1-0-3

The nurse is preparing a client w/a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client’s bedside?
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. increase rate of IV fluids

a 30 y/o G2P1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbulatine sulfate (Brethine) 0.25 mg subq. Which assessment is the highest priority for the nurse to monitor during the administration of this drug?
B. maternal and fetal HRs

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
A. 3 + DTRs and hyperclonus

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.)

reposition the client
increase IV fluid
Provide oxygen via face mask.
Call the healthcare provider.

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.

We have an expert-written solution to this problem!
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.

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.

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.

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.

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
C. Gonorrhea

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
A,C,E
A. Pain in the lower back that radiates to abdomen
C. Progressive cervical dilation and effacement
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
C. Gravida 2, para 0

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.
B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect.

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.
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.
B. Her arms and hands receive the infant and she then traces the infant’s profile with her fingertips.

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 & E (Possible signs of Preeclampsia)
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

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.”
B. “Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day.”

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.

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)
A. Cramping with bright red spotting
B. Extreme tenderness of the breast
C. Lack of tenderness of the breast
D. Increased amounts of discharge
E. Increased right-side flank pain
A, C, E
A. Cramping with bright red spotting
C. Lack of tenderness of the breast
E. Increased right-side flank pain

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.
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
C. 5

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

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.”

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client’s expected date of birth (EDB)?
A. November 22
B. November 8
C. December 22
D. October 22
A. November 22

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

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 is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information?
A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC)
C. Fetal heart rate (FHR)

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

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.
C. Move about every hour.

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.

At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention?

A. Uterine cramping

A client states, “During the three months I’ve been pregnant, it seems like I have had to go to the bathroom every five minutes.” Which explanation should the nurse provide to this client?

D. The growing uterus is putting pressure on the bladder.

The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first?

C. Assess the infant’s blood glucose level

An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing intervention?

B. Begin humidified oxygen via hood

When assessing a newborn infant’s heart rate, which technique is most important for the nurse to use?

C. Count the heart rate for at least one full minute

The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, “Wait! I don’t want my baby to have a shot.” Which response would be best for the nurse to make?

B. Explore the mother’s concerns about the infant receiving an injection of vitamin K

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

Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?

D. Encourage early initiation of breast of formula feeding

A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur?

D. The heart develops in the third to fifth weeks after conception

A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide?

B. The fetus in utero is capable of hearing and does respond to the mother’s voice

A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide?

B. The fetus can respond to sound by 24-weeks gestation

A woman whose pregnancy is confirmed asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?

C. Secretes both estrogen and progesterone

Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation?

A. Decrease in pulse rate

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

Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation?

A. PICA

During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide?

B. Make sure to include adequate folic acid in the diet

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy?

A. “Protein helps the fetus grow while I am pregnant.”

A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client?

D. Abstinence is strongly recommended throughout the pregnancy

A female client who wants to deliver at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide?

B. The pregnancy should progress normally and be considered low risk

When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth?

D. Medical backup should be available quickly in case of complications

The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address the best advantage of gravity during delivery?

B. Squatting

A client in the first stage of labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light headed, dizzy, and states that her fingers are tingling. What action should the nurse implement?

B. Help her breathe into a paper bag

A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal disturbance, what action should the nurse take?

C. Perform a nitrazine test

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mmHg at the peak. Based on this information, what action should the nurse implement?

D. Document the findings in the client record

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first?

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

During an assessment of a multiparous client who delivered an 8 lb 7 oz infant 4 hours ago, the nurse notes the client’s perineal pad is completely saturated within 15 minutes. What action should the nurse implement next?

A. Perform fundal massage

The nurse is assessing a full-term newborn’s breathing pattern. Which findings should the nurse assess further? (Select all that apply)

B. Chest breathing with nasal flaring
C. Diaphragmatic with chest retraction
F. Grunting heard with a stethoscope

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

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand?

D. Report uterine cramping or low backache

A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client?

C. Abdominal ultrasound

The nurse is planning for the care of a 30 year old primigravida with pre-gestational diabetes. What is the most important factor affecting this client’s pregnancy outcome?

C. Degree of glycemic control during pregnancy

A client with asthma who is 8 hours post delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer?

A. Oxytocin (Pitocin)

The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32 weeks gestation who has severe preeclampsia with pulmonary edema. What action should the nurse implement?

C. Monitor for premature ventricular contractions

A client at 28 weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage?

C. Changes in fetal heart rate patterns

A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client’s membranes rupture after 5 hours of active labor. Which finding would require the nurse to take action?

B. Intensity of contractions is 130 mmHg

A primigravida at 37 weeks gestation tells the nurse that her “bag of water” has broken. While inspecting the client’s perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement?

C. Place the client in the knee-chest position

The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion?

D. The fetal heart rate is 180 bpm without variability

The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage?

C. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia

What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal?

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.”

A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant’s weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action?

C. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia

An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide?

D. The pinpoint spots are benign and disappear within 48 hours

Which finding for a client in labor at 41 weeks gestation requires additional assessment by the nurse?

D. One fetal movement noted in an hour

A primigravida at 12 weeks gestation who just moved to the United States indicates she has not received any immunizations. Which Immunizations should the nurse administer at this time? (Select all that apply)

A. Tetanus
C. Diphtheria
E. Hepatitis B

A gravid client develops maternal hypotension following regional anesthesia. What interventions should the nurse implement? (Select all that apply)

A. Administer oxygen
B. Increase IV fluids
E. Place the client in a lateral position
F. Monitor fetal status

A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client?

B. Ultrasonography

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide?

C. A large body surface area favors heat loss to the environment

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?

B. Observe the mother for other attachment behaviors

The nurse notes an irregular bluish hue on the sacral area of a 1 day old Hispanic infant. How should the nurse document this finding?

B. Mongolian spots

An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement?

B. Monitor temperature

A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tahcycardia, and a cutaneous rash. What nursing intervention should be implemented first?

B. Stop the transfusion

The nurse assesses a high risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate’s feet are blanched. What nursing action should be implemented?

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

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate?

D. Oral sucrose and nonnutritive sucking

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37 weeks gestation. What nursing action should be implemented first?

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

A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time?

C. Observe interactions of family members with the newborn and each other

A client at 39 weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39 weeks, 34 weeks, and 35 weeks. Using GTPAL, what is the most accurate summary of her history?

B. 4-1-2-0-3

A client delivers her first infant and asks the nurse if her skin changes from pregnancy are permanent. Which change should the nurse tell the client will remain after pregnancy?

D. Striae gravidarum

The nurse administers meperidine (Demerol) 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. What medication should the nurse anticipate administering to the infant?

A. Naloxone (Narcan)

A client in labor receives an epidural block. What intervention should the nurse implement first?

C. Monitor blood pressure

A client is experiencing “back” labor and complains of intense pain in the lower lumbar-sacral area. What action should the nurse implement?

C. Apply counter pressure against the sacrum

A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement?

C. Ask the client to describe why she thinks she is in labor

A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give?

A. Apply ice to the breasts

Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day?

B. Exhibit interest in learning more about infant care

A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement?

B. Continue breastfeeding every 2 hours

The nurse is giving discharge instructions for a client following a suction for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide?

C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy

The nurse is assessing a 12 hour old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)?

C. Flat nasal bridge

Which client finding should the nurse document as a positive sign of pregnancy?

D. Fetal heart tones (FHT) heard with a doppler

A primigravida at 12 weeks gestation tells the nurse that she does not like dairy products. Which food should the nurse recommend to increase the client’s calcium intake?

C. Canned sardines

A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next?

A. Determine the firmness of the fundus

When assessing the integument of a 24 hour old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next?

C. Document the finding as erythema toxicum

The nurse is teaching a primigravida at 10 weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care

C. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects

The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1200 mg during pregnancy. The client responds, “I don’t like milk.” What dietary adjustments should the nurse recommend?

B. Eat more green, leafy vegetables

A client at 35 weeks gestation visits the clinic for a prenatal check up. Which complaint by the client warrants further assessment by the nurse?

A. Periodic abdominal pain

A client at 28 weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client?

D. The weight gain is acceptable for the number of weeks pregnant

A multigravida client at 35 weeks gestation is diagnosed with pregnancy induced hypertension. Which symptom should the nurse instruct the client to report immediately?

C. Blurred vision

A 36 week gestation client with pregnancy induced hypertension is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider?

D. Respiratory rate of 11 breaths/minute

Which procedure evaluates the effect of fetal movement on fetal heart activity?

D. Non-stress test (NST)

The nurse notes a pattern of the fetal of the fetal heart rate decreasing after each contraction. What action should the nurse implement?

A. Give 10 liters of oxygen via face mask

A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement?

D. Notify the healthcare provider

A newborn infant who is 24 hours old is on a 4 hour feeding schedule of formula. To meet daily caloric need, how many ounces are recommended at each feeding?

D. 3.5 ounces

A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, “I wish my baby could have lived.” Which response is best for the nurse to give?

C. “I am sorry for your loss. Do you want to talk about it?”

A client who is at 24 weeks gestation presents to the emergency department holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation?

C. Other parts of her body have injuries that are in different stages of healing

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta?

B. Hard, board like abdomen

Which action is most important for the nurse to implement for a client at 36 weeks gestation with vaginal bleeding?

C. Determine fetal heart rate and maternal vital signs

A multiparous client is bearing down with contractions and crying out, “The baby is coming!” Which immediate action should the nurse implement?

B. Visualize the perineum for bulging

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routinestanding order for methylergonovine maleate (Methergine)?

A. Pregnancy induced hypertension

While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change?

A. Fetal well being with labor progression

Which nursing intervention is the priority during the fourth stage of labor?

B. Assess for hemorrhage

The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occuring with the peak of each contraction. What action should the nurse implement?

C. Place the client in a side-lying position

What information should the nurse include about perineal self-care for a client who is 24 hours post delivery?

D. Spray with warm water from front to back using a squeeze bottle

Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)?

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

A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, “Can I still breastfeed my baby?” What is the best response for the nurse to provide?

B. Inform the client to continue breastfeeding

While inspecting a newborn’s head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document?

B. Cephalohematoma

A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first?

D. Gently rub the infant’s feet or back

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement?

C. Assess for abdominal distention

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding?

D. Caput succedaneum

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

Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma?

D. Vitamin K (AquaMEPHYTON)

A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider?

D. Bilirubin

The nurse is assessing a full-term newborn’s breathing pattern. Which findings should the nurse assess further? (select all that apply)

B. Chest breathing with nasal flaring
C. Diaphragmatic with chest retraction
F. Grunting heard with stethoscope

A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate slows at the onset of several contractions with subsequent return to baseline. What action should the nurse implement?

D. Document the finding in the client record

An infant born at 37 weeks gestation, weighing 4.1 kg is 2 hours old and appears large for gestational age, flushed, and tremulous. What procedure should the nurse follow to implement?

1. Wrap the infant’s foot with a heel warmer for 5 minutes
2. Collect a spring-loaded automatic puncture device
3. Restrain the newborn’s foot with your free hand
4. Cleanse puncture site on the lateral aspect of the heel

What position does the Pavlik harness put infants with developmental dysplasia of the hip stay in?
The Pavlik harness keeps the infant in an abducted position allowing the hips and knees flexed

When should jaundice in a newborn be concerning?
If jaundice is present less than 24 hours of delivery, it may indicate excess bilirubin

What is the action of terbutaline sulfate (Brethine)?
Stop labor contractions

Primary side effects of terbutaline sulfate (Brethine)?
Tachycardia and nervousness along with increased CO, restlessness, and headache

When does the anterior fontanel close?
12-18 months

When does the posterior fontanel close?
End of second month

Why is erythromycin indicated 2 hours post-delivery of a newborn?
Prevent opthalmia neonatorum which is an eye infection caused by gonorrhea and conjunctivitis which is an infection caused by chlamydia

Antepartum pt is chewing ice instead of the food on her breakfast tray. What should the nurse do?
Call HCP immediately. Practice of pica will displace nutrients. Evaluate the pt for anemia

28 wk gestation pt calls the antepartal clinic about bleeding a small amount of bright red blood with no uterine contractions, but is not bleeding anymore. What may this possibly be?
Placenta previa

Is bleeding a small amount of bright red blood life-threatening to the fetus?
It is not at risk for hypovolemia or life-threatening.

What may sudden onset bleeding with present uterine contractions indicate?
Abruptio placenta

When is child-birth class recommended?
30 weeks

What should a primigravida who has present leg swelling d/t sitting 8 hrs a day do to minimize the swelling?
Move around every hour

What is important to do for an amniotomy?
Monitor FHR before, during, and after procedure. The fluid should also be assessed for color, odor, and consistency.

When is an amniotomy indicated?
(artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable

How often should maternal blood pressure be done during an amniotomy?
Maternal BP should be assessed every 15 to 20 minutes during labor

Why is maternal temperature important to monitor after an amniotomy?
Maternal temperature is monitored hourly after the membranes are ruptured to detect development of amnionitis.

Is it ok for a breastfeeding mother to drink alcohol?
No, alcohol is excreted through breast milk.

Laboring client is doing accelerated blow breathing and states that she is feeling tingling in her fingers and dizziness. What should the nurse do?
Have the pt breathe into her cupped hands. She is hyperventilating and excreting too much carbon dioxide.

When does ovulation occur?
14 days before first day of menstrual period

What is the goal for labor augmentation (administration of Oxytocin/pitocin)
produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress.

Is it normal for FHR to increase during contractions and return to baseline?
Yes it is normal for FHR to increase, but this is indicative to increase the pitocin infusion to stimulate the intensity and frequency of the contractions

What should be done if fetal stress is present during labor?
-Place a wedge on the pts left side
-Administer 10L oxygen nasal cannula

What is important to tell the HCP during the third trimester of pregnancy?
Signs of preeclampsia–heartburn not relieved by antacids and chronic headaches behind the eye

Normal signs of the last trimester of pregnancy?
-Increase in fetal heart rate
-Shoes and ring are right
-Inability to sleep for more than 2 hours

Milia
White pinpoint spots found on the nose and chin that represent blockage of sebaceous glands

Meconium
First stool that is tarry black

Is pseudostrabismus normal in a newborn?
Pseudostrabismus is normal until about the 3rd or 4th month. It does not require surgery

A baby is born with an abnormal headshape. How long should it take for it to possibly return to normal?
It will take 7-10 days for the head to return to a round shape.

Cephalhematoma
Localized swelling that occurs from forcep trauma between periosteum and skull

At what time after delivery is a cephalhematoma most likely?
Within the first 24 hours of delivery

Molding
Occurs when there is too much pressure on the cranium during vaginal delivery. It is common variation and will last about 5-7 days

Can a subarachoid or subdural hematoma be observed from a physical assessment?
No, these types of hematomas will require further assessment

Signs of hypoglycemia in a newborn
-Shaking during moro reflex assessment
-Hypothermia
-Lethargy

What is a key characteristic of an infant whose mother smoked during pregnancy?
Low birth weight

Nagele’s Rule
Obtain LMP
Subtract 3 months and at 7 days

Umbilical cord care at home:care
Allow to air-dry as much as possible

Is it recommended to take a warm shower after breastfeeding?
Not recommended because warm water will stimulate the production of breast milk. It will be more painful.

What is mastitis?
Plugged milk ducts r/t breast engorgement

What should be told to the breast-feeding mother with mastitis?
It is ok to breastfeed to reduce the engorgement and reduce the inflammation

The blood pressure of a pt in labor drops from 120/80 to 90/60. What should the nurse do?

Get the pt in a lateral position by placing a pillow or wedge under one hip to deflect the uterus.
Increase rate of Iv infusion
Administer O2 via face mask

Signs of possible miscarriage
Cramping and bright red spotting
Lack of breast tenderness

Sign of ectopic pregnancy
Increased right side flank pain

TRIPLE SCREEN shows low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample. What may this mean?
Possible chromosomal defect

TRIPLE SCREEN shows high levels of MSAFP and estriol in the blood sample after 15 weeks of gestation
Possible neural tube defect, not chromosomal defect

Will there be traces of MSAFP, estriol, and hCG in the blood sample of a pt past 15 wks gestation?
Yes MSAFP, estriol, and hCG will be present

Caring for an infant post-circumcision
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.

Are early decelerations FHR an ominous sign?
Not necessarily, nurse must continue to monitor

At what age are infants of HIV-positive mothers tested for HIV?
Tested at 18 months, at this time maternal antibodies are no longer present

Early ROM has FHR several suiddenly decreases with quick return to baseline, with and without contractions. What should the nurse do?
This is indicative of cord compression. Minimize the amount of pressure on the umbilical cord by assisting the pt to Trendelenburg position

Most common cause for nipple soreness?
Incorrect positioning of the infant on the breast for latching on is the most common cause for nipple soreness.

The baby’s body is in alignment with ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast

Silverman-Anderson index
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.

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color and asks when the flow will stop. How should the nurse respond?
When the placental site has healed–it is about 3-6 weeks.

At 6 weeks, lochia flow should be finished.

What is the primary cause of hot flashes?
Vasomotor instability caused by decreased estrogen levels. Sudden fluctuations between vasodilation to vasoconstriction

Where does a fertilized ovum implant in the uterus?
Endometrium

Depo-provera injection instructions
-Call if experiencing painful headaches
-Delayed return of fertility is common
-Weight gain is a common side effect (3-20 pounds)
-Take the shot every 90 days

What may occur if gonorrhea goes untreated?
Obstructed fallopian tubes from fibrous tissue that hardens and constricts the lumen causing sterility and a high risk for ectopic pregnancy

Where does fertilization normally take place?
Fallopian tubes

Where does sperm production take place?
Testes

What hormones are the reason why pregnant women commonly experience water retention and fatigue?
Increased estrogen and progesterone cause sodium retention–which lead to fluid retention and fatigue

What is the major function of amniotic fluid?
Maintain fetal temperature and stability (cushion, aid in dilation of cervix, temp—ABCs)

What is a suspected reason why pregnancy induced hypertension (PIH) occurs in LES groups?
Less protein involved in the diet

What is a major function of the placenta?
Provides an exchange of nutrients and waste products between the mother and fetus

Key characteristic of placenta previa?
Painless bleeding

A pregnant woman who is a known cocaine user is at risk for developing what condition?
Abruptio placentae–cocaine causes vasoconstriction and contraction of uterine smooth muscle which can result in preterm labor and abruptio placentae (as well as hypertension, CV failure, and other complications)

Ptyalism
Excessive salivation commonly seen with hyperemesis gravidarum

Polyhydramnios
Excessive amniotic fluid

Vena cava syndrome
Compressison of the IVC by the uterus in the third trimester

At what wks gestation can the fetal heartbeat be heard?
18-20 wks. This is also when the mother can feel the fetus move.

How are contractions timed?
From the beginning of one contraction to the beginning of the next

What does pregnancy induced hypertension increase the risk for?
This increases the risk for placentae abruptio

What medication is often given after the delivery of a newborn?
IV oxytocin (pitocin) to allow uterine contractions and deliver the placenta

What is the most common cause of postpartal hemorrhage?
Uterine atony–control the bleeding by staying tightly contracted.

Uterine atony often happens to multiparas

Nurse assesses a patient in labor with a prolapsed umbilical cord. What position should the patient be in?
Knee-chest position or slight trendelenburg position to relieve pressure of the presenting part away from the cord

A patient in labor has FHR of 90 bpm. What intervention must the nurse do next?
Placental insufficiency and late decelerations indicate that the nurse place the patient on her left side and administer oxygen

Fetal presentation is at +1. What does this mean?
1 cm below ischial spine

What will the mother feel when the fetus is in occiput posterior position?
Severe back pain–the largest part of the fetal head is at the back, increasing pressure on the maternal sacral nerves and causing backpain

What will be felt if the fetus is in breech presentation?
Hard round mass palpated in the patient’s upper adbomen or fetal heart sounds heard in the patients upper right abdomen

What type of pelvis is most favorable for labor and birth?
Gynecoid pelvis–a normal female pelvis and is the most favorable for successful labor and delivery

What type of pelvis is the male pelvis?
Android pelvis

What type of pelvis is oval shaped with a narrow pubic arch?
Anthropoid pelvis

What type of pelvis is a wide pelvis with a short diameter
Platypelloid pelvis

What cm is active labor usually?
4-7 cm

What change in FHR would be suspected to have umbilical cord compression?
Variable deceleration–insufficient blood flow to the fetal system. Reposition to her side to help relieve the compression

What is important post-discharge of a newborn?
Call the HCP if the baby does not void within 24 hours–may be a fluid intake, hydration status, body temp, or renal problem.

What hormone stimulates prolactin production so that breast-feeding may begin?
A decrease in progesterone

After delivery of the placenta, high levels of progesterone are lost.

Within the first 12 hours postpartum, the fundus is usually where in relation to the umbilicus?
Approximately 1 cm above the umbilicus.

By postpartum day 3, where should the fundus be in relation to the umbilicus?
Below the umbilicus

How long does the postpartum blues last?
1-2 weeks

During what time frame is postpartum depression likely?
Within 6 months of delivery

How many calories a day should the breast-feeding mother increase to?
Increase to 500 calories a day

1 hour postpartum, the mother complains of chills and has bright red lochia with a firm fundus. What should the nurse do
This is a normal postpartum response since the uterus is still contracting. Documen.

A full bladder is likely to push the uterus in what position?
It will push the uterus to the right of midline.

Taking-in phase
First 24-48 hours after birth

Focus on maternal needs

Taking-hold phase
48 hours-7 days after birth

Maternal need to control her life. She is ready to learn

Letting-go phase
Mother and family move forward as a system with interacting members

Letting-down phase
Let-down reflex seen with lactation and breastfeeding

12 hours postpartum, a patient experiences a temperature of 101F. What may this indicate?
Dehydration

A fever after 24 hours is indicative of what?
Puerperal infection

Is breast-feeding recommended for a patient who is HIV positive?
No. Breastfeeding is not recommended for HIV positive women since it is isolated in breast milk and could be transmitted to the newborn

Neonates looks how much of the birth weight within the first few days of birth?
5-10% of their weigh

PDA, ASD, and VSD may increase the risk of what problem in infants?
Congestive heart failure

The umbilical cord has how many arteries and veins?
2 arteries, 1 vein

Is brain damage directly associated with cranial molding?
No. The molding usually disappears in a few days without any other interventions or long-lasting effects.

In the time of using forceps during a delivery, what must the nurse assess the infant for post-delivery?
Facial paralysis if the forceps compress cranial nerve VII (facial) anterior to the ears.

This paralysis is mild and temporary lasting several days.

Torticollis
Deformity of the neck not associated with newborns

What may occur in the event of dystocia, vacuum extraction, or large birth weight?
A fractured clavicle

What is cephalhematoma
Extravasation of blood from ruptured vessels between the skull bone and its external coverings known as the periosteum. The hematoma does not cross over a cranial suture

What age should the Moro reflex disappear?
4 months, also known as the startle reflex

What defects are involved in Tetralogy of Fallot
-Right ventricular hypertrophy
-Stenosis of the pulmonary artery
-VSD
-Overriding aorta

Are Mongolian spots permanent?
No, they fade over time

What is a sign of postmaturity?
Long, brittle fingernails

An infant has myelomeningocele. What would the nurse expect?
-Impaired bowel and bladder function d/t the innervation of the anal sphincter and the bladder is decreased causing incontinence.
-Paralysis of the legs d/t nerves of the cauda equina.

What is considered physiological jaundice?
Jaundice within 24 hours of birth.

What would be manifested more commonly in a newborn born C-section vs. a newborn born vaginally?
C-section newborns are at higher risk for respiratory distress syndrome

An infant born breech is at risk for what complication?
Brachial palsy–which results from the stretching of nerve fibers in the neck, shoulder, and arm where the shoulder is being pulled away from the neck during a breech delivery.

What are some observations that the newborn is nursing well to breastfeeding?
-Swallowing is audible
-Mother reports a pulling sensation on her nipple
-The tip of the infant’s nose and chin touch the breast

Signs of ineffective nursing of an infant
-Clicking/smacking sound during breastfeeding
-The infant’s cheeks are dimpled

Why do infants need a vitamin K injection immediately after delivery?
Infants have a sterile intestinal tract and cannot synthesize vitamin K

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