A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of
... [Show More] the following findings should the nurse instruct the client to notify the provider?
Shortness of breath
A. Shortness of breath
The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
Leakage of fluid from the vagina
B. Leakage of fluid from the vagina
Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.
A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?
Answer: September 3rd
A. September 3rd
When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
Answer: Biophysical profile (BPP)
C. Biophysical profile (BPP)
The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.
A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?
Answer: "You can share your room with your baby for the next few weeks."
A. "You can share your room with your baby for the next few weeks."
The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?
Answer: Apply sacral counterpressure.
A. Apply sacral counterpressure.
The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?
Answer: Cover the newborn's eyes while under the phototherapy light.
A. Cover the newborn's eyes while under the phototherapy light.
Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next?
Answer: Apply internal upward pressure to the presenting part using two gloved fingers.
B. Apply internal upward pressure to the presenting part using two gloved fingers.
Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (SATA)
Answer: Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.
Excess vaginal bleeding is correct.
Oxytocin enhances uterine contractility, decreasing vaginal bleeding.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
Answer: "Staff members who take care of your baby will be wearing a photo identification badge."
D. "Staff members who take care of your baby will be wearing a photo identification badge."
The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.
A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Answer: Vomiting
D. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
Answer: Vomiting
A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?
Answer: Left lower quadrant
A. Left upper quadrant
The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant.
B. Right upper quadrant
The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant.
C. Left lower quadrant
The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant.
D. Right lower quadrant
The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant.
A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?
Answer: Stop suctioning when the newborn's cry sounds clear.
D. Stop suctioning when the newborn's cry sounds clear.
The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
Answer: Platelets 50,000/mm3
D. Platelets 50,000/mm3
A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.
A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta?
A. The nurse should identify this as an image of spina bifida occulta.
External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.
Answer: A
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
Answer: A client who is at 34 weeks of gestation and reports epigastric pain
B. A client who is at 34 weeks of gestation and reports epigastric pain
When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicated an understanding of the teaching?
Answer: "I will eat foods that taste good instead of balancing my meals."
A. "I will eat foods that taste good instead of balancing my meals."
Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?
Answer: Demonstrate to the client how to perform a newborn bath.
D. Demonstrate to the client how to perform a newborn bath.
Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
Answer: Swelling of the face
A. Swelling of the face
Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.
A nuse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?
Answer: Jitteriness
A. Jitteriness
Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?
Answer: "I will have blood tests because my potassium might decrease."
A. "I will get injections of the medication once daily until my labor stops."
Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr.
B. "My blood sugar may be low while I'm on this medication."
An adverse effect of terbutaline is hyperglycemia.
C. "I will have blood tests because my potassium might decrease."
An adverse effect of terbutaline is hypokalemia.
D. "My blood pressure may increase while I'm on this medication."
An adverse effect of terbutaline is hypotension.
A nurse is planning care for a client who is in labor and is having an amniotomy. Which of the following assessments should the nurse identify as the priority?
Answer: Temperature
B. Temperature
The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non-pharmacological interventions should the nurse include in the plan of care for lactation suppression?
Answer: Apply cabbage leaves to the breasts.
B. Apply cabbage leaves to the breasts.
Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Answer: Determine respiratory function.
A. Determine respiratory function.
The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
Answer: "I will continue taking my insulin if I experience nausea and vomiting."
C. "I will continue taking my insulin if I experience nausea and vomiting."
The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Answer: Chin quivering
B. Chin quivering
Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interperate the client's statement as an indication of which of the following?
Answer: Emotional lability
A. Emotional lability
The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives? (SATA)
Cholecystitis is correct.
A history of gallbladder disease is a contraindication for the use of oral contraceptives.
Hypertension is correct.
Hypertension is a contraindication for the use of oral contraceptives.
Human papillomavirus is incorrect.
The presence of human papillomavirus is not a contraindication for the use of oral contraceptives.
Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives.
Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
Answer: "You should take the medication within 72 hours following unprotected sexual intercourse."
A. "You should take the medication within 72 hours following unprotected sexual intercourse."
Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.
A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?
Answer: Place the retainer clip at the level of the newborn's armpits.
B. Place the retainer clip at the level of the newborn's armpits.
The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
Answer: The nurse should have calcium gluconate readily available
B. Have calcium gluconate readily available.
The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.)
The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part.
Second, the nurse should determine the location of the fetal back.
Third, the nurse should palpate for the fetal part presenting at the inlet.
Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
Answer: Headache that is unrelieved by analgesia
C. Headache that is unrelieved by analgesia
A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?
Answer: Massage the client's fundus.
A. Massage the client's fundus.
The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?
Answer: Just above the symphysis pubis
B. Just above the symphysis pubis
At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.
A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching?
Answer: "You will be offered orange juice to drink during the test."
C. "You will be offered orange juice to drink during the test."
A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Answer: Instruct the client to press the provided button each time fetal movement is detected.
D. Instruct the client to press the provided button each time fetal movement is detected.
Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.
A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
Answer: "You can miss your period for several other reasons. Describe your typical menstrual cycle."
A. "You can miss your period for several other reasons. Describe your typical menstrual cycle."
Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.
A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
Answer: Explain to the client this is an expected occurrence.
B. Explain to the client this is an expected occurrence.
Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.
A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1g orally now." Available is 250 mg tablets. How may tablets should the nurse administer?
Answer: 4
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?
Answer: "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."
D. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."
Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.
A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
Answer: Verify the newborn's identification.
B. Verify the newborn's identification.
When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery. [Show Less]