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 per... [Show More] ineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next?
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
2. 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?
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
3. 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 client’s condition, what information is most important for the nurse to provide?
A. Total amount of Pitocin infused
B. Maternal Blood pressure
C. Maternal Apical Pulse rate
D. Time Pitocin infusion completed
4. 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?
A. Sweating during feedings
B. Weak peripheral pulse
C. Bluish tinge to the tongue
D. Increased respiratory rate
5. A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client?
A. When ambulating to void does not cause dizziness
B. After the vitamin K injection is given to the baby
C. After the baby no longer demonstrates acrocyanosis
D. When there is no significant vaginal bleeding
6. 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?
A. Weight perineal pads
B. Weight daily
C. Measure intake and output
D. Ambulate 15 minutes QID
7. 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?
A. Treatment options, while limited due to the pregnancy, are available
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
8. 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?
A. Human placental lactogen
B. Gonadotrophin-releasing hormone
C. Human chorionic gonadotrophin
D. Prostaglandin E2 Alpha
9. 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
10. 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
11. The nurse is caring for a postpartum patient who is exhibiting symptoms of spinal headaches 24 hours following delivery of a normal newborn. Prior to anesthesiologist’s arrival on the unit, which action should the nurse perform?
A. Place procedure equipment at bedside
B. Apply an abdominal binder
C. Cleanse the spinal injection site
D. Insert an indwelling Foley catheter
12. 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?
13. 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?
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
14. At 0600 while admitting a woman for a scheduled repeat c section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. What action should the nurse take first?
a. Ensure preoperative lab results are available
b. Start prescribed IV with Lactated Ringers
c. Inform the anesthesia care provider
d. Contact the client’s obstetrician
15. 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
16. A 3-hour old male infant’s hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best for the nurse to implement?
A. Perform a heel- stick to monitor blood glucose level
B. Gradually warm the infant under a radiant heat source
C. Administer oxygen by mask at 2L/minute
D. Notify the pediatrician of the infant’s unstable vital signs
17. Calculated by Nagele’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?
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
18. 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
19. The nurse is assessing a 35-week primigravida with a breech presentation who is experiencing 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?
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
20. 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?
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”
21. A diabetic client delivers a full term large for gestational age infant who is jittery. What action should the nurse take first?
A. Obtain a blood glucose level
B. Administer oxygen
C. Feed the infant glucose water (10%)
D. Decrease environmental stimuli
22. 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
23. 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.?
24. A term multigravida, who is receiving oxytocin (Pitocin) for labor augmentation, is requesting pain medication. Review of the client’s record indicates that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the clients cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?
A. Medicate the client with an additional 1 mg of Stadol IV push
B. Instruct the client to use deep breathing during a contraction
C. Discontinue the Pitocin infusion
D. Notify the healthcare provider
25. The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond?
A. Encourage the parents to report this to the healthcare provider
B. Explain the newborns normal stepping reflex
C. Acknowledge the parent’s observation
D. Schedule the newborn for further neurological testing
26. At 34- weeks gestation, a primigravida is assessed at her bimonthly clinic visits, which assessment finding is important for the nurse to report to the hcp?
A. Increased appetite
B. Fetal heart rate of 110 beats/minute
C. Fundus below the xiphoid
D. Weight gain of 7 pounds
27. 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 siblings 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
28. 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 dilated 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
29. Which topic is most important for the nurse to include in a nutrition teaching program for pregnant teenagers?
A. Gestational diabetes
B. Iron-deficiency anemia
C. Excessive weight gain
D. Elevated cholesterol
30. 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 Babinski reflexes
31. 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
32. 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/hours should the nurse program the infusion pump?
33. 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?
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 cephalohematoma (THIS ONE DOES NOT CROSS THE SL & IS MORE CRITICAL)
34. 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 lochia flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
A. Heart rate and blood pressure
B. Abdominal contour and bowel sounds
C. Urinary output and IV fluid intake
D. Hemoglobin and Hematocrit
35. 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?
A. Inspect the client’s perineum
B. Turn on the infant warmer
C. Notify a healthcare provider
D. Push the call light for help
36. A client who is receiving oxytocin (Pitocin) to augment early labor begins to experience hyper systolic or tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?
A. Reposition the fetal monitor transducers
B. Alert the charge nurse to the patient’s condition
C. Turn off the Pitocin infusion
D. Decrease the rate of the Pitocin infusion
37. 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
38. A new infant is receiving positive pressure ventilation after delivery. Based on which assessment finding should the nurse initiate chest compressions?
A. Apgar score 7
B. Heart rate 54
C. Limp muscle tone
D. Central cyanosis
39. 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?
A. Presence of a neural tube defect
B. Gender of the fetus
C. Fetal lung maturity
D. Chromosomal abnormalities
40. 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?
A. Notify the hcp
B. Assess the maternal vital signs
C. Turn to a side-lying position
D. Increase the IV infusion rate
41. A woman who delivered a normal newborn 24 hours ago complains, “I seem to be urinating every hour or so. Is that ok?”. Which action should the nurse implement?
A. Catheterize the client for residual urine volume
B. Measure the next voiding, then palpate the client’s bladder
C. Evaluate for normal involution, then massage the fundus
D. Obtain a specimen for urine culture and sensitivity
42. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of 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?
A. Determine current cervical dilation
B. Request placement of the epidural
C. Give bolus of intravenous fluids
D. Decrease the oxytocin infusion rate
43. The health care provider hands a newborn to the nurse after a vaginal delivery. What action is most important for the nurse to implement?
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
44. 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?
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 [Show Less]