4. The nurse is teaching a client with gestational diabetes about nutrition and insulin need for
pregnancy. Which content should the nurse include in
... [Show More] this client’s teaching plan?
A) Insulin production is decreased during pregnancy
B) increase daily caloric intake is needed ?
C) injection requirements remain the same
D) Blood sugars need less monitoring in the first trimester
The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant.
When discussing birth control, which method should the nurse recommend to this client as best
for her to use in preventing an unwanted pregnancy?
A Breastfeed exclusively at least every 3 to 4 hours
B Condoms and contraceptive foam or gel
C Rhythm method (natural family planning)
D Combined estrogen-progesterone oral contraceptives ??
1. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should
the nurse do first?
D. Stimulate the infant to cry.
A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant
with her first child and is at 32-weeks gestation. The client tells the nurse that she has been
having intermittent back pain since the night before. What is the priority nursing intervention?
A Ask the client’s mother to call an ambulance for transport to the hospital immediately
B Determine what physical activities the client has performed for the past 24 hours
C Teach the client how to perform pelvic rock exercises and observe for correct feedback ?
D Ask the client if she has experienced any recent changes in vaginal discharge
A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above
the level of her heart. Which assessment finding should the nurse report to the healthcare
provider immediately?
A Itching sensation under the cast
B Swelling of fingers with brisk capillary refill
C Numbness and inability to move fingers
D Visible bruising above the cast
At 39-weeks gestation, a multigravida is having a nonstress test (NST). The fetal heart rate
(FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which
action should the nurse implement?
A Initiate an intravenous infusion
B Observe the fetal heart rate pattern for 30 more minutes
C Schedule a biophysical profile
D Place an acoustic stimulator on the abdomen
1. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had
an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the
umbilicus and obtains current vital signs. Which intervention should the nurse implement next?
**SEE SCREEN SHOT FOR RATIONALE**
A. Document number of pad changes in the last hour
B. Increase the rate of the oxytocin infusion
C. Palpate the suprapubic area for bladder distention
D. Provide bedpan to void if unable to ambulate
3.After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum
room to help change the newborns diaper. As the mother begins the diaper change, the newborn
spits up the breast milk. What action should the nurse implement first?
**SEE SCREEN SHOT FOR RATIONALE**
A. Wipe away the spit-up and assist the mother with the diaper change
B. Turn the newborn to the side and bulb suction the mouth and nares
C. Sit the newborn up and burp by rubbing or patting the upper back
D. Place the newborn in a position with the head lower than the feet
7. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding
after the IV Pitocin is infused. When notifying the hcp of the clients condition, what information
is most important for the nurse to provide? **FOUND IN EXIT EXAM**
A. Total amount of Pitocin infused
B. Maternal Blood pressure
C. Maternal Apical Pulse rate
D. Time Pitocin infusion completed
8. The nurse is caring for a newborn infant who was recently diagnosed with congenital heart
defect. Which assessment finding warrants immediate intervention by the nurse? **SEE
SCREEN SHOT FOR RATIONALE**
A. Sweating during feedings
B. Weak peripheral pulse
C. Bluish tinge to the tongue
D. Increased respiratory rate
9. A client who delivered a healthy newborn an hour ago asks the nurse when can she go home.
Which information is most important for the nurse to provide the client? **SEE SCREEN
SHOT FOR RATIONALE**
A. When there is no significant vaginal bleeding
B. When ambulating to void does not cause dizziness
C. After the vitamin K injection is given to the baby
D. After the baby no longer demonstrates acrocyanosis
10. A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and
no contractions are noted on the external monitor. Which intervention should the nurse
implement? **SEE SCREEN SHOT FOR RATIONALE**
A. Weight perineal pads
B. Weight daily
C. Measure intake and output
D. Ambulate 15 minutes QID
12. A client at 20 weeks gestation comes to the antepartum clinic complaining of vaginal warts
(human papillomavirus). What information should the nurse provide this client? **SEE
SCREEN SHOT FOR RATIONALE**
A. Treatment options, while limited due to the pregnancy, are available (Pregnancy
complications are not linked to HPV)
B. The client should be treated with Penicillin G
C. This client should be treat with acyclovir (Zovirax)
D. Termination of the pregnancy should be considered
13. One week after missing her menstrual period, a woman performs an OTC pregnancy test and
it is positive. Which hormone is responsible for producing the positive result? **SEE SCREEN
SHOT FOR RATIONALE**
A. Human placental lactogen
B. Gonadotrophin-releasing hormone
C. Human chorionic gonadotrophin
D. Prostaglandin E2 Aplha
14. A new mother, who is lacto-ovo vegetarian, plans to breastfeed her infant. What information
should the nurse provide prior to discharge?
A. Avoid using lanolin-based nipple cream or ointment
B. Continue prenatal vitamins with B12 while breast feeding
C. Offer iron- fortified supplemental formula daily
D. Weigh the baby weekly to evaluate the newborns growth
16. A primigravida at 36-weeks gestation, who is Rh negative, experienced abdominal trauma in
a motor vehicle collision. Which assessment finding is most important for the nurse to report to
the health care provider?
A. Fetal heart rate of 162 beats/minute
B. Trace of protein in the urine
C. Positive fetal hemoglobin test
D. Mild contractions every 10 minutes
18. The nurse is counseling a client who is at 6 weeks gestation and is experiencing morning
sickness, but does not want to take any drugs for this discomfort. Which herbal supplement is
likely to help this client with the nausea she is experiencing?
A. Ginko
B. Chamomile
C. Peppermint
D. Ginger
19. The nurse is assessing a postpartum client who delivered a 10 pound infant vaginally two
hours ago. The clients fundus is 2 fingerbreadths above the umbilicus, deviated to the right side,
and boggy. After the client voids 250 ml of urine using a bedpan, what action should the nurse
implement? **SEE SCREEN SHOT FOR RATIONALE**
A. Re-evaluate the client in 15 minutes
B. Assist the client to the bathroom to void
C. Palpate the suprapubic region for distention
D. Encourage the client to breastfeed
21. A client who is in active labor is receiving magnesium sulfate and begin to experience slurred
speech and decreased reflexes. Which action should the nurse implement first?
A. Obtain a serum magnesium level
B. Measure the clients hourly urinary output
C. Provide an emesis basin for vomiting
D. Turn off the magnesium sulfate infusion
23. Calculated by Naegele’s rule, a primigravida client is at 28 weeks gestation. She is
moderately obese and carrying twins and the nurse measures her fundal height at 27 cm. During
the previous visit 3 weeks ago, the fundal height measured at 28 cm. Based on these findings,
what should the nurse conclude? **SEE SCREEN SHOT FOR RATIONALE**
A. Fundal height measurement may indicate intrauterine growth retardation
B. The healthcare provider needs to be notified immediately since this fundal height
measurement is greater than expected
C. Confirm the fundal height measurement with another nurse
D. Recognize this as a reasonable fundal height measurement for this client
24. Following the vaginal delivery of a large for gestation age (LGA) infant, a woman is
admitted to the ICU due to post partum hemorrhaging. The client’s medical record describes
Jehovah’s Witness notes as her religion. What action should the nurse take next?
A. Inform the client of the critical need for a blood transfusion
B. Obtain consent from the family to infuse packed red blood cells
C. Clarify the clients wishes about receiving blood products
D. Prepare to infuse multiple units of fresh frozen plasma
25. The nurse is assessing a 35 week primigravida with a breech presentation who is expericing
moderate uterine contraction every 3-5 minutes. During the examination the client tells the nurse,
“I think my water just broke”. Inspection of the perineal area reveals the umbilical cord
protruding from the vagina. After activating the call bell system for assistance, what intervention
should the nurse implement? **SEE SCREEN SHOT FOR RATIONALE**
A. Administer oxygen at 10 liters via face mask
B. Don gloves and push the cord back into the vagina
C. Wrap the umbilical cord with sterile gauze
D. Position the client into a knee-chest position
26. The nurse is discussing involution with a post-partum client. Which statement best indicates
that the client understands the effect of breastfeeding on the resumption of menstrual cycle? **
CHAPTER 25 PAGE 621 IN LOWDERMILK**
A. “My period will most likely return in 6 to 8 months”
B. “I should expect my period to return in 6 to 8 weeks”
C. “My period started as soon as the baby was born”
D. “While I am breastfeeding, my period may be delayed”
28. A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor. What
is the priority nursing action for this client?
A. Observe for signs of uterine hemorrhage
B. Encourage direct contact with the infant
C. Assess the blood pressure for hypertension
D. Gently massage fundus every four hours
29. A multigravida client in labor is receiving oxytocin Pitocin 4mu/minute to help promote an
effective contraction pattern. The available solution is Lactated Ringers 1,000 ml with Pitocin 20
units. The nurse should program the infusion pump to deliver how many ml/hr? **SEE SCREEN
SHOT FOR RATIONALE**
ANS: 12
33. At 34- weeks gestation, a primigravida is assessed at her bimonthly clinic visist,. Which
assessment finding is important for the nurse to report to the hcp? **SEE SCREEN SHOT FOR
RATIONALE**
A. Increased appetite
B. Fetal heart rate of 110 beats/minute
C. Fundus below the xiphoid
D. Weight gain of 7 pounds
34.A newborn infant is receiving immunization prior to discharge. Which action should the nurse
implement?
A. Give the first dose of the vaccine for Rotavirus if any sibilings have diarrhea now
B. Ask the mother if she wants the infant immunized for Haemophilus influenza
C. Prepare the first dose for Diphtheria, tetanus toxoid and acellular pertussis (DTap)
D. Obtain signed consent from the mother for administration of hepatitis B vaccine
35. A multiparous woman at 38-weeks gestation with a history of rapid progression of labor is
admitted for induction due to signs and symptoms of preeclampsia. One hour after the Pitocin
infusion is initiated, she complains of a headache. Her contractions are occurring every 1 to 2
minutes, lasting 60 to 75 seconds, and a vaginal exam indicates that her cervix is 90% effaced
and dialted to 6 cm. What intervention is most important for the nurse to implement?
A. Turn the client on her left side
B. Discontinue the Pitocin infusion
C. Prepare for immediate delivery
D. Measure deep tendon reflexes
36. Which topic is most important for the nurse to include in a nutrition teaching program for
pregnant teenagers?*GREEN PG 276*
A. Gestational diabetes
B. Iron-deficieny anemia
C. Excessive weight gain
D. Elevated cholesterol
37. The nurse is assessing a 38- week gestation newborn infant immediately following a vaginal
birth. Which assessment finding best indicates that the infant is transitioning well to extra-uterine
life?
A. Flexion of all four extremities
B. Cries vigorously when stimulated
C. Heart rate of 22 beats/minute
D. A positive Babinki reflex
38. While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal
heartrate pattern that falls and rises abruptly with a “V” shaped appearance. What action should
the nurse take first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position
39. A 32- week primigravida who is in preterm labor receives a prescription for an infusion of
D5W 500 ml with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hour should the
nurse program the infusion pump?
**SEE SCREEN SHOT FOR RATIONALE**
ANS: 25
40. During the admission of a newborn, the nurse identifies a localized swelling that does not
cross the suture line on the posterior area of the parietal bone. What action should the nurse
implement? **GOT THIS ANSWER FROM GREEN HESI BOOK PG 262**
A. Assess neurological vital signs every 4 hours
B. Apply direct pressure to the caput succedaneum (THIS ONE CROSSES THE SUTURE
LINES)
C. Submit a request for a stat CT scan of the head
D. Notify the pediatrician of the cephalhematoma (THIS ONE DOES NOT CROSS
THE SL & IS MORE CRITICAL)
41. The nurse if caring for a postpartum client who is complaining of severe pain and a feeling of
pressure in her perineum. Her fundus if firm and she has a moderate lochial flow. On inspection,
the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should
the nurse obtain first? **SEE SCREEN SHOT FOR RATIONALE**
A. Heart rate and blood pressure
B. Abdominal contour and bowel sounds
C. Urinary output and IV fluid intake
D. Hemoglobin and Hematocrit
43. A multiparous client at 38- weeks gestation is admitted to labor and delivery with a compliant
of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital
gown, the nurse hears a baby crying. What action should the nurse take first? **SEE SCREEN
SHOT FOR RATIONALE**
A. Inspect the clients perineum
B. Turn on the infant warmer
C. Notify a healthcare provider
D. Push the call light for help
44. A client who is receiving oxytocin (Pitocin) to augment early labor begins to experience
hypersystolic or tetanic contractions with variable fetal heart decelerations. Which action should
the nurse implement? **GOT FROM A L&D NURSE**
A. Reposition the fetal monitor transducers
B. Alert the charge nurse to the patients condition
C. Turn off the Pitocin infusion **she said this is what the book prolly says to do**
D. Decrease the rate of the Pitocin infusion
45. The nurse is assessing a newborn who was precipitously delivered at 38 weeks gestation. The
newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important
for the nurse to implement?
A. Determine reactivity of neonatal reflexes
B. Perform gestational age assessment
C. Weight and measure the newborn
D. Obtain a drug screen for cocaine
48. A new infant is receiving positive pressure ventilation after delivery. Based on which
assessment finding should the nurse initiate chest compressions? **GOT THIS ANSWER
FROM GREEN HESI BOOK PAGE 295**
A. Apgar score 7
B. Heart rate 54
C. Limp muscle tone
D. Central cyanosis
50. The nurse is scheduling a client with gestational diabetes for an amniocentesis because the
fetus has an estimated weight of 8 pounds at 36- weeks gestation. This amniocentesis is being
performed to obtain which information? **SEE SCREEN SHOT
A. Presence of a neural tube defect
B. Gender of the fetus
C. Fetal lung maturity
D. Chromosomal abnormalities
51. Vaginal prostaglandin gel is used to induce labor for a woman who is at 42 weeks gestation.
Thirty minutes after insertion of the gel, the client complains of vaginal warmth, and is
experiencing 90 second contractions with fetal heart rate decelerations. What action should the
nurse implement first? **SEE PAGE CHAPTER 32- PAGE 781 IN LOWDERMILK BOOK**
A. Notify the hcp
B. Assess the maternal vital signs
C. Turn to a side-lying position
D. Increase the IV infusion rate
52. A woman who delivered a normal newborn 24 hours ago complains, “ I seem to be urinarting
every hour or so. Is that ok?”. Which action should the nurse implement? **SEE SCREEN
SHOT FOR RATIONALE**
A. Catheterize the client for residual urine volume
B. Measure the next voiding, then palpate the clients bladder
C. Evaluate for normal involution, then massage the fundus
D. Obtain a specimen for urine culture and sensitivity
53. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an
epidural for pain control. Findings f the last vaginal exam, performed 1 hour ago, were 3 cm
cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement
first? **SEE SCREEN SHOT FOR RATIONALE**
A. Determine current cervical dilation
B. Request placement of the epidural
C. Give bolus of intravenous fluids
D. Decrease the oxytocin infusion rate
54. The health care provider hands a newborn to the nurse after a vaginal delivery. What action is
most important for the nurse to implement? **SEE SCREEN SHOT FOR RATIONALE**
A. Allow the mother to touch the infant
B. Complete a physical assessment
C. Place the infant under a warming unit
D. Determine the APGAR score
55. The father of a 3- day- old infant who is breast feeding calls the postpartum help line to
report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently
cried for no apparent reason. What information is most important for the nurse to provide to this
father? **SEE SCREEN SHOT FOR RATIONALE**
A. A fluctuation in hormones in the early postpartum period can cause mood changes
B. Recommend giving supplemental bottle feedings to the baby between breast feeding
C. Contact the clinic if the behaviors continue for more than two weeks or become
worse
D. Tell the father to count the newborns number of soiled diapers over the next few days
A full term infant is admitted to the newborn nursery 2 hours after delivery. The delivery record reports
that the mother is positive for HIV and received AZT intravenously during labor. What action should the
nurse implement first ?
A. Ensure that AZT is given within 6 hours after birth
B. Collect venous specimen for serum glucose level
C. Asses for the presence of the Moro reflex
D. Obtain consent for the Hep B vaccine
1- A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6mg/dl and a
hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet?
-Cheese.
-Carrots.
-Chicken.
-Yogurt.
3- The nurse that the client is experiencing a complication from the amniocentesis?
-A Epigastric pain.
-B Increased fetal movement.
-C Headache and blurred vision.
-D Low back pain with pelvic cramping.
6-Which findings of depression in the postpartum client require additional action by the nurse?
(Select all that apply).
_A Decreased appetite.
_B Feeling of sadness.
_C Return of lochia rubra.
_D Trouble falling as leep.
_E Engorged, painful breasts.
7-A 3-hour-old male infant’s hands and feet are cyanotic, and he has an axillary temperature of
96.5 F, respiratory rate of 40 breaths/min, and a heart rate of 165 beasts/min. What nursing
intervention is best for the nurse to implement?
_A Gradually warm the infant under a radiant heat source.
_B Perform a heel-stick to monitor blood glucose level.
_C Notify the pediatrician of the infant’s unstable vital signs.
_D Administer oxygen by mask at 2l/minute.
8-A woman who delivered a 9 pound baby boy by cesarean section under spinal anesthesia is
recovering in the post anesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous
trickle of bright red blood with no clots from the vagina is observed by the nurse. Which action
should the nurse implement?
_A Apply ice pack to perineum.
_B Massage the fungus vigorously.
_C Let the infant breast feed.
_D Assess her blood pressure
9_While assessing a 40-week gestation primigravida in active labor, the client’s membranes
rupture spontaneously and the nurse notes that the amniotic fluid is meconium stained. Which
additional finding is most important for the nurse to report to the healthcare provider?
_A Contractions occurring every 2 to 3 minutes.
_B Vaginal exam reveals a cervix 6 cm dilated.e
_C Maternal blood pressure of 130/85 mmHg.
_D Fetal heart rate of 100 to beast/minute.
10-The nurse working in an antepartal clinic measures a 38cm fundal height on a client who is at
30-week gestation by dates. What action is most important for the nurse to take?
_A Ask the client to return to the clinic next week for reassessment of fundal height.
_B Record the findings so that an on-going assessment can be properly.
_C Obtain a prescription for an ultrasound and schedule it as soon as possible.
_D Explain to the client that this finding could indicate she has a twin pregnancy.
11-The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24
hours following delivery of a normal newborn. Prior to the anesthesiologists arrival on the unit,
which action should the nurse perform?
_A Insert an indwelling Foley catheter.
_B Cleanse the spinal injection site.
_C Apply an abdominal binder.
_D Place procedure equipment at bedside.
12-The nurse is preparing to draw blood from a newborn to obtain hemoglobin and hematocrit
levels. What is the best method to obtain this blood sample?
_A Use a small gauge needle to puncture the vastus lateralis.
_B Draw blood from the infant”s antecubital vein using a small gauge needle.
_C Use a lancet to puncture the outer lateral aspect of the heel.
_D Use a butterfly, small gauge needle to do a venous puncture on the hand.
13- The nurse is preparing a client with Type 1 diabetes who is at 35-weeks gestation for an
amniocentesis. After obtaining maternal vital signs and a baseline fetal heart rate, which nursing
intervention has the highest priority?
_A Intiate a heparin lock.?
_B Provide family support.
_C Review maternal Rhesus (Rh) factor status.
_D Obtain a baseline complete blood count.
14- A 34-week primigravida with preeclampsia is receiving Ringer’s Lactate 500ml with
magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hours should the nurse
program the infusion pump? (Enter numeric value only).
75 ml/h
18- The postpartum admission prescriptions for a client who delivered a healthy newborn
includes one liter of Lactated Ringer’s with oxytocin (Pitocin) 20 units to infuse over 8 hours.
How many milliunits/minute is the client receiving? (Enter the numerical value only. If round is
required, round to the nearest whole number.) 42
19- The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm
labor. What maternal prescription is most important in preventing this fetus from developing
respiratory distress syndrome?
_A Ampicillin 1 Gram IV push q8h.
_B Betamethasone (Celestone) 12 mg deep IM.
_C Butorphanol 1 mg IV push q2h PRN pain.
_D Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3.
20- A couple, concerned because the woman has not been able to conceive, is referred to a
healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which
complaint would indicate to the nurse that the woman’s fallopian tubes are patent?
A Back pain.
B Leg cramps.
C Shoulder pain.
D Abdominal pain.
21- The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant.
When discussing birt control, which method should the nurse recommend to this client as best
for her to use in preventing an unwanted pregnancy?
A Condoms and contraceptive foam or gel. ?
B Combined estrogen-progesterone oral contraceptives.
C Breastfeed exclusively at least every 3 to 4 hours.
D Rhythm method (natural family planning).
21-A client at 38-weeks gestation complains of severe abdominal pain. Upon palpation, the nurse
notes that the abdomen is rigid. How should the nurse document the findings?
A Chorioamnionitis.
B Abruptio placenta.
C Oligohydramnios.
D Placenta previa.
22-A mother asks the nurse what to use when changing her newborn’s diaper. What substance is
best for the nurse to recommend to this mother?
A Clear water.
B Baby lotion.
C Talcum powder.
D Corn starch powder.
23- A client at 28-weeks gestation whose hemoglobin level is 10.7 mg/dl and hematocrit is
32.3%, tell the nurse that she eats plenty of green vegetables. When the client asks the nurse how
the pregnancy might affect the laboratory finding, what information should the nurse provide?
A Plasma volume increases, making the blood count appear low.
B Almost all women at 28-weeks gestation have anemia.
C Increasing intake of protein might improve these values.
D It might be necessary to take an iron supplement twice daily.
25- A woman who delivered a 9 pound baby boy by cesarean section under spinal anesthesia is
recovering in the post anesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous
trickle of bright red blood with no clots from the vagina is observed by the nurse. Which action
should the nurse implement?
_A Apply ice pack to perineum.
_B Massage the fungus vigorously.
_C Let the infant breast feed.
_D Assess her blood pressure.
During a routine prenatal vital a client 32 weeks gestation complains of urinary frequency has
increased during the day as well at night. The nurse determines the client is having irregular
uterine contractions. What should the nurse implement ?
A. Ask the client if she had sexual intercourse yesterday
B. Determine if she has change in vaginal discharge
C. Collect urine sample from dipstick analysis
D. Obtain a midstream urine specimen for culture
A 6 year old child with acute infectious diarrhea is placed on a rehydration therapy regulation.
What action should the nurse instruct the parents to take if the client begins to vomit ?
A. Continue giving ORS frequently small amounts
B. Withhold all oral medications
C. Supplement ORS with gelatin or chicken broth
D. Provide only bottle water
3. The nurse is preparing to administer methylergonovine maleate (Methergine)
to a postpartum client. Based on what assessment finding should the nurse
withhold the drug?
• Respiratory rate of 22 breaths/min
• A large amount of lochia rubra
• Blood pressure 149/90
• Positive Homan’s sign
Note: The only contraindication that has this medicine is HBP, page 581 Matern…
book.
4. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid
arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints
and surrounding muscle. Which physical therapy regimen should the nurse
encourage the adolescent to implement?
• Begin a training program lifting weights and running
• Splint affected joints during activity
• Exercise in a swimming pool
• Perform passive range of motion exercises twice daily
Note: page 1710 MB (Maternity book)
5. A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
• Pain level
• Blood pressure
• Infusion site
• Contraction pattern
• The XXXX muscle groups of males can be impacted by a lack of the
protein dystrophyn in the mother
• Birth trauma with a breech vaginal birth causes damage to the spinal
cord, thus weakening the muscles
Note: page 1733 MB
28. A 4 month old girl is brought to the clinic by her mother because she has
had a cold for 2 or 3 days and woke up this morning with a hacking cough and
difficulty breathing. Which additional assessment finding should alert the nurse
that the child is in acute respiratory distress?
• Bilateral bronchial breath sounds
• Diaphragmatic respiration
• A resting respiratory rate of 35 breathe per minute
• Flaring of the nares
Note: page 1354 MB
29. A two year old child with a heart failure(HF) is admitted for replacement
of a graft for coarctation of the aorta. Prior to administering the next dose of
digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What
action should the nurse implement?
• Determine the pulse deficit
• Administer the schedule dose
• Calculate the safe dose range
• Review the serum digoxin level
Note: page 1460 MB
30. Which nursing intervention is most important to include in the plan of care
for
for a child with acute glomerulonephritis?
• Encourage fluid intake
• Promote complete bed rest
• Weight the child daily
• Administer vitamin supplements
Note: page 1539 MB
9. If mother has DM type 1, what do you expect for fetal complications? Hypoglycemia
10. Pt has history of “heart damage”. She has the potential to have heart failure. What is her
nursing diagnosis? fluid volume excess.
11. Mom comes out of room screaming that her baby is missing. What do you do – initiate a lockdown
12. Mom has post partial hemorrhage. What is most likely the cause – she is a multigravida
13. Mom has mitral stenosis, what symptom is common with this diagnosis – persistent cough
14. Pt is administered with anesthesia, what is the highest priority – side rails up and call bell in reach
15. Patient is showing signs of mag toxicity (nausea, feeling of warmth, flushing) – stop infusion
Good source of folic acid - peanuts
16. Signs of fetal alcohol syndrome – flat nose bridge Mom has been on mag sulfate and is now postpartum,
what is she at increased risk for – uterine atony (hemorrhage)
Mom is prescribed hemabate – give antiemetic before hemabate due to s/e (also cause diarrhea so give antidiarrheal)
During fundal massage, place one hand at the fundus, what is the second hand used for – to anchor fundus
There is a question that has to be put in order – isolate the baby, move mom to private room, collect u/a, start iv
How do you measure the frequency of contractions – from the beginning of one to the beginning of the next
Mothers Hemoglobin A1C – give her a consultation to a nutritionist
Baby shows cyanosis in hands and feet and has elevated respirations – gradually warm the baby
Baby is showing signs of mottling – check temperature
Mom is at 20 week gestation and has gained 20 lbs, what is of most concern out of the data of mom – increased
weight gain
Mom asks why her baby is being screened for T4 and TSH levels – it is state protocol to monitor for metabolic
abnormalities
Patient is having labor back pain – counter pressure on lower back (sacrum)
Woman had cleft lip, dads uncle had cleft lip – send them for genetic testing
Woman in labor and they look at vagina and see cord – put woman in Trendelenburg position
Pregnant woman has a diaphragm – she needs to have it refitted for another diaphragm
Baby starts showing signs of respiratory difficulty (nasal flaring, expiratory grunt, cyanosis) – check O2 saturation
levels
Baby progressing in extrauterine life would show what signs – good vigorous cry with stimulation
Baby has peri-oral cyanosis – assess the oral mucosa
Before surgery mom is given an anticholinergic/atropine with anesthesia. What is the therapeutic response of the
anticholinergic – increase pulse and decrease oral secretions
Question about cytotec – answer is you are at an increased risk for abortion
Patients uterus is above the umbilicus and to the right during postpartum, what do you do first – palpate the bladder
for distention
Mom feels the urge to defecate during labor – do a vagina exam
What is the reason to do an ultrasound on a mother at 20 weeks gestation – ultrasound for gestation and fetal growth
Patient is taking mag sulfate and urine output is 25 mL/hr, respirations 14/min, pulse is 116/min, what should the
nurse do first – discontinue mag sulfate (signs of mag tox)
Postpartum with bathroom privileges, what possible condition would the nurse place the patient on temporary bed
rest for – possible thrombus in the leg if positive Homan’s sign is present
Pregnant woman has an increased costal angle and diaphragm is elevated , how does the nurse document this – as a
normal finding
Moms Hgb and Hct is low, what food to tell her to eat that contains the most iron? – chicken (other sources: liver,
meats, whole grains, enriched bread, cereal, dried fruits)
Mom wakes up in a pool of blood and comes to emergency room. What to check first – blood pressure
3. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not
know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide?
C. Let the nipple dry thoroughly after each feeding.
4. A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which
preoperative nursing intervention should the nurse implement first?
A. Place the infant on the abdomen to protect the sac.
5. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her
teenage son’s acne cream, benzoyl peroxide, on the baby’s face. Which answer should the nurse to
provide?
A. “ Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare
provider”
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
A. "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B. "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times
a day."
C. "Offer the baby extra bottled milk after her feeding and see if she still seems hungry."
D. "If you're concerned, you might consider bottle feeding so that you can monitor
intake."
6. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What
intervention has the greatest priority?
D. Have a meconium aspirator available at delivery.
7. A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby,
the infant’s skin tastes salty. The nurse should prepare the mother for what standard diagnostic test
to screen for cystic fibrosis (CF)?
A. Sweat-chloride test.
A primipara has delivered a stillborn fetus at 30-weeks gestation. To assist the parents with the
grieving process, which intervention is most important for the nurse to implement?
Provide an opportunity for the parents to hold their infant in private
A primigravida at 40 weeks gestation is contracting q2 minutes, and her cervix is 9 cm dilated,
and 100% effaced. The rate is 120 breaths/minute. The client is screaming and her husband is
alarmed. Which intervention should the nurse take?
Notify rapid response team
Have delivery table set up
Ask the husband to step out
Administer a PRN narcotic
Peds
1. MALE CHILD IN IV THERAPY FOR GROIN ABSCESS: EXPOSURE TO PISON IVY 6 DAYS AGO.
2. SICKEL CELL CRISI. WHICH IS THE EARLIEST SIGN EXHIBIT: PAIN.
3. BABYSITTER OF A 7yold WHO HAS TYPE 1 DIABETES AND IS VERY IRRITABLE, PERSPIRING
AND SAHKING. SHE CALL THE NURSE, WHAT IS THE BEST RESPONSE: GIVE THE CHILD AN 8
oz= 1 cup OF MILK.
4. MOTHER OF A 3 MONTHS WHO IS SPITTING UP EVERY TIME SHE BREATS FEED HIM. WHAT
ACTION SHOULD THE NURSE TAKE? EXPLAIN THAT SPITTING UP IS NORMAL AND USUALLY IS
NOT A PROBLEM .
5. ORDER THE CLIENT HAVE A CRISIS OF DKA FOR THE 2ND TIME IN 5 MONTHS ACCORDING TO
THE HIGHST PRIORITY TO THE LOWEST SELECT:
5.1- ASK THE CLIENT
5.2- EVALUATE THE CLIENT KNOWLEGDE ABOUT HIS SIT.
5.3- ASSESS THE CLIENT’S RESOURCES AND FAMILY SUPPORT.
5.4- PROVIDE INFORMATION ABOUT A SUPPORT GROUP.
6. PREGNANT TEENAGER: IRON-DEFICIENCY ANEMIA
7. BABY WITH HYPOSPADIAS, MOTHER CONCERNED R/T JEWISH FAITH TRADITION: “I
UNDERSTAND YOUR CONCERN. WOULD YOU LIKE TO TALK W/THE PEDIATRICIAN”?
8. BETA-ADRENERGIC AGONIST ALBUTEROL (PROVENTIL): ASSURE THE MOTHER THAT IS
CORRECT.
9. GROUP B STREPTOCOCCUS (GBS), WHICH INMEDIATE TREATMENT: ADMINISTRATION OF
ANTIBIOTICS.
10. 8.6 (DOSAGE CALCULATION).
11. NURSE ASSESSING 3yold BOY AFTER AND UPPER RESPIRATORY TRACT INFECTION, HE
DEVELOP ACUTE OTITIS MEDIA (OM). WHICH FACTOR PLACES HIM AT GREATEST RISK?
CHILDREN HAS THE EUSTACHIAN TUBE IS SHORTER THAT ADULTS.
12. ASHKENAZI JEWISH WOMAN: TAY-SACHS DISEASE (THIS POPULATION ARE MORE
SUSCEPTIBLE GENETIC DISEASES LIKE T-S DISEASE = A condition where children develop
normally until about four to six months of age. It is at this time that the central nervous system
begins to degenerate. Individuals with Tay - Sachs disease lack an enzyme called
hexosaminidase (Hex A). The child loses all motor skills and becomes blind, deaf and
unresponsive).
13. INDOMETHACIN (INDOCIN): FOR PREMATURE WHO HAS PATTERN DUCTUS ARTERIOSIS =
PDT because works by causing the PDA to constrict, and this closes the blood vessel. DECREASE
RESPIRATION
14. A CLIENT AT 40 WKS, ACTIVE LABOR, WHO IS HIV+ AFTER A BLOOD TEST. WHAT ACTIONS
SHOULD THE NURSE INCLUDE IN THE PLAN OF CARE REGARDING TO THE LABOR PROCESS,
SELECT ALL THAT APPLY:
14.1- USE STANDARD PRECAUTION.
14.2- GIVE ANTIVIRAL MEDS (HIV+ MOM’S CANN’T BREASTFEED, MUST HAVE C/S, AMONG
OTHERS).
15. A CHILD WITH HIRSCHSPRUNG’S DISEASE (that affects the large intestine (colon) and causes
problems with passing stool, CONGENITAL) HAVE BEEN 2 DAYS W/ FEVER AND WATERY
EXPLOSIVE DIARRHEA. WHICH INTERVENTION WILL BE THE FIRST: INSERT A LARGE BORE IV
CATHETER.
16. AN 11yold WITH BUDDING BREAST AND SACNT PUBIC HAIR: TANNER SCALE 2 (physical
measurements such as the size of the breasts, genitals, testicular volume and development of
pubic hair).
17. LABORING CLIENT, FHR PATTERN FALLS AND ARRISES ABRUPTLY IN A “V” (THIS ARE
VARIABLE DECELERATIONS= CORD COMPRESSION) SHAPE, WHICH ACTION: REPOSITION THE
MOM. ADM O2 AT 8-10L BY FACE MASK, STOP PITOCIN AND LASTLY CALL MD.
18. 12.5 DOSAGE CALCULATION.
19. WHICH OF THE FOLLOWING CHILD WILL BE EVALUATED FOR A PEDIATRICIAN/: 3yold
WALKING IN A TIPTOES (COULD BE A S/S OF NEUROLOGICAL PROBLEMS.)
20. SNACK FOR A PT W/OSTEOMYELITIS (BONE INFECTION): MILKSHAKE (OR APPLESAUCE).
21. DRAWN BLOOD FROM A NEWBORN FOR Hb/ HEM: A heel-stick TEST
22. MEASURES OF A RUBELLA VACCINATION OF A MOTHER W/ 2 CHILDRENS ONE OF 3 MONTHS
AND 13 MONTHS. THE ANSWER CAN NOT BE HAVE THEIR KIDS TO HAVE THE VACCINE
BECAUSE IT START 12-15 MONTHS.
23. ABREASTFEEDER MOM HAVE MASTITIS AND ANTIBIOTICS IS PRESCRIBE, WHAT SHE CAN DO
RELATED TO BREASTFEEDING? : SHE CAN BREASTFEED UNLESS HAVE AN ABCSESS, steps:
BEFORE BREAST-FEEDING YOUR BABY, PLACE A WARM, WET WASHCLOTH OVER THE AFFECTED
BREAST FOR ABOUT 15 MINUTES. TRY THIS AT LEAST 3 TIMES A DAY. START W/ AFFECTED
BREAST TO DECREASE PAIN if too much pain begin with the unaffected
24. NURSING DIAGNOSIS FOR A CHILD W/ BLADDER Exstrophy (CONGENITAL EXTRUSION TO
THE OUTSIDE OF THE BODY): RISK FOR URINARY ELIMINATION/URINARY INCINTINENCE.
25. A NURSE RECEIVED FOR PREGNANT WOMENS WHICH ONE SHOULD ASSESS FIRST: THE ONE
WHO HAVE BLODDY SHOW
26. A MOTHER HAVE JUST HAVE A NORMAL VD OF A HEALTHY NEWBORN SHE ASK THE NURSE
WHEN SHE CAN GO HOME: HOW MUCH YOU’RE STILL BLEEDING (ASSESSMENT OF BLEEDING).
27. A 10- year old girl who was bitten by a tick during a Girl Scout camping trip receives a
prescription for tetracycline (Achromycin) for Lyme’s disease. What information should the
nurse provide to ensure the client understands? Do not take tetracyclines with milk or
antacids.
28. The nurse is planning care for a client at 30-weeks’ gestation who is experiencing preterm
labor: BETHAMETHASONE.
29. RHEUMATIC FEVER: sore throat.
30. The parents of 15-month-old boy tell the nurse that they are concerned because their son
brings his spoon to his mouth but not turn it over. What action should the nurse implement
first? Normal development.
31. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant,
notes that the FOC has increased 5 inches since birth and the child’s head appears large in
relation to body size. Which action is most important for the nurse to take next? Palpate the
anterior fontanel for tension and bulging.
32. ANIMAL THAT IS AT RISK FOR A GRAVIDA: CAT (TOXOPLASMOSIS).
33. A BREASTEFEEDING INFANT SCREENED FOR CONGENITAL HYPOTHYROIDS IS FOUND TO
HAVE LOW LEVELS OF T4 AND HIGH OF TSH, BEST EXPLANAITION: THE TSH IS HIGH BECAUSE OF
THE LOW PRODUCTION OF T4 BY THYROID.
34. 500 ML OF MgSO4/ 20 GRAMS = 75 ml.
35. A NEONATE WHO HAS CONGENITAL ADRENAL HYPERPLASIA PRESENTS W/ AMBIGOUS
GENITALIA. WHAT IS THE PRIMARY NURSING CONSIDERATION WHEN SUPPORTING THE
PARENTS OF A CHILD WITH THIS ANOMALY: OFFER INFO ABOUT SONOGRAPHY AND
GENOTYPING TO DETERMINE SEX ASSIGNMENT? IS A MEDICAL EMERGENCY.
36. An adolescent girl comes to the school clinic immediately after falling and the nurse
suspects that she may have a fracture ulna. The nurse removes jewelry from the affected arm
and places a splint on it. What priority action should the nurse implement? Evaluate the
quality of the pulses in her wrists. [Show Less]