A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse interest the room and observes the client having a seizure. Afte... [Show More] r turning the Clients head to one side, which of the following actions should the nurse take immediately after the seizure?
(Ans- Administer oxygen via a nonrebreather mask
A nurse is transporting a newborn back to the patient's room following a procedure. Which of the following actions should the nurse take?
(Ans- Verify that the parents identification van matches the newborns identification band
A nurse is providing teaching about nonpharmacological pain management to a client who is breast-feeding and has engorgement. The nurse should recommend the application of which of the following items?
(Ans- Cold cabbage leaves
A nurse is assessing a client who is at 36 weeks of gestation period which of the following findings should the nurse report to the provider?
(Ans- Report of visual disturbances
A nurse is providing discharge teaching to a client who had a cyst Syrian birth three days ago. Which of the following instructions should the nurse include?
(Ans- You can still become pregnant if you are breast-feeding
A nurse in antepartum Clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the clients medical record, which of the following findings should the nurse report to the provider?
(Ans- Fundal height measurement
I nurse is assessing a client who is at 38 weeks of gestation during our weekly prenatal visit. What should the following findings should the nurse report to the provider?
(Ans- Weight gain of 2.2 kg (4.8lb)
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complication should the nurse assess?
(Ans- Abrupto placenta
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestation should the nurse expect? Select all that apply
(Ans-
Acrocyanosis
Positive babinski reflex
Two umbilical arteries visible
A nurse is preparing to administer magnesium sulfate 2 g/h IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% and water (D5W). The nurse should set the IV infusion pump to administer how many milliliters per hour?
(Ans- 50 mL/hr
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
(Ans- A newborn who is 18 hours old and has an axillary temperature of 37.7°C (99.9 degrees Fahrenheit)
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation period which of the following findings should the nurse expect? (Ans- FHR 152/min
A nurse is performing a vaginal examination on a client who is in labor and observe the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?
(Ans- Insert to go out fingers into the vagina and apply upward pressure to the presenting part
A nurse is caring for a client who has uterine atony And is experiencing postpartum hemorrhage. Which of the following actions is the nurses priority?
(Ans- Massage the clients fundus.
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12mg IM. Which of the following outcome should the nurse expect?
(Ans- A reduction in respiratory distress in a newborn
They charge nurse on the labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers which of the following images in the case the first step of Leopold maneuvers?
(Ans- Picture where both of the nurses hands are on the superior surface of the fundus
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
(Ans- Respiratory distress
A nurse is providing teaching to a client about the Physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statement indicates an understanding of the teaching?
(Ans- I will likely need to use alternative positions for sexual intercourse
A nurse is caring for a client who is at 38 weeks of gestation period which of the following actions should the nurse take prior to applying and external transducer for fetal monitoring?
(Ans- Perform Leopold maneuvers: The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.
I nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
(Ans- BUN 25 mg/dL: The nurse should report an elevated BUN to the provider since it can indicate dehydration.
A nurse is assessing a newborn who has delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect?
(Ans- Petechiae over the head: Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?
(Ans- Blurred vision: The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the families seven-year-old child in excepting the new family member?
(Ans- Obtain a gift from the newborn to present to the sibling: Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of oxytocin infusion and should be reported to the provider?
(Ans- Late decelerations: Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? Select all that apply (Ans- Heart rate 154 per minute
Respiratory rate 58 per minute
Weight 2600 g (5lb 12oz)
I nurse is assessing a newborn who is 16 hours old. Which of the following findings should the nurse report to the provider? (Ans- Substernal retractions: The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention.
I nurse is caring for a client who is at 36 weeks gestation it has a prescription for Ambien SNT EHS. Which of the following recent should the nurse prepare the client for an ultrasound?
(Ans- To locate a pocket of fluid: An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
(Ans- Schedule an ultrasound examination: The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
A nurse is preparing to collect a blood specimen from a newborn via and he'll stick. Which of the following techniques should the nurse used to help minimize the pain of the procedure for the newborn?
(Ans- Play is the newborn skin to skin on the mothers chest: Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.
A nurse is assessing a newborn who it was born at 26 weeks of gestation using the new Ballard score. Which of the following findings should the nurse expect?
(Ans- Minimal arm recoil: The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?
(Ans- Maintain the client on bed rest: The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended. [Show Less]
