MATERNAL NEWBORN PROCTORED RETAKE 2024 GRADED A LATEST VERSION UPDATED APRIL 2025 CONTAINI, Exams of Nursing

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MATERNAL NEWBORN PROCTORED RETAKE 2024 GRADED A

LATEST VERSION UPDATED APRIL 2025 CONTAINING

DIFFERENT VERSIONS WITH QUESTIONS AND VERIFIED

ANSWERS ALREADY GRADED A

1. A nurse is caring for a client who is 2 weeks postpartum following a cesarean birth. Which of the following clinical findings should the nurse identify as an indication of postpartum infection? a. Unilateral breast pain b. Stretch marks c. Lochia alba d. WBC 12,
2. A nurse is assessing a client who has preeclampsia during a prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood glucose 110 b. DTR 2+ c. Urine protein 3+ d. Hemoglobin 13
3. A nurse is providing teaching about the expected effects of magnesium sulfate to a client who is at 28 weeks gestation and has preeclampsia. Which of the following responses by the nurse is appropriate? a. “This medication increases cardiac output” b. “This medication improves tissue perfusion.” c. “This medication stabilizes the fetal heart rate.” d. “This medication prevents seizures”
4. A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include? a. “You will have dilation and effacement of the cervix” b. “Your contractions will become temporarily regular” c. “You will have bloody show.” d. “Your contractions will become more intense when walking.”
5. A nurse manager is revising a maternal unit policy to ensure the proper identification of newborns. Which of the following should the nurse include in the policy? a. Check the newborn’s identification using the crib card. b. Replace the infant’s identification band after his name has been recorded. c. Require visitors to wear an identification band.

d. Obtain an imprint of the infant’s feet prior to taking him to the nursery.

6. A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take? a. Apply an ice pack to the incision cite. b. Replace the surgical dressing. c. Administer 500 mL LR IV bolus d. Evaluate Urinary Output.
7. A nurse is providing discharge instructions to a client who is postpartum and has engorged breasts. Which of the following nonpharmacological comfort measures should the nurse include in the teaching? a. Wear nipple shields during the feeding. b. Use a breast binder for 2 days.

c. Use plastic-lines breast pads. d. Apply cabbage leaves after feedings

8. A nurse is calculating the estimated date of birth using Nagele’s rule for a client who is pregnant and whose last menstrual cycle started June 21. Which of the following is the estimated date of delivery in the next year? a. March 14 b. March 21 c. March 28 d. April 4
9. A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take? a. Inform the client that the law requires her to name the fetus. b. Limit the amount of time the fetus is in the client’s room. c. Instruct the client that an autopsy should be performed within 24 hours. d. Prepare the client for what to expect the fetus to look like.
10. A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client’s arms, the mother states, “No, the baby is too tired to be held.” Which of the following actions should the nurse take? a. Demonstrate how to hold the newborn and allow the client to practice b. Persuade the client to breastfeed the newborn to promote bonding. c. Offer to take the newborn to the nursery to finish his feeding. d. Insist that the mother pick up the newborn to feed him.
11. A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client? a. Intense contractions lasting 45-60 seconds b. An urge to have a bowel movement during contractions c. A sense of excitement and warm, flushed skin d. Progressive sacral discomfort during contractions
12. A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider? a. Hemoglobin

b. Urine protein concentration 200mg/24hr c. Creatinine 0. d. Platelet count 60,

13. A nurse in a clinic is preparing to measure the fundal height of a client who is pregnant. Which of the following actions should the nurse take? a. Lay the tape measure horizontally over the middle of the client’s abdomen b. Place the client in a left-lateral position to obtain the measurement. c. Ensure that the client has a full bladder before taking the measurement d. Measure from the upper border of the symphysis pubic to the upper border of the fundus.
14. A nurse is caring for a client who is at 20 weeks of gestation and reports constipation. Which of the following recommendations should the nurse make to help relieve this common discomfort of pregnancy?

a. Include 18g/day of fiber in the diet b. Drink 2-3 L of water each day c. Add 30 mL of mineral oil to each meal. d. Take 60 mL of magnesium hydroxide once daily.

15. A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. Whn using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heartbeat. Which of the following terms should the nurse use to document this finding? a. Goodell’s Sign b. Funic souffle c. Quickening d. Hegar’s Sign
16. A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask b. Place newborn bassinets at least 3 feet apart c. Place the newborn’s foot on a sterile field during a heelstick d. Maintain airborne precautions in the nursey
17. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. The nurse notes a respiratory rate of 8/min and absent DTR’s. Which of the following medications should the nurse administer? a. Phytonadione b. Acetylcysteine c. Protamine Sulfate d. Calcium gluconate.
18. A nurse is caring for a client who is 8 hours postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? a. Apply suprapubic pressure b. Administer a diuretic to the client c. Insert an indwelling urinary catheter d. Encourage the client to void in the shower
19. A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. “Mothers will receive prophylactic treatment with acyclovir prior to delivery.” b. “Transmission can occur via the saliva and urine of the newborn” c. “This infection requires airborne precautions to be initiated for the newborn.” d. “Lesions are visible on the mother’s genetalia.”
20. A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory test used to evaluate this condition? a. Liver enzymes b. CBC c. Urine ketones d. Thyroid levels
21. A nurse in a prenatal clinic is reviewing the lab results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? (Exhibit question*) a.

Administer ceftriaxone IM b. Administer rubella vaccine c. Obtain a maternal serum alpha-fetoprotein specimen d. Obtain a blood culture

22. A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching? a. “Your risk of pregnancy is greatest on days 21-28 of your cycle.” b. “You should take your temperature before getting up for the day.” c. “You should abstain from intercourse when your temperature is above 100 F.” d. “Your temperature may increase slightly immediately prior to ovulation.”
23. A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? a. “You will lie on your side for 40 minutes after I administer the medication.” b. “I will begin an oxytocin infusion within 2 hours of your last dose of medication.” c. “You will receive an antacid containing magnesium before this medication.” d. “I will insert a nurinary catheter before I administer the medication.”
24. A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? a. The client will identify individual family member roles b. The client will have adequate nutritional intake c. The client will verbalize appropriate car seat safety d. The client will demonstrate proper bathing of the infant
25. A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching? a. “Limit your fluid intake to four 8-ounce glasses per day.” b. “Count your baby’s movements daily.” c. “Reduce your calcium intake to less than 1 gram per day.” d. “Alternate arms each time you check your blood pressure.”
26. A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? a. “We need to know if you are positive for GBS at the time of delivery.” b. “There was no indication of GBS in your earlier prenatal testing.” c. “You didn’t report ay symptoms of GBS during your pregnancy.” d. “Your previous deliveries were all negative for GBS.”
27. A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider? a. Single palmar creases b. Transient circumoral cyanosis c. Rust-stained urine d. Subconjunctival hemorrhage

28. A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? a. Respiratory Rate 18/min b. Cool, clammy skin c. Urine output 30 mL/hr d. Bounding pulses
29. A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? a. “You can take 400 mg of ibuprofen for discomfort.” b. “You should take 600 micrograms of folic acid per day.” c. “You can take black cohosh once a day for insomnia.” d. “You should limit your daily fluid intake to 1000 mL/day.”
30. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? a. Increase infusion rate every 30-60 minutes. b. Maintain the client in a supine position c. Limit IV intake to 4L/24 hours d. Titrate infusion rate by 4 miliunits/min
31. A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? a. “You should expect your uterus to double in tize.” b. “Your stomach will empty rapidly.” c. “Your nipples will become lighter in color.” d. “You should expect nasal stuffiness.”
32. A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take? a. Verify that the informed consent is obtained prior to administration b. Allow the medication to reach room temperature prior to administration c. Instruct the client to avoid urinary elimination until after administration d. Place the client in a semi-Fowler’s position for 1 hour after administration
33. A nurse is preparing to administer metronidazole 2 g PO to a client who has pelvic inflammatory disease. Available is metronidazole 500 mg tablets. How many tablets should the nurse administer? (round to the nearest whole number) a. 4 tablets
34. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend for an interdisciplinary care conference? a. A client who is at 37 weeks of gestation and has an L/S ratio 2: b. A client who is at 35 weeks of gestation and has a biophysical profile of 6 c. A client who is at 39 weeks of gestation and has a negative contraction stress test d. A client who is at 28 weeks of gestation and has a negative coombs titer
35. A nurse is planning to teach a group of clients who are pregnant about breastfeeding after returning to work. Which of the following information should the nurse include in the teaching?

a. “Thawed breast milk that is unused can be refrozen.” b. “Breast milk can be stored at room temperature for up to 12 hours.” c. “Breast milk can be stored in a deep freezer for 12 months.” d. “Thawed breast milk cna be refrigerated for up to 72 hours.”

36. A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect? a. Erythema toxicum b. Periauricular papillomas c. Telangiectatic nevi d. Facial petechiae
37. A nurse is assessing a newborn upon admission to the nursery. Which of the following findings should the nurse expect? a. Length from head to heel of 40 cm b. Bulging fontanels c. Chest circumference 2 cm smaller than the head circumference d. Nasal flaring
38. A nurse is assisting with precipitous delivery of a term newborn. After the head emerges, the nurse palpated the cord around the newborn’s neck. Which of the following actions should the nurse take? a. Apply fundal pressure b. Place the client in the knee-chest position c. Apply a water-based lubricant to the cord d. Slip the cord over the newborn’s head.
39. A nurse is planning care for a newborn who is to undergo a circumcision using a plastic bell device. Which of the following interventions should the nurse include in the plan of care? a. Wash the circumcision site with mild soap and water 24 hours following the procedure b. Take off the plastic bell 2 hours after the procedure c. Monitor for bleeding every 15 minutes for the first hour d. Remove the yellow drainage on the second postoperative day
40. A nurse is providing discharge instructions to a client who is 24 hours postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching? a. “Shower daily, allowing warm water to run directly over your breasts.” b. “Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule.” c. “Weat a loos-fitting, nonbinding bra for 72 hours.” d. “Pump your breasts twice daily to relieve discomfort from engorgement.”
41. A nurse is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hours postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication? a. Respiratory rate 14/min b. Blood pressure 142/ c. Urine output 100 mL in 3 hr d. Pulse 58/min

42. A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has molding with overlapping suture lines b. A female newborn who has blood-tinged vaginal discharge c. A newborn who has a high-pitched cry with exaggerated Moro reflex. d. A male newborn who has scrotal edema
43. A nurse in a provider's office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make? a. “We cna schedule the procedure for later today if you’d like.” b. “You cannot have an amniocentesis until you are at least 35 years of age.” c. “This procedure determines if your baby has genetic or congenital disorders.” d. “Your provider will schedule a chorionic villus sampling to determine the sex of your baby.”
44. A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain following the administration of oxycodone/acetaminophen. Which of the following actions should the nurse take first? a. Resposition the client b. Apply an ice pack to the client’s perineum c. Assess the client’s perineal area for swelling d. Administer ibuprofen to the client
45. A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor? a. Chorioamnionitis b. Vaginal laceration during birth c. Excessive bleeding after birth d. oligohydramnios
46. A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take? a. Decrease the rate of IV fluids b. Elevate the client’s head c. Administer oxygen via a face mask d. Perform fetal scalp stiulation
47. A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction? a. Keep the newborn in a side-lying position b. Restrict the newborn’s fluid intake c. Cover the newbor’s bladder with a sterile, non-adherent dressing d. Exert gentle pressure on the newborn’s bladder with sterile gauze
48. A nurse is reviewing the laboratory report for a client who is 24 hours postpartum vaginal delivery. The client has a Hgb 9.0 and Hct of 25%. Which of the following actions should the nurse take? a. Initiate IV access for isotonic solution with an 18-gauge catheter. b. Prepare the client for a blood transfusion

c. Administer an iron supplement to the client d. Instruct the client that the provider will check for placental fragments

49. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for severe preeclampsia. Which of the following findings should the nurse report to the provider? a. DTR 2+ b. Absence of clonus c. Facial flushing d. Urine output 20 mL/hr
50. A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? a. Place an ice pack on the newborn’s heel 5 min before the procedure b. Cleanse the newborn’s heel with an alcohol swab after the procedure c. Use an automatic puncture device on the heel d. Puncture the heel in the inner aspect of the foot
51. A nurse is caring for a client who has bladder distension following a vaginal birth. Which of the following actions should the nurse take first? a. Assist the client to the bathroom. b. Offer the client a sitz bath c. Insert a urinary catheter d. Pour warm water over the client’s perineum
52. A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? a. Lentils b. Oatmeal c. Cabbage d. asparagus
53. A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? a. Proteinuria b. Hyperemesis c. hypoxia d. Hemorrhage
54. A nurse is in a clinic caring for a client who is in her second trimester of pregnancy. The client expresses concern about preparing her 2-year-old for a new sibling. Which of the following is an appropriate response by the nurse? a. “Move your toddler to his new bed 2 months before the baby comes home.” b. “Let the toddler see you carrying the baby into the home for the first time.” c. “Avoid bringing your toddler to prenatal visits.” d. “Require scheduled interactions between toddler and the baby.”
55. A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The nurse should recognize that pregnancy is a contraindication to the administration of which of the following medications? a. Azithromycin b. Metformin c. Diphenhydramine d. Isotretinoin
56. A nurse is assessing a client who is at 39 weeks of gestation and determined that the fetus is in a left occipitoanterior position (LOA). On which of the following sites should

the nurse place the external fetal monitor to hear the point of maximum impulse of the FHR? a. Place the fetal monitor on the LLQ

57. A nurse is reviewing the immunization status of a client who is pregnant. The nurse should inform the client that it is safe for her to receive which of the following immunizations during pregnancy? a. Varicella b. rubella c. Tetanus d. rubeola
58. A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider? a. Creatinine 0. b. WBC 11, c. Fasting blood glucose 180 mg/dL d. Hematocrit 35%
59. A nurse is caring for a client who is at 35 weeks of gestation and is on bed rest due to preeclampsia. Which of the following is an important action for the nurse to take? a. Maintain NPO status b. Obtain BP every 8 hours c. Keep the lights dimmed in the room d. Auscultate fetal heart tones twice per day
60. A nurse is caring for a client who is klvgbi/ postpartum and states “I want to continue breastfeeding, but my nipples are sore.” Which of the following responses should the nurse make? a. “Removing the breast shields from your bra will decrease discomfort.” b. “You should switch your infant to formula until the soreness goes away.” c. “Allow expressed mild to air dry on the nipples after feeding your infant.” d. “Apply an antibiotic ointment to the nipples prior to each feeding.”
61. A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn’s mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. a. Assess the newborn for reflex bradycardia b. Compress the bulb syringe c. Use the bulb syringe to suction the newborn’s nose d. Place the bulb syringe in the newborn’s mouth Correct order: B, D, C, A
62. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who reports abdominal pain during breastfeeding b. A client who reports changing her perineal pad every 2 hours c. A client who has a urine output of 250 mL in 6 hours d. A client who has hyporeflexia while receiving magnesium sulfate
63. A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching? a. “Insert the diaphragm up to 12 hours before intercourse.” b. “Remove the diaphragm 2 hours after intercourse.”

c. “Replace the diaphragm every 2 years.” d. “Use 2 teaspoons baby oil to lubricate the diaphragm before insertion.”

64. A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determined the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? a. Hyperemesis gravidarum b. Postpartum hemorrhage c. Incompetent cervix d. Ectopic pregnancy
65. A nurse is providing vehicle safety education to parents of a premature newborn. Which of the following statements should the nurse include in the teaching? a. “You should secure your newborn’s car seat at a 60 degree angle.” b. “Your newborn will need to have a car seat prior to discharge.” c. “Place your newborn in a front-facing car seat in the back seat of the vehicle.” d. “Position the retainer clip at the level of your newborn’s abdomen.”
66. A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? a. Allow the baby to feed at least every 3 hours b. Offer the newborn 30 mL (1 oz.) of water between feedings c. Expect 2-4 wet diapers every 24 hours d. Feed the newborn 5-10 minutes each breast
67. A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicated a complication? a. Hypotonic uterus b. Hct 36% c. Platelet count 370, d. Perineal edema
68. A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.) a. Labor induction with oxytocin b. History of uterine atony c. Newborn weight 2.948 kg (6lb 8oz) d. History of human papilloma virus e. Vacuum-assisted delivery
69. A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider? a. Temperature of 36.5 C (97.7 F) b. Blood Pressure 80/ c. RR 55/min d. HR 72/min
70. A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following findings should the nurse report to the provider? (Select all that apply) a. RR 11/min b. Urine output 130 mL/4hr

c. Absent DTRs d. Fetal heart rate 120/min e. Flushing face

71. A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following findings indicated narcotic withdrawal? a. Excessive crying b. Unequal pupils c. Respiratory rate of 50/min d. hypotonia
72. A client and her partner ask the nurse for information about permanent contraception. Which of the following statements should the nurse include in the counseling? a. “Most sterilization procedures are considered irreversible.” b. “A woman should use contraception for 1-2 months after a tubal ligation” c. “A man is usually sterile immediately after a vasectomy” d. “The menstrual cycle is shorter after a tubal ligation”
73. A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client includes an understanding of the teaching? a. Premenstrual tension will no longer be present b. Ovulation will remain the same c. Hormone replacements will be needed following this procedure d. My monthly menstrual period will be shorter
74. A nurse is admitting a client who is in preterm labor to the labor and delivery unit. The nurse should anticipate which of the following tests to assess for fetal lung maturity? a. lecithin/sphingomyelin ratio b. Direct coombs test c. Biophysical profile d. Chorionic villi sampling
75. A nurse is assessing a newborn who is 2 hours old. Which of the following findings should the nurse report to the provider? a. Transient nystagmus b. Overlapping sutures with molding c. Single transverse palmar crease bilaterally d. Lanugo on the pinna of the ears
76. A nurse is planning care for a newborn who is large for gestational age due to maternal gestational diabetes mellitus. The nurse should recognize that the newborn is at risk for which of the following conditions? (Select all that apply.) a. Polycythemia b. Hypoglycemia c. Hyperbilirubinemia
77. A nurse is discussing family planning with a client who has a history of DVT. The nurse should inform the client that this condition is a contraindication for which of the following birth control methods? a. Oral contraceptives b. Cervical cap c. Diaphragm d. Intrauterine device

78. A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed? a. The newborn is beginning to cough b. The newborn’s respiratory rate is irregular c. The newborn’s pulse oximetry is 91% d. The newborn’s respiratory rate is 32/min
79. A nurse is providing teaching to the parents of a newborn about the plasti bell circumcision technique. Which of the following information should the nurse include? a. Yellow exudate will form at the surgical site in 24 hours b. The plastibell will be removed 4 hours after the procedure c. Make sure the newborn’s diaper is snug d. Notify the provider if the end of your baby’s penis appears dark red
80. A nurse in a prenatal clinic is discussing quickening with a client who is in the first trimester of her first pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. I will feel movement at about 16-20 weeks
81. A nurse on the postpartum unit is reviewing the prevention of new diaper rash with a client. Which of the following statements indicated an understanding of the teaching? a. I will allow the diaper area to dry before applying a clean diaper
82. A nurse is caring for a client who is in active labor. The nurse administers butorphanol IV bolus for pain. Which of the following findings should the nurse report to the provider following this medication? a. Respiratory rate 10/min b. Moderate fetal heart rate variability c. Urinary output 120 mL/2 hr d. Blood pressure 136/
83. A nurse is caring for a client who is in the first stage of labor and the fetal head is in a posterior position. The client reports pressure and pain in her lower back. Which of the following non-pharmacological comfort measures should the nurse suggest first? a. Counter pressure
84. A nurse is providing discharge teaching to the parent of a newborn about surgical site care following circumcision using a clamp technique. Which of the following statements by the parent indicated understanding? a. I will check the site hourly for bleeding b. I will remove the crust with each diaper change c. I will wash the penis with soap and water daily d. I will apply petroleum jelly to the area with each diaper change
85. A nurse is assessing a newborn following vaginal delivery. Which of the following findings should the nurse report to the provider? a. The newborn’s anterior fontanel bulges when he is quiet b. The newborn’s head circumference is greater than the chest circumference c. The newborn exhibits apneic episodes of 30 seconds d. The newborn has a HR of 70/min while sleeping

1. A nurse is assessing a newborn following a forceps-assisted birth. Which of the

following clinical manifestations should the nurse identify as a complication of the

birth method?

a. Hypoglycemia

b. Polycythemia

c. Facial Palsy

d. Bronchopulmonary dysplasia

2. A nurse is providing teaching about terbutaline to a client who is experiencing

preterm labor. Which of the following statements by the client indicates an

understanding of the teaching?

a. “The medication could cause me to experience heart palpitation”

b. “This medication could cause me to experience blurred vision”

c. “This medication could cause me to experience ringing in my ears”

d. “This medication could cause me to experience frequent …”

3. A nurse is caring for a client who has hyperemesis gravidarum. Which of the

following laboratory tests should the nurse anticipate?

a. Urine Ketones

b. Rapid plasma regain

c. Prothrombin time

d. Urine culture

4. A nurse is caring for a client who is in labor and requests nonpharmacological

pain management. Which of the following nursing actions promotes client

comfort?

a. Assisting the client in a squatting position

b. Having the client lie in a supine position

c. Applying fundal pressure during contractions

d. Encouraging the client to void every 6 hr

5. A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis.

Which of the following findings should the nurse expect?

a. Thick, White Vaginal Discharge

b. Urinary Frequency

c. Vulva Lesions

d. Malodorous Discharge

6. A nurse is caring for a client who is 14 weeks of gestation. At which of the

following locations should the nurse place the Doppler device when assessing

the fetal heart rate?

a. Midline 2 to 3 cm (0.8 to 1.2 in) above the symphysis pubis

b. Left Upper Abdomen

c. Two fingerbreadths above the umbilicus

d. Lateral at the Xiphoid Process

7. A nurse is assessing a client who is at 27 weeks of gestation and has

preeclampsia. Which of the following findings should the nurse report to the

provider?

a. Urine protein concentration 200 mg/ 24 hr

b. Creatinine 0.8 mg/ dL

c. Hemoglobin 14.8 g/ dL

d. Platelet Count 60.000/ mm

8. A nurse is teaching about clomiphene citrate to a client who is experiencing

infertility. Which of the following adverse effect should the nurse include? a. Tinnitus

b. Urinary Frequency

c. Breast Tenderness

d. Chills

9. A nurse is assessing a newborn upon admission to the nursery. Which of the

following should the nurse expect?

a. Bulging Fontanels

b. Nasal Flaring

c. Length from head to the heel of 40 cm (15.7 in)

d. Chest circumference 2 cm (0.8 in) smaller than the head

circumference

10.A A nurse is planning care for a newborn who has neonatal abstinence syndrome.

Which of the following interventions should the nurse include in the plan of care?

a. Increase the newborn’s visual stimulation

b. Weigh the newborn every other day

c. Discourage parental interaction until after a social evaluation

d. Swaddle the newborn in a flexed position

11.A A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer

reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which

of the following actions should the nurse take?

a. Obtain a blood sample for a serum glucose level

b. Feed the newborn immediately

c. Administer 50 mL of dextrose solution IV

d. Reassess the blood glucose level prior to the next feeding

12.A A nurse is providing teaching to a client about exercise safety during pregnancy.

Which of the following statements by the client indicates an understanding of the

teaching? (Select all that apply).

a. “I will limit my time in the hot tub to 30 minutes after exercise.”

b. “I should consume three 8-ounce glasses of water after I exercise.” c.

“I will check my heart rate every 15 minutes during exercise sessions.”

d. “I should limit exercise sessions to 30 minutes when the weather is humid.”

e. “I should rest by lying on my side for 10 minutes following exercise.”

13.A A charge nurse is teaching a group of staff nurses about fetal monitoring during

labor. Which of the following findings should the charge nurse instruct the staff

members to report to the provider?

a. Contraction duration of 95 to 100 seconds

b. Contraction frequency of 2 to 3 min apart

c. Absent early deceleration of fetal heart rate

d. Fetal heart rate is 140/min

14.A A nurse in a woman’s health clinic is obtaining a health history from a client.

Which of the following findings should the nurse identify as increasing the client’s

risk for developing pelvic inflammatory disease (PID)?

a. Recurrent Cystitis

b. Frequent Alcohol Use

c. Use of Oral Contraceptives

d. Chlamydia Infection

15.A A nurse is teaching a prenatal class about immunizations that newborns

receive following birth. Which of the following immunizations should the nurse

include in the teaching?

a. Hepatitis B

b. Rotavirus

c. Pneumococcal

d. Varicella

16.A A nurse is providing nutritional guidance to a client who is pregnant and follows

a vegan diet. The client asks the nurse which foods she should eat to ensure

adequate calcium intake. The nurse should instruct the client that which of the

following foods has the highest amount of calcium?

a. 1⁄2 cup cubed avocado

b. 1 large banana

c. 1 medium potato

d. 1 cup cooked broccoli

17.A A nurse in a provider’s office is assessing a client at her first antepartum visit.

The client states that the first day of her last menstrual period was March 8. Use

Nagele’s rule to calculate the estimated date of delivery. (Use the MMDD format

with four numerals and no spaces or punctuation.)

a. Dec 15

18.A A nurse is caring for a client who is in the second stage of labor. Which of the

following manifestations should the nurse expect?

a. The client expels the placenta

b. The client experiences gradual dilation of the cervix

c. The client begins to have regular contractions.

d. The client delivers the newborn

19.A A nurse is assessing a client who is at 37 weeks of gestation. Which of the

following statement by the client requires immediate intervention by the nurse?

a. “It burns when I urinate.”

b. “My feet are really swollen today.”

c. “I didn’t have lunch today, but I have breakfast this morning.”

d. “I have been seeing spot this morning”

20.A A nurse is providing discharge teaching to a new parent about car seat safety.

Which of the following statements by the parent indicates an understanding of

the teaching?

a. “I should position my baby’s car seat at a 45-degree angle in the car.”

b. “I should place the car seat rear facing until my baby is 12 months

old.”

c. “I should place the harness snugly in a slot above my baby’s shoulders.”

d. “I should position the retainer clip at the top of my baby’s abdomen.”

21.A A nurse is developing an educational program about hemolytic diseases in

newborns for a group of newly licensed nurses. Which of the following genetic

information should the nurse include in the program as a cause of hemolytic

disease?

a. The mother is Rh positive and the father is Rh negative

b. The mother is Rh negative and the father is Rh positive

c. The mother and the father are both Rh positive

d. The mother and the father are both Rh negative

22.A A nurse on an antepartum unit is reviewing the medical records of four clients.

Which of the following clients should the nurse assess first?

a. A client who has diabetes mellitus and an HbA1c of 5.8%

b. A client who has preeclampsia and a creatinine level of 1.1 mg/ dL

c. A client who has hyperemesis gravidarum and a sodium level of 110

mEq/L

d. A client who has placenta previa and a hematocrit of 36%

23.A A nurse is assessing a newborn immediately following a vaginal birth. For which

of the following findings should the nurse intervene?

a. Molding

b. Vernix Caseosa

c. Acrocyanosis

d. Sternal retractions

24.A A nurse on the postpartum unit is caring for four clients. For which of the following

clients should the nurse notify the provider?

a. A client who has a urinary output of 300 ml in 8 hr

b. A client who reports abdominal cramping during breastfeeding

c. A client who is receiving magnesium sulfate and has absent deep

tendon reflexes

d. A client who reports lochia rubra requiring changing perineal pads every 3 hr

25.A A nurse is caring for a client who has active genital herpes simplex virus type 2.

Which of the following medications should the nurse plan to administer?

a. Metronidazole

b. Penicillin

c. Acyclovir

d. Gentamicin

26.A A nurse is caring for a client following an amniocentesis. The nurse should

observe the client for which of the following complications?

a. Hyperemesis

b. Proteinuria

c. Hypoxia

d. Hemorrhage

27.A A nurse is planning care for a client who is receiving oxytocin by continuous IV

infusion for labor induction. Which of the following interventions should the nurse

include in the plan?

a. Increase the infusion rate every 30 to 60 min.

b. Maintain the client in a supine position.

c. Titrate the infusion rate by 4 milliunits/min.

d. Limit IV intake to 4 L per 24 hr.

28.A A nurse is caring for a 2-day-old newborn who was born at 35 weeks of

gestation. Which of the following actions should the nurse take? (Click on the

“Exhibit” button for additional information about the newborn. There are three

tabs that contain separate categories of date.)

a. Administer nitric oxide inhalation therapy to the newborn

b. Insert an orogastric decompression tube with low wall suction.

c. Provide the newborn with an iron-rich formula containing vitamin B12 every

2 hr.

d. Measure the abdominal circumference at the level of the newborn’s

umbilicus every 2 hr.

29.A A nurse is caring for a client who is receiving oxytocin for induction of labor

and notes late decelerations of the fetal heart rate on the monitor Tracing. Which

of the following action should the nurse take?

a. Decrease maintenance IV solution infusion rate.

b. Place the client in the lateral position.

c. Administer misoprostol 25 mcg vaginally

d. Administer oxygen via face mask at 2 L/min

30.A A nurse is planning care for a client who is pregnant and has HIV. Which of the

following actions should the nurse include in the plan of care?

a. Instruct the client to stop taking the antiretroviral medication at 32 weeks of

gestation.

b. Use a fetal scalp electrode during labor and delivery.

c. Administer a pneumococcal immunization to the newborn within 4 hr

following birth.

d. Bathe the newborn before initiating skin-to-skin contact

31.A A nurse is preparing to administer methylergonovine 0.2 mg orally to a client

who is 2 hr postpartum and has a boggy uterus. For which of the following

assessment findings should the nurse withhold the medication?

a. Blood pressure 142/92 mm Hg

b. Urine output 100 mL/hr

c. Pulse 58/min

d. Respiratory rate 14/min

32.A A nurse is reviewing laboratory results for a client who is pregnant. The Nurse

should expect which of the following laboratory values to increase?

a. RBC count

b. Bilirubin

c. Fasting blood glucose

d. BUN

33.A A nurse is caring for a client who is experiencing preterm labor and has a

prescription for 4 doses of dexamethasone 6 mg IM 12 hr. Available in

dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse

administer per dose? (Round the answer to the nearest tenth. Use a leading zero

if it applies. Do not use trailing zero.)

a. 0.6 mL

34.A A nurse is caring for four clients. For which of the following clients should the

nurse auscultate the fetal heart rate during the prenatal visit?

a. A client who has an ultrasound that confirms a molar pregnancy

b. A client who has a crown-rump length of 7 weeks gestation

c. A client who has a positive urine pregnancy test 1 week after missed

menses

d. A client who has felt quickening for the first time

35.AA nurse is planning care for a full-term newborn who is receiving

phototherapy. Which of the following actions should the nurse include in the

plan of care?

a. Dress the newborn in lightweight clothing.

b. Avoid using lotion or ointment on the newborn skin.

c. Keep the newborn supine throughout treatment

d. Measure the newborn’s temperature every 8hr

36.A A nurse is receiving laboratory results for a term newborn who is 24 hr old. Which

of the following results require intervention by the nurse?

a. WBC count 10,000/mm

b. Platelets 180,000/mm

c. Hemoglobin 20g/dL

d. Glucose 20 mg/dL

37.A A nurse is assessing a client following an amniocentesis. Which of the

following findings should the nurse recognize as complications? (select all that

apply).

a. Amnionitis

b. Urinary tract infection

c. Polyhydramnios

d. Leakage of amniotic fluid e. Preterm labor

38.A A nurse on a labor and delivery unit is receiving infection control standards with

a newly licensed nurse. The nurse should instruct the newly licensed nurse to

don gloves for which of the following procedures?

a. Assisting a mother with breastfeeding

b. Performing a newborn’s initial bath

c. Administering the measles, mumps, and rubella vaccine

d. Performing umbilical cord care

39.A A nurse is providing teaching to a client who has mild preeclampsia and will be

caring for herself at home during the last 2months of pregnancy. This of the

following statements by the client indicates an understanding of the teaching.

a. “I will count baby’s movements every day.”

b. “I will alternate the arm use to check my blood pressure.”

c. “I will consume 50 grams of protein daily.”

40.A A nurse is caring for four newborns. Which of the following newborns should the

nurse assess first?

a. a newborn who has nasal flaring

b. a newborn who has subconjunctival hemorrhage of the left eye

c. A newborn who has overlapping suture lines

d. A newborn who has no rust-stained urine

41.A A nurse is reviewing the electronic medical record of a postpartum client.

The nurse should identify which of the following factors paces the client at

risk for infection.

a. Meconium stained fluid

b. placenta previa

c. Midline episiotomy

d. Gestational hypertension

42.*A nurse is caring for a client who is 4hr postpartum and is experiencing

hypovolemic shock. Which of the following actions should the nurse take?

a. Administer indomethacin

b. Insert a second using a 22 gauge IV catheter

c. Insert an indwelling urinary catheter.

d. Administer oxygen at 4L/min via nasal cannula.

43.A A nurse is teaching a client who is 28 weeks of gestation and not up-to-date on

current immunization. Which of the following immunizations should the nurse

inform the client to anticipate receiving following birth?

a. Pneumococcal

b. Hepatitis

c. Human papillomavirus

d. Rubella

44.A A nurse is caring for a newborn who is 24 hr old. Which of the following

Laboratory findings should the nurse report to the provider?

a. Hgb 20 g/dL

b. Bilirubin 2mg/dL

c. Platelets 200 .000/mm3

d. WBC count 32.000/mm3

45.A A nurse is caring for a newborn who is 1 hr old and has a respiratory rate of

50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F).

Which of the following actions should the nurse take?

a. Give the newborn a warm bath.

b. Apply a cap to the newborn head.

c. Reposition the newborn.

d. Obtain an oxygen saturation level

46.A A nurse is planning care for a newborn who is scheduled to start phototherapy

using a lamp. Which of the following actions should the nurse include in the plan?

a. Apply a thin layer of lotion to the newborn skin every 8 hrs.

b. Give the newborn 1oz of glucose water every 4 hrs

c. Ensure the newborn eyes are closed beneath the shield.

d. Dress the newborn in a thin layer of clothing during therapy

47.A A nurse is caring for a client following vaginal delivery of a term fetal demise.

Which of the following statement should the nurse make?

a. “You can bathe and dress your baby if you’d like to.”

b. “If you don’t hold the baby it will make letting go much harder.”

c. “You should name the baby so she can have an identity.”

d. “I’m sure you will be able to have another baby when you’re ready.”

48.A A nurse is providing teaching to a client who is at 38 weeks of gestation and

has a prescription to receive misoprostol intravaginally. Which of the following

statement should the nurse make?

a. “you will need to stay in a side-lying position for 30 minutes after

each dose.”

b. “You will receive an IV infusion of oxytocin 1 hour after your last dose.”

c. ”You will receive a magnesium supplement immediately following therapy.”

d. ”You will need to have a full bladder before the therapy begins.”

49.AA nurse is assessing a newborn who was born Postterm. Which of the following

findings should the nurse expect?

a. Nails extending over tips of fingers

b. Large deposits of subcutaneous fat

c. Pale, translucent skin

d. A thin covering of fine hair on the shoulders and back

50.A A nurse is planning to teach a group of clients about breastfeeding after

returning to work. Which of the following instructions should the nurse include in

the teaching?

a. “Thawed breast milk can be refrigerated for up to 72 hours.”

b. “Breast milk can be stored in a deep freezer for 12 months.”

c. Breast milk can be stored at room temperature for up to 12 hours.”

d. “Thawed breast milk that is unused can be refrozen.”

51.A A nurse on the postpartum unit caring for four clients. Which of the following

clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization?

a. An Rh-negative mother who has an Rh-positive infant

b. An Rh-positive mother who has an Rh-negative infant

c. An Rh-positive mother who has an Rh-positive infant

d. An Rh-negative mother who has an Rh-negative infant

52.A A nurse is caring for an infant who has signs of neonatal abstinence syndrome.

Which of the following actions should the nurse take?

a. Provide a stimulating environment

b. Monitor blood glucose level every hr.

c. Initiate seizure precautions.

d. Place the infant on his back with legs extended.

53.A A nurse is reviewing signs of effective breathing with a client who is 5 days

postpartum. Which of the following information should the nurse include in the

teaching?

a. “You should feel a tugging sensation when the baby is sucking.”

b. “You should expect your baby to have two to three wet diapers in 24-hour

period.”

c. “Your baby’s urine should appear dark and concentrated.”

d. “Your breast should stay firm after the baby breastfeeds.”

54.A A nurse is teaching a client who is at 41 weeks of gestation about a non-stress

test. Which of the following information should the nurse include in the teaching?

a. “This test will confirm fetal lung maturity.”

b. “This test will determine the adequacy of placental perfusion.”

c. “This test will detect fetal infection.”

d. “This test will predict maternal readiness for labor.”

55.A A nurse on the labor and delivery unit is assessing four clients. Which of the

following clients is a candidate for induction of labor with misoprostol?

a. A client who has active genital herpes

b. A client who has gestational diabetes mellitus

c. A client who has a previous uterine incision

d. A client who has placenta previa

56.A A nurse is monitoring a client who has preeclampsia and is receiving

magnesium sulfate by continuous IV infusion. Which of the following findings

should the nurse report to the provider?

a. Blood pressure 148/94mm Hg

b. Respiratory rate 14mm

c. Urinary output 20 mL/hr

d. 2+deep tendon reflexes

57.A A nurse is caring for a client who is in the transition phase of labor and reports

a pain level of 7 on a scale of 0 to 10. Which of the following actions should the

nurse take?

a. Instruct the client to use effleurage

b. Apply counter pressure to the client's sacral.

c. Assist the client with patterned-paced breathing.

d. Teach the client the technique of biofeedback.

58.A A nurse is caring for a newborn immediately following birth and notes a large

amount of mucus in the newborn’s mouth and nose. Identify the sequence the

nurse should follow when performing suction with a bulb syringe. (Move the steps

into the box on placing them in the selected order of performance. Use all the

steps.)

a. Assess the newborn for reflex bradycardia.

b. Compress the bulb syringe

c. Place the bulb syringe in the newborn’s mouth.

d. Use the bulb syringe to suction the newborn’s nose Correct order: B, C, D,

A

59.A A community health nurse is providing education on gestational diabetes

mellitus (GDM) to a group of clients who are pregnant when discussing risk

factors, which of the following ethnicities should the nurse identify as having the

lowest incidence of GDM?

a. Asian

b. Non-Hispanic White American

c. Hispanic

d. African American

60.A A nurse is assessing a client who is at 37 weeks of gestation. Which of the

following statement by the client requires immediate intervention by the nurse?

a. “It burns when I urinate.”

b. “My feet are really swollen today.”

c. “I didn’t have lunch today, but I have breakfast this morning.”

d. “I have been seeing spot this morning.”

61.A A nurse is providing teaching about expected changes during pregnancy to a

client who is at 24 weeks of gestation. Which of the following information should

the nurse include?

a. “Your stomach will empty rapidly”

b. “You should expect your uterus to double in size”

c. “You should anticipate nasal stuffiness.”

d. “Your nipples will become lighter in color.”

62.A A nurse is teaching a prenatal class regarding false labor. Which of the following

information should the nurse include?

a. “your contraction will become more intense when walking”

b. “you will have dilation and effacement of the cervix”

c. You will have bloody show

d. “Your contraction will become temporally regular”

63.A A nurse is caring for a client who is receiving an epidural block with an opioid

analgesic. The nurse should monitor for which of the following findings as an

adverse effect of the medication?

a. Hypnosis

b. Polyuria

c. Bilateral crackles

d. Hyperglycemia

64.A A nurse is caring for a client who is receiving prenatal care and is at her 24-week

appointment. Which of the following laboratory tests should the nurse plan to

conduct?

a. Group B strep culture

b. 1-hr glucose tolerance test

c. Rubella titer

d. Blood type and Rh

65.A A nurse is caring for a client who has bacterial vaginosis. Which of the following

medication should the nurse expect to administer?

a. Metronidazole

b. Fluconazole

c. Acyclovir

66.A A nurse is caring for a client who is experiencing sore nipples from breastfeeding.

Which of the following actions should the nurse take?

a. Place a snug dressing on the client’s nipple when not breastfeeding.

b. Ensure the newborn’s mouth is wide open before latching to the

breast.

c. Encourage the client to limit the newborn’s feeding to 10 min on each breast.

d. Instruct the client to begin the feeding with the nipple that is most tender.

67.A A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which

of the following finding should the nurse expect?

a. Minimal arm recoil

b. The popliteal angle of less than 90

c. Creases over the entire sole

d. Sparse lanugo

68.A A nurse on a labor and delivery unit is providing teaching to a client who plans

to use hypnosis to control labor pain. Which of the following information should

the nurse include?

a. Focusing on controlling body functions

b. “Synchronized breathing will be required during hypnosis”

c. “Hypnosis can be beneficial if you practiced it during the prenatal

period”

d. “Hypnosis does not work for controlling pain associated with labor”

69. A nurse is caring for a client who is in active labor. Following epidural placement,

the nurse got a maternal blood pressure of 98/58 mmHg and minimal FHR

variability on the fetal monitor. Which of the following images indicates the action

the nurse should take?

I believe the answer is to put the client in lateral left side placement to

increase perfusion to the fetus