2024 PN Maternal Newborn Practice Exam A & B New Latest Version Best Studying Material w, Exams of Nursing

Download 2024 PN Maternal Newborn Practice Exam A & B New Latest Version Best Studying Material w and more Exams Nursing in PDF only on Docsity! 2024 PN Maternal Newborn Practice Exam A & B New Latest Version Best Studying Material with All Questions and Answers Practice A A nurse is observing a client bathe her 1 day old newborn. Which of the following actions should the nurse identify as an indication that the client understands how to bathe her newborn? -------- Correct Answer ----------- The client washes the newborn's hair before unwrapping her A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? -------- Correct Answer ----------- Insert an indwelling urinary catheter A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal examination. Which of the following findings should the nurse report to the provider? ---- ---- Correct Answer ----------- Blurred vision A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn. The client reports a perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority? -------- Correct Answer ----------- Help the client ambulate to the toilet A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? -------- Correct Answer ----------- Prolonged deceleration of FHR A nurse is collecting date from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider? -------- Correct Answer ----------- Apical heart rate of 90/min while crying A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions should the nurse take? -------- Correct Answer ----------- Place an opaque mask over the newborn's eyes A nurse is reviewing the medication administration record for a client who is receiving nifedipine for gestational hypertension. The nurse should identify that which of the following medications is contraindicated for use with nifedipine? -------- Correct Answer - ---------- Magnesium sulfate A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? ------ -- Correct Answer ----------- Subcutaneous A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? -------- Correct Answer ----------- Hematocrit 30% A nurse is reinforcing teaching about butorphanol tartrate with a client who is in labor. Which of the following client statements indicates an understanding of the teaching? ---- ---- Correct Answer ----------- This medication might make me dizzy A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? -------- Correct Answer ----------- Epigastric pain A nurse is contributing to the plan of care for a newborn who was circumcised with a plastic bell device. Which of the following actions should the nurse include in the plan? - ------- Correct Answer ----------- Apply pressure with sterile gauze if bleeding occurs at the site A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include? -------- Correct Answer ----------- You will need to be in active labor before using hydrotherapy A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first? -------- Correct Answer ----------- Check the newborn's blood glucose level A nurse is planning to administer phytonadione to a newborn. Which of the following actions should the nurse take? -------- Correct Answer ----------- Use the vastus lateralis as the injection site A nurse is discussing family planning with a client who is requesting information about available contraceptive methods. Which of the following client statements indicates an understanding of the teaching? -------- Correct Answer ----------- I should use water- soluble lubricant when my partner wears a condom A nurse is reinforcing teaching about interventions to treat breast engorgement with a client who is breastfeeding. Which of the following instructions should the nurse include in the teaching? -------- Correct Answer ----------- Breastfeed the newborn at least every 2 hours. A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the A nurse is reinforcing teaching about food sources that are high in folate with a group of women who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? -------- Correct Answer ----------- 1/2 cup dried peas A nurse is caring for a client who has received methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication? -------- Correct Answer ----------- Hypertension A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplements is to do which of the following? -------- Correct Answer ----------- Prevent certain kinds of birth defects A nurse is preparing to administer clindamycin 450 mg PO to a client who has endometritis. The amount available is clindamycin 150 mg/capsule. How many capsules should the nurse administer? -------- Correct Answer ----------- 3 A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take? -- ------ Correct Answer ----------- Explain to the client that she will receive the hepatitis B immune globulin immediately A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect? -------- Correct Answer ----------- Urine output of 3,000 mL in 24 hr A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? -------- Correct Answer ----------- If my baby rides in a car with no back seat, the passenger airbag must be turned off A nurse is collecting data from a client who is in her second trimester of pregnancy. Which of the following findings should the nurse report to the provider? -------- Correct Answer ----------- Frequent uterine contractions A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include? -------- Correct Answer ----------- Allow 20 to 30 min for feedings A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication? -------- Correct Answer ----------- Cessation of uterine contractions A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting. Which of the following instructions should the nurse include? -------- Correct Answer ----------- Consume small meals frequently each day Practice B a nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort? ---------- Correct Answer --------- have the client perform relaxing breathing techniques a nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements is true? ---------- Correct Answer --------- you must be at least 37 weeks before hydrotherapy a nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the clients understands the instructions? ---------- Correct Answer --------- i will report any drainage from baby's umbilical cord a nurse is reinforcing discharge instructions about home care with the parent of the newborn. Which of the following instructions should the nurse include? ---------- Correct Answer --------- ensure the water temperature during your newborn's bath is maintained at 100 degrees f A nurse is assisting with the admission of a newborn who has respiratory distress. While collecting data, which of the following should the nurse report to the provider? select all that apply ---------- Correct Answer --------- nasal flaring intercostal retractions grunting A nurse in a provider's office is reinforcing teaching with a client. Which of the following statements should the nurse include? ---------- Correct Answer --------- "You might experience a metallic taste in your mouth while taking your medication" a nurse is collecting data from a client who is 37 weeks of gestation. Which of the following finding should the nurse report to the provider? ---------- Correct Answer --------- blurred vision a nurse is assisting with the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the following images indicates a characteristic response of the tonic neck reflex? ---------- Correct Answer --------- picture where baby's face is facing the same side as the extended leg (downward) and arm (more outward); other leg & arm should be bent, should be the first pic a nurse is collecting data from client who is a primigravida and has hyperthyroidism. Which of the following findings should the nurse expect? ---------- Correct Answer --------- diaphoresis a nurse is reinforcing teaching about nonstress test with a client who is at 33 weeks of gestation. Which of the following statements should the nurse include? ---------- Correct Answer --------- you will press a button when you feel the baby move a nurse is assisting with the care of a client who is postpartum and is receiving lactated Ringer's 1,500 mL IV to infuse over 10 hr. set pump's setting to deliver how many mL/hr? ---------- Correct Answer --------- 150 mL/hr a nurse is reinforcing discharge teaching with a client who has mastitis of the left breast. Which of the following instructions should the nurse include? ---------- Correct Answer --- ------ . pump the affected breast frequently a nurse is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider? ---------- Correct Answer ------- -- glycosuria a nurse is collecting data from the parent of a newborn immediately following birth. The parent states she is so tiny. We dont know how to pick her up without hurting her. Which of the following actions should the nurse take first to promote parent-newborn attachment? ---------- Correct Answer --------- demonstrate to the parent how to hold the newborn a nurse is assisting with monitoring a client after an amniocentesis. Which of the following findings should the nurse expect? ---------- Correct Answer --------- FHR 120/min a nurse is contributing to the plan of care for a client who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend? ---------- Correct Answer --------- monitor i and o a nurse is contributing to the plan of care for a client who is pregnant and has intermittent constipation. Which of the following interventions should the nurse recommend for pain? ---------- Correct Answer --------- drink 2 L of water per day a nurse is planning to reinforce discharge teaching about formula feeding with the guardian of a newborn. Which of the following instructions should the nurse plan to include? ---------- Correct Answer --------- provide the newborn with 6-8 feedings during a 24 hour period a nurse is reinforcing teaching about seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching? type of birth a nurse is caring for client who delivered vaginally 6 hr ago. Which of the following findings should the nurse report to the provider? ---------- Correct Answer --------- . perineal pad soaked in 15 minutes a nurse is contributing to the plan of care for a client who is at 18 weeks gestation and has just learned that the fetus has trisomy 21. Which of the following resources should the nurse recommend for the client? ---------- Correct Answer --------- genetic counseling a nurse is assisting with the care of a client who is at 39 weeks of gestation. Which of the following statements should alert the nurse as a sign of a potential complication? ---- ------ Correct Answer --------- i have pain in my upper right abdomen a nurse is reinforcing teaching about newborn home safety precautions with a group of guardians. Which of the following instructions should the nurse include? ---------- Correct Answer --------- you should ensure the crib slats are no more than 2.25 inches apart a nurse is caring for a 12 hour old male newborn who was delivered from a breech position. Which of the following findings should the nurse report to the charge nurse? --- ------- Correct Answer --------- skin appears jaundice A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes? ---------- Correct Answer ---- ----- IM a nurse is collecting data from a client who is 1 day postpartum. Which of the following findings should the nurse identify as an indication of infection? ---------- Correct Answer - -------- WBC 35,000/mm^3 a nurse is caring for a client who is in preterm labor and is receiving bethamethasone. Which of the following actions should the nurse take? ---------- Correct Answer --------- . inject the medication into the client's vastus lateralis muscle a nurse on a postpartum unit is contributing to the discharge teaching plan of a client. Which of the following instructions should the nurse suggest for the plan? ---------- Correct Answer --------- use a firm mattress in the newborn's crib a nurse is collecting data from a client who is receiving magnesium sulfate IV for preclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider? ---------- Correct Answer --------- RR 10/min Extra Study Questions CONTRACEPTION ---------- Correct Answer ---------- A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding? A. "A water-soluble lubricant should be used with condoms." B. "A diaphragm should be removed 2 hours after intercourse." C. "Oral contraceptives can worsen a case of acne." D. "A contraceptive patch is replaced once a month." ---------- Correct Answer ---------- "A water-soluble lubricant should be used with condoms." A nurse is instructing a client who is taking an oral contraceptive about manifestations to report to the provider. Which of the following manifestations should the nurse include? A. Reduced menstrual flow B. Breast tenderness C. Shortness of breath D. Increased appetite ---------- Correct Answer ---------- Shortness of breath A nurse is reinforcing teaching with a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (select all that apply) A. Tinnitus B. Irregular vaginal bleeding C. Weight gain D. Nausea E. Gingival hyperplasia ---------- Correct Answer ---------- 1. Irregular vaginal bleeding 2. Weight gain 3. Nausea A nurse in an obstetrical clinic is reinforcing teaching with a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? A. "An IUD should be replaced annually during a pelvic exam." B. "I cannot get an IUD until after I've had a child." C. "I should plan on regaining fertility 5 months after the IUD is removed." D. "I will check to be sure the strings of the IUD are still present after my periods." -------- -- Correct Answer ---------- "I will check to be sure the strings of the IUD are still present after my periods." A nurse in a clinic is reinforcing teaching with a client about a new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply) A. "Weigh fluctuations can occur." B. "You are protected against STIs." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "Irregular vaginal spotting can occur." ---------- Correct Answer ---------- 1. "Weigh fluctuations can occur." 2. "You should increase your intake of calcium." 3. "Irregular vaginal spotting can occur." CHANGES DURING PREGNANCY ---------- Correct Answer ---------- A nurse is caring for a client who is pregnant and states that their last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15 ---------- Correct Answer ---------- January 8 A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: G3 T1 P0 A1 L1. How should the nurse interpret this information? (select all that apply) A. Client has delivered one newborn at term B. Client has experienced no preterm labor C. Client has been through active labor D. Client has had two prior pregnancies E. Client has one living child ---------- Correct Answer ---------- 1. Client has delivered one newborn at term 2. Client has experienced no preterm labor 3. Client has had two prior pregnancies 4. Client has one living child A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (select all that apply) A. Montgomery's glands B. Goodell's sign C. Ballottement D. Chadwick's sign E. Quickening ---------- Correct Answer ---------- 1. Goodell's sign 2. Ballottement 3. Chadwick's sign A nurse in a prenatal clinic is caring for a client who is pregnant and experiencing episodes of maternal hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make? A nurse in a clinic is reinforcing teaching with a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency? A. Iron deficiency anemia B. Poor bone formation C. Macrosomic fetus D. Neural tube defects ---------- Correct Answer ---------- Neural tube defects A nurse is reviewing a new prescription for iron supplements with a client who is at 8 weeks of gestation and has iron deficiency anemia. Which of the following beverages should the nurse reinforce the client to take the iron supplements with? A. Ice water B. Low-fat or whole milk C. Tea or coffee D. Orange juice ---------- Correct Answer ---------- Orange juice A nurse is assisting the charge nurse with reviewing postpartum nutrition needs with a group of clients who have begun breastfeeding their newborns. Which of the following statements by a member of the group indicates an understanding of the teaching? A. "I am glad I can have my morning coffee." B. "I should take folic acid to increase my milk supply." C. "I will continue adding 330 calories per day to my diet." D. "I will continue my calcium supplements because I don't like milk." ---------- Correct Answer ---------- "I will continue my calcium supplements because I don't like milk." DETERMINATION OF FETAL WELL-BEING ---------- Correct Answer ---------- A nurse is reviewing findings of client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (select all that apply) A. Fetal weight B. Fetal breathing movement C. Fetal tone D. Fetal position E. Amniotic fluid volume ---------- Correct Answer ---------- 1. Fetal breathing movement 2. Fetal tone 3. Amniotic fluid volume A nurse is assisting with the car of a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should review which of the following tests to check fetal lung maturity? A. Alpha-fetoprotein (AFP) B. Lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. Indirect Coombs' test ---------- Correct Answer ---------- Lecithin/sphingomyelin (L/S) ratio A nurse is assisting with the care of a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make? A. "It is used to stimulate uterine contractions." B. "It will decrease the incidence of uterine contractions." C. "It lulls the fetus to sleep." D. "It awakens a sleeping fetus." ---------- Correct Answer ---------- "It awakens a sleeping fetus." A nurse is reinforcing teaching with a client who is of 22 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make? A. "You will lay on your right side during the procedure." B. You should not eat anything for 24 hours prior to the procedure." C. "You should empty your bladder prior to the procedure." D. "The test is done to determine gestational age." ---------- Correct Answer ---------- "You should empty your bladder prior to the procedure." A nurse is assisting with the care of a client who is pregnant and is to undergo a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply) A. Decreased fetal movement B. Intrauterine growth restriction (IUGR) C. Postmaturity D. Placenta previa E. Amniotic fluid emboli ---------- Correct Answer ---------- 1. Decreased fetal movement 2. Intrauterine growth restriction (IUGR) 3. Postmaturity BLEEDING DURING PREGNANCY ---------- Correct Answer ---------- A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device." The nurse should suspect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole ---------- Correct Answer ---------- Ectopic pregnancy A nurse is assisting with care for a client who has a marginal abruptio placentae. Which of the following findings are risk factors for developing the condition? (select all that apply) A. Fetal position B. blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking ---------- Correct Answer ---------- 1. blunt abdominal trauma 2. Cocaine use 3. Cigarette smoking A nurse is assisting with the care of a client who is at 32 weeks of gestation and has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following medications should the nurse expect the provider will prescribe? A. Betamethasone B. Indomethacin C. Nifedipine D. Methylergonovine ---------- Correct Answer ---------- Betamethasone A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea; vomiting; and scant, prune-colored discharge. The client has experienced no weight loss and has a fundal height larger than expected. Which of the following complication should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor ---------- Correct Answer ---------- Hydatidiform mole A nurse is assisting with the care for a client who is experiencing a ruptured ectopic pregnancy. Which of the following findings is expected with this condition? A. No alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus C. Blood progesterone greater than the expected reference range D. Report of severe shoulder pain ---------- Correct Answer ---------- Report of severe shoulder pain INFECTIONS ---------- Correct Answer ---------- 3. Decreased level of consciousness A nursing assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine B. Pyridoxine C. Ferrous sulfate D. Calcium gluconate ---------- Correct Answer ---------- Calcium gluconate A nurse is reviewing a new prescription of ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I will take this pill with my breakfast." B. "I will take this medication with a glass of milk." C. "I plan to drink more orange juice while taking this pill." D. "I plan to add more calcium-rich foods to my diet while taking this medication." -------- -- Correct Answer ---------- "I plan to drink more orange juice while taking this pill." EARLY ONSET OF LABOR ---------- Correct Answer ---------- A nurse is assisting with the care for a client who reports manifestations of preterm labor. Which of the following findings are risk factors of this condition? (select all that apply) A. Urinary tract infection B. Multifetal pregnancy C. Oligohydramnios D. Diabetes mellitus E. Uterine abnormalities ---------- Correct Answer ---------- 1. Urinary tract infection 2. Multifetal pregnancy 3. Diabetes mellitus 4. Uterine abnormalities A nurse is assisting with providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? A. Calcium gluconate B. Indomethacin C. Nifedipine D. Betamethasone ---------- Correct Answer ---------- Betamethasone A nurse is assisting with the care for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? A. blood-tinged sputum B. Dizziness C. Pallor D. Somnolence ---------- Correct Answer ---------- Dizziness A nurse is assisting with the care for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (select all that apply) A. Fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension ---------- Correct Answer ---------- 1. Fetal distress 2. Vaginal bleeding 3. Cervical dilation greater than 6 cm A nurse is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include? A. Use a condom with sexual intercourse B. Avoid bubble bath solution when take a tub bath C. Wipe from the back to the front when performing perineal hygiene D. Keep a daily record of fetal kick counts ---------- Correct Answer ---------- Keep a daily record of fetal kick counts NURSING CARE OF THE CLIENT IN LABOR ---------- Correct Answer ---------- A nurse is assisting with the care for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing? A. Second stage B. Fourth Stage C. Transition phase D. Latent Phase ---------- Correct Answer ---------- Transition phase A nurse is assisting with the care for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal exam by the registered nurse reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply) A. Encourage use of patterned breathing techniques B. Insert an indwelling urinary catheter C. Administer opioid analgesic medication D. Suggest application of cold E. Provide ice chips ---------- Correct Answer ---------- 1. Encourage use of patterned breathing techniques 2. Administer opioid analgesic medication 3. Suggest application of cold A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which of the following information should the nurse include? A. An episiotomy is a perineal tear that is created while pushing during labor B. A fourth degree episiotomy extends into the rectal area C. An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus D. A mediolateral episiotomy is easier to repair than a median episiotomy ---------- Correct Answer ---------- An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus A nurse is assisting with the care for a client who is at 42 weeks of gestation and is having an ultrasound. For which of the following conditions should the nurse prepare for an autoinfusion? (Select all that apply) A. Oligohydramnios B. Hydramnios C. Fetal cord compression D. Hydration E. Fetal immaturity ---------- Correct Answer ---------- 1. Oligohydramnios 2. Fetal cord compression A nurse is assisting with the care of a client in active labor. The nurse observes clear fluid and a loop of pulsating umbilical cord outside the client's vagina. Which of the following actions should the nurse perform first? A. Place the client in the Trendelenburg position B. Apply finger pressure to the presenting part C. Administer oxygen at 10 L/min via a nonrebreather D. Call for assistance ---------- Correct Answer ---------- Call for assistance FETAL MONITORING DURING LABOR ---------- Correct Answer ---------- D. Decreased response with sexual activity ---------- Correct Answer ---------- Sore nipple with cracks and fissures A nurse is preparing to reinforce education to a client who is 2 hr postpartum and has perineal laceration. Which of the following information should the nurse include? (select all that apply) A. Use a perineal squeeze bottle to cleanse the perineum B. Sit on the perineum while resting in bed C. Apply a topical anesthetic cream or spray to the perineum D. Wipe the perineum thoroughly with a back and forth motion E. Apply cold or ice packs to the perineum ---------- Correct Answer ---------- 1. Use a perineal squeeze bottle to cleanse the perineum 2. Apply a topical anesthetic cream or spray to the perineum 3. Apply cold or ice packs to the perineum COMPLICATIONS OF THE POSTPARTUM PERIOD ---------- Correct Answer ---------- A nurse is contributing to the plan of care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse recommend? A. Apply cold compresses to the affected extremity B. Massage the affected extremity C. Allow the client to ambulate D. Measure leg circumferences ---------- Correct Answer ---------- Measure leg circumferences A nurse is reinforcing teaching with a client who is breastfeeding and has mastitis. Which of the following responses should the nurse make? A. "Limit the amount of time the infant nurses on each breast." B. "Nurse the infant only on the unaffected breast until resolved." C. "Completely empty each breast at each feeding or use a pump." D. "Wear a tight-fitting bra until lactation has ceased." ---------- Correct Answer ---------- "Completely empty each breast at each feeding or use a pump." A nurse is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (Select all that apply) A. Epidural anesthesia B. Urinary bladder catherization C. Frequent pelvic examinations D. History of UTIs E. Vaginal birth ---------- Correct Answer ---------- 1. Epidural anesthesia 2. Urinary bladder catherization 3. Frequent pelvic examinations 4. History of UTIs A nurse is assisting with the care of a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these manifestations? A. Postpartum fatigue B. Postpartum psychosis C. Letting-go phase D. Postpartum blues ---------- Correct Answer ---------- Postpartum blues A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed B. Ask the client if they have thoughts of harming themselves or their infant C. Monitor the infant for indications of failure to thrive D. Review the client's medical record for a history of bipolar disorder ---------- Correct Answer ---------- Ask the client if they have thoughts of harming themselves or their infant LOW-RISK NEWBORN: DATA COLLECTION ---------- Correct Answer ---------- A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g and is in the 60th percentile for weight. Based on the weight and gestation age, the nurse should assign the newborn which of the following classifications? A. Low-birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age ---------- Correct Answer ---------- Appropriate for gestational age A nurse is collecting data from a newborn and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions? A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls ---------- Correct Answer ---------- Epstein's pearls A nurse is preparing to collect data about the reflects of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Hold t he newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward ---------- Correct Answer ---------- Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward A nurse is collecting data from a newborn following birth. Which of the following physical findings indicate the newborn is adapting to extrauterine life? (select all that apply) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10 second periods D. Obligatory nose breathing E. Crackles and wheezing ---------- Correct Answer ---------- 1. Apnea for 10 second periods 2. Obligatory nose breathing A nurse is reinforcing teaching with new parents on bathing a newborn and observes a bluish brown marking across the newborn's lower back. Which of the following statements should the nurse make concerning the variation? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery." ---------- Correct Answer ---------- "This is more commonly seen in newborns who have dark skin." LOW RISK NEWBORN: NURSING CARE OF NEWBORNS ---------- Correct Answer ---- ------ A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone ---------- Correct Answer ---------- Erythromycin A nurse is assisting with the care of a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath A. Hand the parent the newborn, and suggest that they change the diaper. B. Ask the parent why they are so anxious and nervous. C. Tell the parent that they will grow accustomed to the newborn. D. Provide reinforcement about infant care when the parent is present ---------- Correct Answer ---------- Provide reinforcement about infant care when the parent is present A nurse is assisting with caring for a client who is postpartum. Which of the following maternal characteristics should the nurse identify as the takin-in phase of maternal postpartum adjustment? A. The client is excited and talkative B. The client is independent with caring for baby C. The client requires assistance with meeting basic needs D. The client is eager to learn new tasks E. The client is desiring to take charge of their care ---------- Correct Answer ---------- 1. The client is excited and talkative 2. The client requires assistance with meeting basic needs A nurse is assisting with care for a client who is 1 day postpartum. The nurse is collecting data for maternal adaptation and parent-infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply) A. Demonstrates apathy when the newborn cries B. Touches the newborn and maintains close physical proximity C. Views the newborn's behavior as uncooperative during diaper changing D. Identifies and relates newborn's characteristics to those of family members E. Interprets and relates newborn's characteristics to those of family members ---------- Correct Answer ---------- 1. Demonstrates apathy when the newborn cries 2. Views the newborn's behavior as uncooperative during diaper changing A nurse is assisting with caring for a client who is 2 days postpartum. The client states, "My 4 year old old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training pants." B. "Your son is showing an adverse sibling response." C. "Your son may need counseling." D. "You should try sending your son to preschool to resolve the behavior." ---------- Correct Answer ---------- "Your son is showing an adverse sibling response." A nurse in the delivery room is planning to promote parent-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. Encourage the parents to touch and explore the neonate's features B. Limit noise and interruption in the delivery room C. Place the neonate at the client's breast D. Position the neonate skin-to-skin on the client's chest. ---------- Correct Answer -------- -- Position the neonate skin-to-skin on the client's chest. A nurse is assisting with the data collection of a newborn who is 1 hr old. Which of the following manifestations should indicate to the nurse that the newborn is experiencing difficulty transitioning to extrauterine life? ---------- Correct Answer ---------- retractions Grunting, nasal flaring, retractions, and tachypnea are manifestations that indicate the newborn is having difficulty transitioning to extrauterine life. The nurse should report the findings to the provider. A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements should the nurse include in the teaching? "You should keep the water temperature at 110 degrees Fahrenheit for your baby's bath." "You should be able to fit at least three fingers between the sides of your baby's crib and the mattress." "You should place your baby's head on a pillow while she is awake." "You should dress your baby in a one-piece sleeper at bedtime." ---------- Correct Answer ---------- You should dress your baby in a one-piece sleeper at bedtime MY ANSWER The nurse should instruct the client to use a sleep sack or one-piece sleeper and refrain from covering the newborn with blankets to reduce the newborn's risk of entrapment or suffocation. A nurse is caring for a client who is at 16 weeks of gestation and is at risk for developing hyperemesis gravidarum. Which of the following conditions places the client at an increased risk for developing this condition? ---------- Correct Answer ---------- diabetes mellitus A nurse is caring for a postpartum client who has an episiotomy. Which of the following actions should the nurse take? ---------- Correct Answer ---------- apply an anesthetic spray to the client's perineal area as needed for pain A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings indicates that the client is at risk for dehydration? ---------- Correct Answer ---------- ketonuria A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. which of the following statement by the guardian demonstrates in understanding of the teaching? "I will place my baby at a 45-degree angle in the car seat." "I will position the harness retainer clip across my baby's stomach." "I will keep my baby's car seat rear-facing until she weighs 20 pounds and is 1 year old." "I will place padding under my baby's back until she reaches 10 pounds." ---------- Correct Answer ---------- I will place my baby at a 45-degree angle in the car seat The newborn should be placed in the car seat at a 45° angle to prevent slumping and airway obstruction. The newborn will be unable to hold their head erect. Therefore, the newborn's head should be supported at all times. A nurse on a postpartum unit is reinforcing teaching with an assistive personnel (AP) about preventing newborn abduction. Which of the following information should the nurse include? ---------- Correct Answer ---------- the AP should have their photo identification badge displayed A nurse is assisting with the care of a client who is in the active stage of labor. For which of the following findings should the nurse notify the provider? ---------- Correct Answer ---------- prolapsed umbilical cord A nurse in an antepartum clinic is collecting data from a client who is at 28 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complications? ---------- Correct Answer ---------- dysuria A nurse is assisting with the care of a client who is in active labor and notes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first? ---------- Correct Answer ---------- place the client in a side-lying position A nurse is planning to administer phytonadione IM to a newborn shortly after birth. The nurse should identify that this medication is administered to prevent which of the following complications? ---------- Correct Answer ---------- hemorrhage disease A nurse is contributing to the plan of care for a client who is in labor and tested positive for group B streptococcus B-hemolytic. which of the following interventions should the nurse include in the plan of care? ---------- Correct Answer ---------- administer ampicillin via intermittent IV bolus A nurse is reviewing the laboratory results of a client who is at weeks of gestation. Which of the following results should the nurse report to the provider? ---------- Correct Answer ---------- Hct 31% A nurse is collecting data from a newborn who has Down syndrome. Which of the following should the nurse expect in a term newborn who has Down syndrome? ---------- Correct Answer ---------- hypotonic muscle tone A nurse is caring for a client who is at 16 weeks of gestation and is at risk for developing hyperemesis gravidarum. Which of the following conditions places the client at an increased risk for developing this condition? Placenta previa Hypertension Iron deficiency anemia Diabetes mellitus ---------- Correct Answer ---------- Diabetes mellitus The nurse should identify diabetes mellitus as a risk factor for the development of hyperemesis gravidarum. Other risk factors for developing this condition include gastrointestinal disorders, hyperthyroid disorders, molar pregnancy, asthma, and migraines A nurse is collecting data from a client who is pregnant and reports that the first day of their last menstrual period was January 27. According to Nägele's rule, the nurse should calculate the client's estimated date of delivery as which of the following? October 20 October 27 November 3 November 10 ---------- Correct Answer ---------- November 3 A nurse is reinforcing discharge teaching with a parent of a newborn following a circumcision using the Plastibell technique. Which of the following statements by the parent indicates an understanding of the teaching? "I will remove the yellow discharge from my baby's penis with a damp cloth." "I will be sure that my baby's diaper does not put pressure on his penis." "I will clean my baby's penis with soap and water after the first 24 hours." "I will remove the bell from my baby's penis 36 hours after the procedure." ---------- Correct Answer ---------- "I will be sure that my baby's diaper does not put pressure on his penis." The nurse should identify that this statement indicates an understanding of the teaching. The diaper should be applied loosely to prevent the application of pressure to the circumcision site. A nurse is reinforcing teaching with a client who is at 11 weeks of gestation about a transvaginal ultrasound. Which of the following client statements indicates an understanding of the teaching? "I might feel some pressure when the probe is moved during the ultrasound." "I will need to be sure my bladder is full before the ultrasound." "This test will require me to take a laxative the day before the ultrasound." "This test will measure the amount of amniotic fluid around my baby." ---------- Correct Answer ---------- "I might feel some pressure when the probe is moved during the ultrasound." MY ANSWER The nurse should instruct the client that a transvaginal ultrasound is not painful. However, the client might feel pressure when the provider moves the probe A nurse on a postpartum unit is reinforcing teaching with an assistive personnel (AP) about preventing newborn abduction. Which of the following information should the nurse include? The AP should use the identification card on the crib to confirm the newborn's identity. The AP should allow the newborn to remain in the mother's room while she showers. The AP should carry the newborn to the nursery. The AP should have their photo identification badge displayed. ---------- Correct Answer ---------- The AP should have their photo identification badge displayed. A nurse is assisting with the admission assessment of a client whose labor is being induced. The client reports using heroin 6 hr ago. For which of the following manifestations of abstinence should the nurse monitor the client? Constipation Insomnia Flaccid muscles Euphoria ---------- Correct Answer ---------- Insomnia A nurse is reinforcing teaching with the guardians of a newborn about the care of the umbilical stump. Which of the following instructions should the nurse include in the teaching? "Clean the umbilical stump with soap and water with each diaper change." "Loosely cover the umbilical stump with the diaper." "Sponge bathe your baby until the umbilical stump has fallen off." "Expect the umbilical stump to separate in about 4 weeks." ---------- Correct Answer ------ ---- "Sponge bathe your baby until the umbilical stump has fallen off." A nurse is collecting data from a newborn who is 6 hr old. Which of the following manifestations should the nurse expect? (Select all that apply.) Rust-stained urine Distended abdomen Overlapping cranial sutures Periodic breathing Yellow coloration of the sclera ---------- Correct Answer ---------- Rust-stained urine is correct. A newborn's first void can contain uric acid crystals, which will give the urine a rust-stained appearance. Overlapping cranial sutures is correct. A newborn's cranial sutures should be palpable without evidence of fusion. Overlapping sutures can occur during a vaginal birth to allow passage of the fetus through the birth canal. Periodic breathing is correct. A newborn's respiratory effort is shallow and irregular and can have periods of 5 to 10 seconds with respiratory effort. A nurse is reinforcing teaching with a client who is pregnant and has iron deficiency anemia. Which of the following food sources should the nurse instruct the client to include in their diet to increase absorption of an iron supplement? Oranges Bran Milk Eggs ---------- Correct Answer ---------- Oranges A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following findings should the nurse identify as a potential complication of phototherapy? Loose stools Decreased urinary output Axillary temperature of 37° C (98.6° F) Skin rash ---------- Correct Answer ---------- Decreased urinary output The nurse should closely monitor urinary output while the newborn is receiving phototherapy. Phototherapy can increase the rate of insensible water loss, which can lead to dehydration. The nurse should ensure the newborn is eating every 2 to 3 hr to promote adequate hydration A nurse is assisting with the care of a postpartum client and their newborn. The nurse observes that the newborn appears to be choking on formula. Which of the following actions should the nurse take? (Select all that apply.) Reposition the newborn. Suction the newborn's mouth with a bulb syringe. Apply oxygen via nasal cannula. Perform chest percussion. Auscultate breath sounds. ---------- Correct Answer ---------- Reposition the newborn is correct. The nurse should reposition the newborn to help facilitate removal of oral secretions. Suction the newborn's mouth with a bulb syringe is correct. The nurse should suction the newborn's mouth with a bulb syringe to facilitate removal of oral secretions, which could be obstructing the airway. Oliguria Hypertension Weight loss ---------- Correct Answer ---------- Flushing A nurse is assisting with the care of a client who is in active labor and notes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first? Palpate the client's uterus to check for tachysystole. Place the client in a side-lying position. Administer oxygen at 10 L/min via nonrebreather face mask. Increase the rate of the client's IV fluids ---------- Correct Answer ---------- Place the client in a side-lying position. A nurse is caring for a postpartum client who has an episiotomy. Which of the following actions should the nurse take? Apply an anesthetic spray to the client's perineal area as needed for pain. Place a donut pillow under the client when sitting in a chair. Apply a moist heat pack to the client's perineal area for 20 min every hour for the first 24 hr after delivery. Assist the client with changing the perineal pad every 8 hr to expedite healing ---------- Correct Answer ---------- Apply an anesthetic spray to the client's perineal area as needed for pain. A nurse in an antepartum clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following findings should the nurse report to the provider? Hematocrit of 35% Weight increase of 3 kg (6.6 lb) in one month Urine dipstick negative for ketones Fetal heart auscultated just above the symphysis pubis ---------- Correct Answer ---------- Weight increase of 3 kg (6.6 lb) in one month A clinic nurse is reviewing dietary instructions with a client who is at 20 weeks of gestation and taking iron supplements. Which of the following statements by the client indicates an understanding of the instructions? "I should take my iron with a cup of coffee." "I should double my iron dose if I forget and miss a day." "I should increase my fluid intake while I am taking iron." "I should limit the fiber in my diet because I am taking iron." ---------- Correct Answer ----- ----- "I should increase my fluid intake while I am taking iron." A nurse is reviewing the laboratory results for a client who has a BP of 156/102 mm Hg and is at 36 weeks of gestation. Which of the following laboratory values should the nurse report to the provider? WBC 11,000/mm3 Hct 35% Platelet count 100,000/mm3 Fasting blood glucose 105 mg/dL ---------- Correct Answer ---------- Platelet count 100,000/mm3 A nurse is reinforcing teaching with the parents of a newborn who is having a newborn screening test. Which of the following statements should the nurse include in the teaching? "The test will check your baby's arterial blood gas levels." "The test will check your baby for jaundice." "The test will check your baby's blood glucose level." "The test will check your baby for phenylketonuria." ---------- Correct Answer ---------- "The test will check your baby for phenylketonuria." A nurse is assisting with the care of a client who is in the active stage of labor. For which of the following findings should the nurse notify the provider? Spontaneous rupture of membranes Prolapsed umbilical cord Pink to bloody mucus discharge Contraction duration of 60 seconds ---------- Correct Answer ---------- Prolapsed umbilical cord A nurse is reinforcing teaching with a guardian about how to care for the umbilical cord of their newborn infant. Which of the following statements by the guardian indicates a need for further teaching? "I know I shouldn't put lotions or creams near the umbilical cord." "I will notify my provider if the cord becomes moist and red." "I will give my newborn a bath once daily." "I will fold the diaper below the umbilical cord." ---------- Correct Answer ---------- "I will give my newborn a bath once daily." A nurse in a clinic is caring for a client who tests positive for gonorrhea. Which of the following findings should the nurse expect during data collection? ---------- Correct Answer ---------- chronic pelvic pain A nurse is reinforcing dietary teaching with a client who is at 10 weeks of gestation. which of the following foods should the nurse identify as containing the highest amount of folate? ---------- Correct Answer ---------- 3 1/2 oz of beef liver A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse report to the provider as potentially indicating a complication of pregnancy? Insomnia Breast tenderness Frequent headaches Leg cramps ---------- Correct Answer ---------- frequent headaches A nurse is assisting with collecting data from a newborn who is 4 hr old. which of the following findings is the priority for the nurse to report to the provider? Generalized petechiae Cephalhematoma Heart rate 170/min Temperature 36.4° C (97.6° F) ---------- Correct Answer ---------- generalized petechiae A clinic nurse is reviewing dietary instruction with a client who is at 20 weeks of gestation and taking Iron supplements. which of the following statements by the client indicates an understanding of the instructions? ---------- Correct Answer ---------- I should increase my fluid intake while I am taking iron A nurse in a clinic is assisting with the plan of care for a client who is at 36 weeks of gestation. Which of the following actions should the nurse include in the plan of care? --- ------- Correct Answer ---------- obtain a culture for group B streptococcus B-hemolytic A nurse in a prenatal clinic is reinforcing nutritional teaching with a client who is at 10 weeks of gestation. Which of the following statements by the client indicates an understanding of the instructions? ---------- Correct Answer ---------- I make sure that I get 1,000 milligrams of calcium per day A nurse in an antepartum clinic is collecting data from a client who is at 12 weeks of gestation. which of the following findings should the nurse report to the provider? --------- - Correct Answer ---------- weight increase of 3kg (6.6lb) in one month A nurse is reinforcing teaching with the guardians of a newborn about the care of the umbilical stump. which of the following instructions the nurse include in the teaching? --- ------- Correct Answer ---------- sponge bathe your baby until the umbilical stump has fallen off A nurse in an antepartum clinic is reinforcing teaching with a client who is at 32 weeks of gestation and is scheduled for a nonstress test. which of the following information should the nurse include in the teaching? ---------- Correct Answer ---------- you will be asked to press a button when you feel your baby move during the test "Concentrate on your level of pain when using a modified-breathing pattern." ---------- Correct Answer ---------- begin and end modified breathing with a deep cleansing breath A nurse is reinforcing teaching with a client who is at 8 wks gestation and has chlamydia. which of the following statements should the nurse include? ---------- Correct Answer ---------- after treatment, you will need another test in 3 wks and again between 35 and 37 wks breech position ---------- Correct Answer ---------- The baby's position in the uterus that causes the buttocks to be the first part to emerge from the vagina. Myelomeningocele (spina bifida) ---------- Correct Answer ---------- most severe form of spina bifida in which the spinal cord and meninges protrude through the spine tonic neck reflex ---------- Correct Answer ---------- elicited when baby head turned to a side, the extremities on that side extend ( birth to 4 months) A nurse is collecting data from a newborn who has Down syndrome. Which of the following findings should the nurse expect in a term newborn who has Down syndrome? Hypotonic muscle tone Abundant lanugo over the shoulders A two-vessel umbilical cord A large anterior fontanel ---------- Correct Answer ---------- Hypotonic muscle tone A nurse is assisting with performing Leopold maneuvers on a client who is at 39 weeks of gestation. Which of the following images indicates that the fetus is in the complete breech position? ---------- Correct Answer ---------- The fetus is in the complete breech position when the buttocks of the fetus lies over the client's cervix. There is flexion of the hips and knees of the fetus. A nurse in an antepartum clinic is reinforcing teaching with a client who is at 32 weeks of gestation and is scheduled for a nonstress test. Which of the following information should the nurse include in the teaching? "You will be lying on your back during the test." "You will be given IV oxytocin to stimulate contractions during the test." "You will be asked to press a button when you feel your baby move during the test." "You will need to drink at least 32 ounces of fluid to fill your bladder before the test." ----- ----- Correct Answer ---------- "You will be asked to press a button when you feel your baby move during the test." A nurse is planning to administer phytonadione IM to a newborn shortly after birth. The nurse should identify that this medication is administered to prevent which of the following complications? Ophthalmia neonatorum Hemorrhagic disease Hypoglycemia Hypothermia ---------- Correct Answer ---------- Hemorrhagic disease A nurse is assisting with the care of a client who is pregnant and receiving magnesium sulfate via a continuous IV infusion. Which of the following findings should the nurse report to the provider? ---------- Correct Answer ---------- Urine output 22 mL/hr A nurse is assisting with the administration of methylergonovine for a client who is experiencing a postpartum hemorrhage. The nurse should monitor the client for which of the following adverse effects of this medication? ---------- Correct Answer ---------- hypertension A nurse is reinforcing teaching with a client who is experiencing preterm labor and has a new prescription for nifedipine. Which of the following statements should the nurse include? ---------- Correct Answer ---------- This medication might cause your face to be flushed A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include? ---------- Correct Answer ---------- You must be at least at 37 weeks of gestation before you can use hydrotherapy. A nurse is assisting with monitoring a client after an amniocentesis. Which of the following findings should the nurse expect? ---------- Correct Answer ---------- FHR 120/min A nurse is collecting data from a client who is at 38 gestation. Which of the following findings should the nurse report to the provider? ---------- Correct Answer ---------- Glycosuria A nurse is reinforcing discharge teaching with a client who has mastitis of the left breast. Which of the following instructions should the nurse include? ---------- Correct Answer --- ------- Pump the affected breast frequently A nurse is caring for a client who ins in preterm labor and is receiving betamethasone. Which of the following actions should the nurse take? ---------- Correct Answer ---------- Inject the medication into the client's vastus lateralis muscle A nurse is planning to perform a blood collection via heel stick on a newborn. After performing hand hygiene and donning gloves, which of the following actions should nurse plan to take next? ---------- Correct Answer ---------- Wrap the newborn's heel with a cloth moistened with warm water A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching? ---------- Correct Answer ---------- I can use water-soluble lubricant when my partner wears a latex condom Greatest risk factor for respiratory distress syndrome is ---------- Correct Answer ---------- prematurity folic acid is important before and during pregnancy ---------- Correct Answer ---------- prevents birth defects A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication? ---------- Correct Answer ---------- cessation of uterine contractions A nurse is reinforcing teaching with a client who is at 20 weeks gestation and has gestational diabetes mellitus. Which of the following information should the nurse include in the teaching? ---------- Correct Answer ---------- consume at least 2,000 cal/day The height of the fundus in centimeters at 20 weeks of gestation is approximately the same as the number of weeks of gestation plus or minus 2 cm. Therefore, a fundal height of 25 cm is greater than the expected finding for 20 weeks of gestation. ---------- Correct Answer ---------- A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching? ---------- Correct Answer ---------- I will ask the nurse to take my baby back to the nursery if I need to leave my room A client requests information about the use of a diaphragm for birth control. Which of the following statements should the nurse make? ---------- Correct Answer ---------- You will need to replace your diaphragm every 2 years A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the following medications should the nurse expect the provider to prescribe? ---------- Correct Answer ---------- methylergonovine A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? ------ ---- Correct Answer ---------- subcutaneous A nurse is reinforcing teaching with a client who is at 20 weeks gestation and reports having constipation. Which of the following information should the nurse include? -------- -- Correct Answer ---------- Consume 28g of fiber per day A nurse is collecting data from a newborn who has Down syndrome. Which of the following should the nurse expect in a term newborn who has Down syndrome? ---------- Correct Answer ---------- hypotonic muscle tone a nurse is collecting data from a client who is pregnant and reports that the first day of their last menstrual period was Jan 27. According to Nagele's rule, the nurse should calculate the client's estimated date of delivery as which of the following? ---------- Correct Answer ---------- Nov 3 A nurse is contributing to the plan of care for a full term newborn whose mother has type 1 diabetes mellitus. Which of the following is the priority action for the nurse to include in the plan of care? Obtain the glucose level of the newborn. Administer vitamin K and erythromycin. Give the newborn a sponge bath. Complete the metabolic screening test. ---------- Correct Answer ---------- obtain the glucose level of the newborn The newborn is at risk for developing hypoglycemia. If brain cells become completely depleted of glucose, brain damage can occur. Therefore, this is the priority action the nurse should include in the plan of care. FLAG A nurse is reinforcing teaching about daily fetal movement count with a client who is at 34 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching? "I should have further testing if my baby moves 10 times in 1 hour." "I should expect my baby's movements to decrease as I get close to my due date." "I will lay flat on my back while counting my baby's movements." "I will notify my provider if I do not feel my baby move for 12 hours." ---------- Correct Answer ---------- "I will notify my provider if I do not feel my baby move for 12 hours." The nurse should instruct the client to report absence of fetal movement for 12 hr to the provider. This is known as the fetal alarm signal, which can indicate fetal distress. "I should have further testing if my baby moves 10 times in 1 hour." MY ANSWER The nurse should instruct the client to count fetal movements for 1 hr each day. The client should notify the provider if the fetus moves less than three times in 1 hr because this finding warrants further testing. "I should expect my baby's movements to decrease as I get close to my due date." The nurse should instruct the client that they should expect to feel at least 10 fetal movements per hour, regardless of the weeks of gestation of pregnancy. The fetus should not exhibit fewer movements toward the end of pregnancy. "I will lay flat on my back while counting my baby's movements." The nurse should instruct the client to lie in a left-lateral position to optimize blood flow to the fetus. Lying supine can cause pressure on the superior vena cava, decreasing blood flow to the fetus, which can decrease fetal movement. FLAG A nurse is contributing to the plan of care for a client who is in labor and tested positive for group B streptococcus ß-hemolytic. Which of the following interventions should the nurse include in the plan of care? Initiate droplet precautions. Prepare the client for a cesarean birth. Report the client's infection to the local health department. Administer ampicillin via intermittent IV bolus. ---------- Correct Answer ---------- Administer ampicillin via intermittent IV bolus. MY ANSWER The nurse should administer ampicillin via intermittent IV bolus to the client who is positive for group B streptococcus ß-hemolytic because transmission can occur during a vaginal birth, which can result in serious illness in or death of the newborn. FLAG A nurse is reviewing the laboratory reports of four newborns. Which of the following laboratory results should the nurse report to the provider? Platelet count 200,000/mm3 Hct 45% Hgb 10 g/dL WBC 15,000/mm3 ---------- Correct Answer ---------- Hgb 10 g/dL A hemoglobin level of 10 g/dL is below the expected reference range of 14 to 24 g/dL for a newborn. The nurse should report this finding to the provider. Platelet count 200,000/mm3 MY ANSWER This platelet count is within the expected reference range of 150,000 to 300,000/mm3 for a newborn. Hct 45% This hematocrit level is within the expected reference range of 44% to 64% for a newborn. Hgb 10 g/dL A hemoglobin level of 10 g/dL is below the expected reference range of 14 to 24 g/dL for a newborn. The nurse should report this finding to the provider. WBC 15,000/mm3 This white blood cell count is within the expected reference range of 9,000 to 30,000/mm3 for a newborn. FLAG A nurse is contributing to the plan of care for a client who plans to formula feed their newborn. Which of the following interventions should the nurse recommend to include? Discard prepared formula after 72 hr. Dilute concentrated formula with equal parts water. Warm formula in the microwave on a low setting. Add two scoops of powdered formula for each ounce of water ---------- Correct Answer -- -------- Dilute concentrated formula with equal parts water. The nurse should instruct the client to dilute concentrated formula with an equal volume of water to provide the correct amount of nutrients to the newborn. Formula prepared with too little water is over concentrated and can provide protein and minerals in quantities that exceed the ability of the newborn's kidneys to excrete them, whereas formula prepared with too much water does not provide an adequate amount of calories for growth Discard prepared formula after 72 hr. The nurse should instruct the client to keep prepared formula in the refrigerator for no longer than 48 hr from the time it was prepared to prevent the growth of bacteria. Dilute concentrated formula with equal parts water. The nurse should instruct the client to dilute concentrated formula with an equal volume of water to provide the correct amount of nutrients to the newborn. Formula prepared with too little water is over concentrated and can provide protein and minerals in quantities that exceed the ability of the newborn's kidneys to excrete them, whereas formula prepared with too much water does not provide an adequate amount of calories for growth. Warm formula in the microwave on a low setting. The nurse should instruct the client not to warm formula in the microwave, because this can result in uneven heating and can cause burns. The client should instead warm the formula by placing the bottle in a pan of warm water. Add two scoops of powdered formula for each ounce of water. MY ANSWER The nurse should instruct the client to add one scoop of powdered formula for every 2 oz of water. The client should then apply the lid to the bottle and shake it well to ensure complete mixing. FLAG A nurse in a clinic is caring for a client who tests positive for gonorrhea. Which of the following findings should the nurse expect during data collection? Chronic pelvic pain Blood in the urine "I will remove the yellow discharge from my baby's penis with a damp cloth." "I will be sure that my baby's diaper does not put pressure on his penis." "I will clean my baby's penis with soap and water after the first 24 hours." "I will remove the bell from my baby's penis 36 hours after the procedure." ---------- Correct Answer ---------- "I will be sure that my baby's diaper does not put pressure on his penis." The nurse should identify that this statement indicates an understanding of the teaching. The diaper should be applied loosely to prevent the application of pressure to the circumcision site. A nurse is reinforcing teaching with a client who is at 11 weeks of gestation about a transvaginal ultrasound. Which of the following client statements indicates an understanding of the teaching? "I might feel some pressure when the probe is moved during the ultrasound." "I will need to be sure my bladder is full before the ultrasound." "This test will require me to take a laxative the day before the ultrasound." "This test will measure the amount of amniotic fluid around my baby." ---------- Correct Answer ---------- "I might feel some pressure when the probe is moved during the ultrasound." MY ANSWER The nurse should instruct the client that a transvaginal ultrasound is not painful. However, the client might feel pressure when the provider moves the probe FLAG A nurse on a postpartum unit is reinforcing teaching with an assistive personnel (AP) about preventing newborn abduction. Which of the following information should the nurse include? The AP should use the identification card on the crib to confirm the newborn's identity. The AP should allow the newborn to remain in the mother's room while she showers. The AP should carry the newborn to the nursery. The AP should have their photo identification badge displayed. ---------- Correct Answer ---------- The AP should have their photo identification badge displayed. MY ANSWER The AP should always wear their photo identification badge so that clients, staff, and families can easily identify them as hospital personnel who work on the maternal newborn unit. FLAG A nurse is assisting with the admission assessment of a client whose labor is being induced. The client reports using heroin 6 hr ago. For which of the following manifestations of abstinence should the nurse monitor the client? Constipation Insomnia Flaccid muscles Euphoria ---------- Correct Answer ---------- Insomnia MY ANSWER Abstinence manifestations begin within 6 hr after the last drug use and might include insomnia, shivering, body aches, vomiting, nausea, body shivers, abdominal pain, muscle jerks, and diarrhea FLAG A nurse is reinforcing teaching with the guardians of a newborn about the care of the umbilical stump. Which of the following instructions should the nurse include in the teaching? "Clean the umbilical stump with soap and water with each diaper change." "Loosely cover the umbilical stump with the diaper." "Sponge bathe your baby until the umbilical stump has fallen off." "Expect the umbilical stump to separate in about 4 weeks." ---------- Correct Answer ------ ---- "Sponge bathe your baby until the umbilical stump has fallen off." MY ANSWER The nurse should reinforce with guardians that submerging the umbilical stump in water can impede healing and promote infection. Therefore, the guardians should sponge bathe their newborn until the umbilical stump has fallen off. FLAG A nurse is collecting data from a newborn who is 6 hr old. Which of the following manifestations should the nurse expect? (Select all that apply.) Rust-stained urine Distended abdomen Overlapping cranial sutures Periodic breathing Yellow coloration of the sclera ---------- Correct Answer ---------- Rust-stained urine is correct. A newborn's first void can contain uric acid crystals, which will give the urine a rust-stained appearance. Distended abdomen is incorrect. A newborn's abdomen should be rounded, and dome shaped. A distended abdomen can indicate a mass or abnormalities of the abdominal wall or structures. Overlapping cranial sutures is correct. A newborn's cranial sutures should be palpable without evidence of fusion. Overlapping sutures can occur during a vaginal birth to allow passage of the fetus through the birth canal. Periodic breathing is correct. A newborn's respiratory effort is shallow and irregular and can have periods of 5 to 10 seconds with respiratory effort. Yellow coloration of the sclera is incorrect. A newborn's sclera could have a bluish hue; however, a yellow coloration can indicate hyperbilirubinemia. FLAG A nurse is reinforcing teaching with a client who is pregnant and has iron deficiency anemia. Which of the following food sources should the nurse instruct the client to include in their diet to increase absorption of an iron supplement? Oranges Bran Milk Eggs ---------- Correct Answer ---------- Oranges MY ANSWER The nurse should reinforce that consuming oranges, which are rich in vitamin C, enhances the absorption of iron supplements. The nurse should also instruct the client to take the supplement on an empty stomach. FLAG A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following findings should the nurse identify as a potential complication of phototherapy? Loose stools Decreased urinary output Axillary temperature of 37° C (98.6° F) Skin rash ---------- Correct Answer ---------- Decreased urinary output The nurse should closely monitor urinary output while the newborn is receiving phototherapy. Phototherapy can increase the rate of insensible water loss, which can lead to dehydration. The nurse should ensure the newborn is eating every 2 to 3 hr to promote adequate hydration Loose stools The nurse should identify that phototherapy causes the breakdown of bilirubin, which increases gastric motility. This increase in motility can cause an increase in bowel movements and loose stools. Decreased urinary output The nurse should closely monitor urinary output while the newborn is receiving phototherapy. Phototherapy can increase the rate of insensible water loss, which can lead to dehydration. The nurse should ensure the newborn is eating every 2 to 3 hr to promote adequate hydration. Axillary temperature of 37° C (98.6° F) The nurse should identify that an axillary temperature of 37° C (98.6° F) is within the expected reference range for a newborn. Skin rash A nurse is collecting data from an antepartum client who reports taking ferrous sulfate twice per day for the past month. The nurse should notify the provider of which of the following findings? Diarrhea Dark green stools Gingivitis Ptyalism ---------- Correct Answer ---------- Diarrhea MY ANSWER The nurse should report diarrhea to the provider because it is a potential adverse effect of the medication. Diarrhea can lead to dehydration, which can cause preterm labor. This finding should be reported to the provider Dark green stools Dark green stools are an expected adverse effect of ferrous sulfate. Gingivitis The nurse should identify that gingivitis is an expected discomfort of pregnancy caused by the increase in vascularity of connective tissue due to estrogen stimulation during pregnancy. Ptyalism The nurse should identify that ptyalism is an expected discomfort of pregnancy, caused by elevated estrogen levels. The nurse should instruct the client to eat hard candy as a comfort measure to help manage any excess saliva. FLAG A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings is the priority for the nurse to report to the provider? Saturated perineal pad within 15 min Voided 3,000 mL/day Fundus palpated to the right of the umbilicus Temperature of 37.8° C (100° F) ---------- Correct Answer ---------- Saturated perineal pad within 15 min MY ANSWER A saturated perineal pad within 15 min can indicate a cervical or vaginal tear. Therefore, the nurse should report this finding to the provider immediately. Voided 3,000 mL/day The nurse should identify that the postpartum client drinks more fluid after birth and might experience diuresis. The nurse should report this finding to the provider. However, there is another finding that the nurse should report first. Fundus palpated to the right of the umbilicus While the fundus should be at 1 fingerbreadth 24 hr after delivery, another finding is the nurse's priority to report to the provider. The fundus can rise due to the bladder filling. The nurse should instruct the client to void. Temperature of 37.8° C (100° F) The nurse should monitor the client for an increase in temperature as postpartal infections can occur. The nurse should report an increase in the client's temperature to the provider. However, there is another finding that the nurse should report first. FLAG A nurse in a prenatal clinic is reinforcing nutritional teaching with a client who is at 10 weeks of gestation. Which of the following statements by the client indicates an understanding of the instructions? "I eat a 6-ounce can of white tuna every other day." "I make sure that I get 1,000 milligrams of calcium per day." "I am consuming 300 micrograms of folate each day." "I limit my caffeine intake to three cups of coffee each day." ---------- Correct Answer ----- ----- "I make sure that I get 1,000 milligrams of calcium per day." MY ANSWER The client should consume a minimum of 1,000 mg of calcium daily during pregnancy to support fetal bone and tooth development "I eat a 6-ounce can of white tuna every other day." The client should not consume more than 12 oz of white tuna per week during pregnancy due to the risk of mercury poisoning. Mercury is a teratogen to the fetus and can affect the development of the fetal nervous system. "I am consuming 300 micrograms of folate each day." The client should consume 600 mcg of folate each day during pregnancy. Adequate folate intake decreases the risk of neural tube defects in the fetus. "I limit my caffeine intake to three cups of coffee each day." The client should limit caffeine intake to 200 mg per day during pregnancy. Excessive caffeine intake can lead to intrauterine growth restriction in the fetus. One cup of coffee contains approximately 100 mg of caffeine. Therefore, the client should consume no more than 2 cups per day. FLAG A nurse is assisting with discharge teaching about pain management to a client who had a cesarean birth and is experiencing gas pains. Which of the following instructions should the nurse include in the teaching? Drink fluids through a straw. Rock in a rocking chair. Lie supine when in bed. Consume whole milk with meals. ---------- Correct Answer ---------- Rock in a rocking chair. MY ANSWER The nurse should instruct the client that rocking in a rocking chair can help to relieve gas pains by aiding the client in expelling the gas Drink fluids through a straw. The nurse should instruct the client that drinking through a straw might cause them to swallow more air, which can increase the retention of excess gas in the intestines. Rock in a rocking chair. MY ANSWER The nurse should instruct the client that rocking in a rocking chair can help to relieve gas pains by aiding the client in expelling the gas. Lie supine when in bed. The nurse should instruct the client that lying on their left side could help to expel gas and relieve gas pains. Consume whole milk with meals. The nurse should instruct the client to avoid gas-forming foods and drinks, such as whole milk and carbonated beverages FLAG A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings indicates that the client is at risk for dehydration? Hematuria Sodium 140 mEq/L Potassium 3.5 mEq/L Ketonuria ---------- Correct Answer ---------- Ketonuria MY ANSWER Ketonuria indicates an excessive amount of ketones in the urine. When ketones are found in the client's urine, the initial indication is dehydration. Therefore, this is the most important initial laboratory test for clients who have hyperemesis gravidarum. The fluid volume deficiency and dehydration are directly related to excessive vomiting Hematuria Hematuria is not a manifestation of hyperemesis gravidarum and does not place the client at risk for dehydration. Sodium 140 mEq/L This sodium level is within the expected reference range of 136 to 145 mEq/L and does not place the client at risk for dehydration. Potassium 3.5 mEq/L Increase the rate of the client's IV fluids ---------- Correct Answer ---------- Place the client in a side-lying position. MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should identify that late decelerations indicate a disruption of oxygen to the fetus. Therefore, the first action the nurse should take is to place the client in a side-lying position to maximize blood flow to the placenta and increase oxygen transfer to the fetus. Palpate the client's uterus to check for tachysystole. The nurse should palpate the client's uterus to monitor for tachysystole because tachysystole decreases blood flow to the placenta and limits the amount of oxygen transferred to the fetus. However, there is another action the nurse should take first. Place the client in a side-lying position. MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should identify that late decelerations indicate a disruption of oxygen to the fetus. Therefore, the first action the nurse should take is to place the client in a side-lying position to maximize blood flow to the placenta and increase oxygen transfer to the fetus. Administer oxygen at 10 L/min via nonrebreather face mask. The nurse should administer oxygen via nonrebreather face mask to the client to maximize oxygen transfer to the fetus. However, there is another action the nurse should take first. Increase the rate of the client's IV fluids. The nurse should increase the rate of the client's IV fluids to increase blood volume, thereby increasing blood flow to the placenta and oxygen transfer to the fetus. However, there is another action the nurse should take first. FLAG A nurse is caring for a postpartum client who has an episiotomy. Which of the following actions should the nurse take? Apply an anesthetic spray to the client's perineal area as needed for pain. Place a donut pillow under the client when sitting in a chair. Apply a moist heat pack to the client's perineal area for 20 min every hour for the first 24 hr after delivery. Assist the client with changing the perineal pad every 8 hr to expedite healing ---------- Correct Answer ---------- Apply an anesthetic spray to the client's perineal area as needed for pain. MY ANSWER The nurse should apply an anesthetic spray to the episiotomy site as needed to decrease pain. Place a donut pillow under the client when sitting in a chair. The nurse should not place a donut pillow under the client when the client sits in a chair. The client should avoid sitting on a donut pillow because it can separate the episiotomy site and impair healing. Apply a moist heat pack to the client's perineal area for 20 min every hour for the first 24 hr after delivery. The nurse should apply a covered ice pack to the perineal area for the first 24 hr following an episiotomy to decrease pain and swelling. Assist the client with changing the perineal pad every 8 hr to expedite healing. The nurse should assist the client with changing the perineal pad a minimum of every 6 hr, with every voiding, and as needed if the pad becomes saturated. Changing the pad every 8 hr delays healing because moisture remains against the client's skin for an extended period of time. This also provides a medium for bacterial growth, which increases the risk of infection. FLAG A nurse in an antepartum clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following findings should the nurse report to the provider? Hematocrit of 35% Weight increase of 3 kg (6.6 lb) in one month Urine dipstick negative for ketones Fetal heart auscultated just above the symphysis pubis ---------- Correct Answer ---------- Weight increase of 3 kg (6.6 lb) in one month The nurse should report a weight increase of 3 kg (6.6 lb) in one month because this is excessive weight gain for the first trimester of pregnancy. A client with a normal prepregnancy weight should gain 1 to 2 kg (2.2 to 4.4 lb) during the first trimester and 0.4 kg (0.9 lb) per week during the second and third trimesters. Hematocrit of 35% MY ANSWER The nurse should identify that a hematocrit greater than 33% during pregnancy is within the expected reference range. Due to the increase in maternal blood volume, physiologic anemia occurs secondary to hemodilution. The nurse should report a hematocrit less than 33% to the provider. Weight increase of 3 kg (6.6 lb) in one month The nurse should report a weight increase of 3 kg (6.6 lb) in one month because this is excessive weight gain for the first trimester of pregnancy. A client with a normal prepregnancy weight should gain 1 to 2 kg (2.2 to 4.4 lb) during the first trimester and 0.4 kg (0.9 lb) per week during the second and third trimesters. Urine dipstick negative for ketones The nurse should identify that a urine specimen that is negative for ketones is an expected finding. Ketonuria is an indication of dehydration and should be reported to the provider. Fetal heart auscultated just above the symphysis pubis The nurse should identify that the gravid uterus can be palpated just above the symphysis pubis between 12 and 14 weeks of gestation. Therefore, fetal heart tones auscultated just above the symphysis pubis is an expected finding at 12 weeks of gestation. FLAG A clinic nurse is reviewing dietary instructions with a client who is at 20 weeks of gestation and taking iron supplements. Which of the following statements by the client indicates an understanding of the instructions? "I should take my iron with a cup of coffee." "I should double my iron dose if I forget and miss a day." "I should increase my fluid intake while I am taking iron." "I should limit the fiber in my diet because I am taking iron." ---------- Correct Answer ----- ----- "I should increase my fluid intake while I am taking iron." MY ANSWER The client should increase their fluid intake while taking iron to help lessen the occurrence of constipation, which is a common adverse effect of iron supplements "I should take my iron with a cup of coffee." The client should avoid taking the iron supplement with coffee because coffee interferes with the absorption of iron. "I should double my iron dose if I forget and miss a day." The nurse should instruct the client not to take two doses of the iron supplement at one time. If the client misses a dose, they can take the missed dose of the iron supplement if it is within 12 hr of the scheduled time. "I should increase my fluid intake while I am taking iron." MY ANSWER The client should increase their fluid intake while taking iron to help lessen the occurrence of constipation, which is a common adverse effect of iron supplements. "I should limit the fiber in my diet because I am taking iron." The client should eat a diet high in fiber and fluids to help lessen the occurrence of constipation, which is a common adverse effect of iron supplements. FLAG A nurse is reviewing the laboratory results for a client who has a BP of 156/102 mm Hg and is at 36 weeks of gestation. Which of the following laboratory values should the nurse report to the provider? WBC 11,000/mm3 Hct 35% Platelet count 100,000/mm3 Fasting blood glucose 105 mg/dL ---------- Correct Answer ---------- Platelet count 100,000/mm3 "I know I shouldn't put lotions or creams near the umbilical cord." The nurse should reinforce that creams, lotions, and oils can slow drying and encourage infection. "I will notify my provider if the cord becomes moist and red." The nurse should reinforce that a moist and red umbilical cord is a clinical finding of infection and the guardian should notify the provider. "I will give my newborn a bath once daily." The nurse should reinforce with the guardian to avoid giving the newborn a daily bath because it can damage the integrity of the newborn's skin. "I will fold the diaper below the umbilical cord." MY ANSWER The nurse should reinforce with the guardian to fold the diaper below the umbilical cord to keep it clean and dry. This will help to prevent infection. A nurse in a clinic is caring for a client who tests positive for gonorrhea. Which of the following findings should the nurse expect during data collection? ---------- Correct Answer ---------- chronic pelvic pain A nurse is reinforcing dietary teaching with a client who is at 10 weeks of gestation. which of the following foods should the nurse identify as containing the highest amount of folate? ---------- Correct Answer ---------- 3 1/2 oz of beef liver A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse report to the provider as potentially indicating a complication of pregnancy? Insomnia Breast tenderness Frequent headaches Leg cramps ---------- Correct Answer ---------- frequent headaches Manifestations such as frequent headaches, visual disturbances, swelling of the face or fingers, and epigastric pain are manifestations of preeclampsia or hypertensive conditions during pregnancy. The nurse should identify frequent headaches as a potential complication of pregnancy and report this manifestation to the provider. Insomnia Insomnia is a common discomfort that occurs during the third trimester of pregnancy which is associated with increased fetal movements and urinary frequency. The nurse should reinforce teaching with the client regarding nonpharmacological interventions to decrease insomnia and promote rest. Breast tenderness Breast tenderness is a common discomfort which is caused by increased vascularity of the breasts that occurs in clients during the first trimester of pregnancy. Leg cramps Leg cramps are a common discomfort that occurs during the third trimester of pregnancy which is caused by the uterus compressing the lower peripheral nerves. A nurse is assisting with collecting data from a newborn who is 4 hr old. which of the following findings is the priority for the nurse to report to the provider? Generalized petechiae Cephalhematoma Heart rate 170/min Temperature 36.4° C (97.6° F) ---------- Correct Answer ---------- generalized petechiae When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is generalized petechiae. This finding is a potential indication of a severe infection or a clotting factor deficiency and should be immediately reported to the provider. provider. Cephalhematoma Cephalhematoma is a condition in the newborn where blood collects between the skull and the periosteum. It usually resolves independently within 2 to 8 weeks. It is considered a nonurgent condition; therefore, there is another finding that is the priority. Heart rate 170/min A heart rate of 170/min is outside of the expected reference range of 120 to 160/min; however, the newborn's heart rate can increase during the first few hours after birth due to increased incidences of crying. If the newborn's heart rate continues to increase, the nurse should contact the provider. However, there is another finding that is the priority. Temperature 36.4° C (97.6° F) A temperature of 36.4° C (97.6° F) is below the expected reference range of 36.5° to 37.8° C (97.7° to 100° F) for a newborn; however, this finding is considered an expected deviation for the newborn due to heat loss after birth caused by evaporation. The nurse should intervene to correct the drop in temperature; however, there is another finding that is the priority. A clinic nurse is reviewing dietary instruction with a client who is at 20 weeks of gestation and taking Iron supplements. which of the following statements by the client indicates an understanding of the instructions? ---------- Correct Answer ---------- I should increase my fluid intake while I am taking iron A nurse in a clinic is assisting with the plan of care for a client who is at 36 weeks of gestation. Which of the following actions should the nurse include in the plan of care? --- ------- Correct Answer ---------- obtain a culture for group B streptococcus B-hemolytic A nurse in a prenatal clinic is reinforcing nutritional teaching with a client who is at 10 weeks of gestation. Which of the following statements by the client indicates an understanding of the instructions? ---------- Correct Answer ---------- I make sure that I get 1,000 milligrams of calcium per day A nurse is assisting with the admission of a client who has pertussis and is at 28 weeks of gestation. which of the following types of transmission based isolation precautions should the nurse initiate for the client? Airborne Contact Droplet Protective environment ---------- Correct Answer ---------- droplet The nurse should initiate droplet precautions for a client who has pertussis. Droplet precautions include a private room or cohorting of clients and the use of a mask when providing client care. Other infections that require droplet precautions include rubella, pneumonia, and influenza. Airborne Airborne precautions are for clients who have infections such as measles, varicella, or tuberculosis. Airborne precautions include a private room with negative-pressure airflow and the use of a respiratory protection device. Contact Contact precautions are for clients who have infections such as herpes simplex, methicillin-resistant Staphylococcus aureus, and wound infections. Contact precautions include a private room or cohorting of clients and wearing gloves and a gown when providing client care. Protective environment Protective environment precautions are for clients who are immunocompromised, such as clients who have received stem cell transplants. A protective environment includes a private room with positive-pressure airflow with at least 12 air exchanges per hour. A nurse is reinforcing teaching with a client who is pregnant and has iron deficiency anemia. which of the following food sources should the nurse instruct the client to include in their diet to increase absorption of an iron supplement? ---------- Correct Answer ---------- oranges Large for gestational age ---------- Correct Answer ---------- excessive sucking The neurotoxic effects of cocaine can lead to excessive sucking and poor feeding patterns in the newborn. Additional manifestations include irritability, hypertonicity, tremors, and abnormal sleep patterns. A nurse is reinforcing teaching about daily fetal movement count with a client who is at 34 weeks of gestation. which of the following statement by the client indicates an understanding of the teaching? ---------- Correct Answer ---------- I will notify my provider if I do not feel my baby move for 12 hours a nurse is collecting data from a newborn who is 6 hr old. which of the following manifestation should the nurse expect? ---------- Correct Answer ---------- Rust-stained urine, overlapping cranial sutures, periodic breathing A nurse is collecting data from a client who is 24 hr postpartum. which of the following findings is the priority for the nurse to report to the provider? ---------- Correct Answer ---- ------ saturated perineal pad within 15 min a nurse is collecting data from an antepartum client who reports taking ferrous sulfate twice per day for the past month. the nurse should notify the provider of which of the following findings? ---------- Correct Answer ---------- diarrhea A nurse is reviewing the laboratory reports of four newborns. which of the following laboratory results should the nurse report to the provider> ---------- Correct Answer ------- --- Hgb 10 g/dL a nurse is reinforcing teaching with a client who plans to use a modified paced breathing technique to relieve labor pain. which of the following instructions should the nurse include in the teaching? "Initiate modified-breathing when you can no longer talk through contractions." "Begin and end modified-breathing with a deep cleansing breath." "Breathe at half your normal breathing rate when using a modified-breathing pattern." "Concentrate on your level of pain when using a modified-breathing pattern." ---------- Correct Answer ---------- begin and end modified breathing with a deep cleansing breath A nurse is reinforcing teaching with a client who is at 8 wks gestation and has chlamydia. which of the following statements should the nurse include? ---------- Correct Answer ---------- after treatment, you will need another test in 3 wks and again between 35 and 37 wks breech position ---------- Correct Answer ---------- Myelomeningocele (spina bifida) ---------- Correct Answer ---------- tonic neck reflex ---------- Correct Answer ---------- A nurse is collecting data from a newborn who has Down syndrome. Which of the following findings should the nurse expect in a term newborn who has Down syndrome? Hypotonic muscle tone Abundant lanugo over the shoulders A two-vessel umbilical cord A large anterior fontanel ---------- Correct Answer ---------- Hypotonic muscle tone MY ANSWER The nurse should expect a newborn who has Down syndrome to display hypotonicity. Other manifestations include epicanthal folds, small ears, and a single palmar crease. Abundant lanugo over the shoulders The nurse should expect abundant lanugo on a newborn who is born prematurely. A two-vessel umbilical cord A two-vessel umbilical cord is not an expected finding in a newborn who has Down syndrome. Two arteries and one vein transport blood back and forth to the embryo. A two-vessel cord might indicate a congenital malformation. A large anterior fontanel The nurse should expect a large anterior fontanel in a newborn who has increased intracranial pressure A nurse is assisting with performing Leopold maneuvers on a client who is at 39 weeks of gestation. Which of the following images indicates that the fetus is in the complete breech position? ---------- Correct Answer ---------- The fetus is in the complete breech position when the buttocks of the fetus lies over the client's cervix. There is flexion of the hips and knees of the fetus. FLAG A nurse in an antepartum clinic is reinforcing teaching with a client who is at 32 weeks of gestation and is scheduled for a nonstress test. Which of the following information should the nurse include in the teaching? "You will be lying on your back during the test." "You will be given IV oxytocin to stimulate contractions during the test." "You will be asked to press a button when you feel your baby move during the test." "You will need to drink at least 32 ounces of fluid to fill your bladder before the test." ----- ----- Correct Answer ---------- "You will be asked to press a button when you feel your baby move during the test." The nurse should instruct the client to press a hand-held button attached to the monitor when they feel the baby move. Pressing the hand-held button will help to accurately correlate fetal movement with the fetal heart rate. "You will be lying on your back during the test." The nurse should instruct the client that they will be positioned in a reclining chair at a slight lateral tilt. This position prevents the uterus from compressing the vena cava, thereby increasing uterine perfusion. "You will be given IV oxytocin to stimulate contractions during the test." The nurse should instruct the client that a nonstress test is noninvasive. The client will not receive IV oxytocin to stimulate contractions during a nonstress test. "You will need to drink at least 32 ounces of fluid to fill your bladder before the test." The nurse should instruct the client that they do not need to have a full bladder for this test. The client should void prior to testing. FLAG A nurse is planning to administer phytonadione IM to a newborn shortly after birth. The nurse should identify that this medication is administered to prevent which of the following complications? Ophthalmia neonatorum Hemorrhagic disease Hypoglycemia Hypothermia ---------- Correct Answer ---------- Hemorrhagic disease The nurse should administer phytonadione because the newborn does not produce vitamin K on their own until 7 days of age, when intestinal flora is present in the newborn's gastrointestinal tract. Therefore, this medication is administered to prevent hemorrhagic disease in the newborn until spontaneous production of vitamin K takes place.