1. The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this ... [Show More] client 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
2. A 38-week primigravida client who is positive for group A beta streptococcus receives a prescription for cefazolin 2grams IV to be infused over 30mins. The medications available in 2 grams/100ml of normal saline. The nurse should program the infusion pump to deliver how many ml/hours?
3. When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum and abdomen. What action should the nurse take?
A) measure bilirubin levels using transcutaneous bilirubinometer.
B) review maternal medical records for blood type and Rh factor
C) Prepare the newborn for phototherapy
D) Evaluate cord a result
4. A new mother asks the nurse about an area of swelling on her baby head near the posterior fontanel that lies across the suture lines. How should the nurse respond?
A) That's called caput succedaneum. It will absorb and cause no problems.
B) That is called a cephalohematoma. It will cause no problems.
C) That is called a cephalohematoma. It can cause jaundice as it is.
D)That is called caput succedaneum. It will have to be drained.
5. A 39-week gestational multigravida is admitted to labor and delivery spontaneous rupture of membranes and contraction occurring 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6cm, 90% effaced and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate has ranged between 170 and 180 beats/minute. What action should the nurse implement?
A) Obtain a blood specimen for hemoglobin
B) Take an oral maternal temperature
C) Straight Catheterize client
D) Send amniotic fluid for analysis
6. An obviously pregnant woman walks into the hospital’s emergency department entrance shouting. “Help me! Help me! My baby is coming! I’m so afraid!” The nurse determines if delivery is indeed imminent, what action is most important for the nurse to take?
A) Determines the gestational age of fetus
B) Assess the amount and color of the amniotic fluid
C) Obtain peripheral IV access and begin administration of IV fluids
D) Provide clear concise instructions in a calm, deliberate manner
7. A client who is 3 weeks postpartum tells the nurse. “I am so tired all the time. I didn't know having a baby would be so hard.” What response should the nurse provide.
a) It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps.
b) It is normal to feel tired for the first couple weeks. Be patient with yourself and rest more.
c) You should not be doing any housework. Are any of your family members helping you?
d) Adjusting to a new baby can be difficult. Tell me more about any help you are receiving.
8. The home health nurse visits a client who delivered a full-term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curl-like patches on the newborns oral mucous membranes. What action should the nurse implement?
A) Discuss the need for medication to treat curl-like oral patches
B) Suggest switching the infant’s formula
C) Assess the baby’s blood glucose level
D) Remind mother not put the baby to bed with a propped bottle
9. 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.
A) Document number of pad changes in the last hour
B) Provide bedpans to void if unable to ambulate
C) Palpate the supra pubic area for bladder distention
D) Increases the rate of the oxytocin infusion
10. 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 cries for no appeared reason. What information is most important for the nurse to provide the father?
A) Contact the clinic if the behaviors continue for more than two weeks or becomes worse
B) Tell the father count the newborns number of soiled diapers over the next few days.
C) A fluctuation in hormones in the early postpartum period can cause mood changes.
D) Recommend giving supplemental bottle feedings to the baby between breast feeding.
11. Which action should the nurse take if an infant, who was born yesterday weighing 7.5lbs (3,317grams) weights 7 lbs. (3,175grams) today.
A) Monitor the stool and urine output of the neonate for the last 24 hours
B) Inform and assure the mother that this is a normal weight loss
C) Encourages the mother to increase frequency of breastfeeding.
D) After verifying the accuracy of the weight, notify the healthcare provider.
12. A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the clients record indication that she was medicated 30minutes ago with butorphanol (Stadol) 2mg and promethazine (Phenergan) 25mg IV push. Vaginal examination reveals that the client cervical dilation is 3cm, 70% effaced, and at a 0 station. What action should the nurse implement?
A) Discontinue the Pitocin infusion
B) Medicate the client with an additional 1mg of Stadol IV push
C) Notify the healthcare provider
D) Instruct the client to use deep breathing during contraction
13. 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 continues trickles of bright red blood with no clots from the vagina in observed by the nurse. Which actions should the nurse implemented.
A) Massage the fundus
B) Assess her blood pressure
C) Apply ice pack to perineum
D) Let the infant breast feed
14. A newborn infant is receiving immunization prior discharge. Which action should the nurse implement?
A) Give the first dose of the vaccine for rotavirus if any have diarrhea now.
B) Obtain signed consent from the mother for administration of hepatitis B vaccine
C) Prepare the first dose for DTaP
D) Ask the mother if she wants the infant immunized for
15. A new mother, who is a 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) Offer iron-fortified supplemental formula daily.
C) Continue prenatal vitamins with B12 while breast feeding
D) Weight the baby weekly to evaluate the newborn’s growth
16. When teaching a gravid client how to perform kick (fetal movement) counts which instruction should the nurse includes.
A) Exercise for 15 before starting the counting to help increase fetal movement
B) Count the movements once daily for one hour, before breakfast
C) Avoid caffeinated drinks for 24 hours before conducting the kick test.
D) If 10 kicks are not felt within 1hr, drink orange juice and count for another hour.
17. A client at 38- weeks gestation complaints of severe abdominal pain. Upon the nurse notes that the abdomen is rigid.
A) Placenta previa
C) Abruptio placenta
18. A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height in measured at 29cm. Based on these findings what actions the nurse implement.
A) Notify the healthcare provider of the finding
B) Document the finding in the medical record
C) Schedule the client for a biophysical profile
D) Request another nurse measure the fundus
19. The nurse is performing a newborn assessment. Which symptoms if present in newborn, would indicate respiratory distress?
A) Abdominal breathing with synchronous chest movement
B) Shallow and irregular respirations
C) Flaring of the nares
D) Respiratory rate of 50 breaths per minute
20. The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client?
A) Administration of Pitocin
B) Artificial rupture of the membrane
C) Amnioinfusion for the baby
D) Administration of antibodies
21. The nurse examines a client who is admitted in active labor and determines the cervix is 3cm dilated 50% effaced, and the presenting part is at 0 stations. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first.
A) Check the pH of the vaginal fluid
B) Review the fetal heart rate pattern
C) Palpate the client’s bladder
D) Determine cervical dilation
22. The nurse’s assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?
A) Position radiant warmer over the crib
B) Assess the infants blood glucose level
C) Nipple feed 1 ounce 1% glucose in water
D) Place the infant in side-lying position
23. Which content should the nurse plan to include in a nutrition class for pregnant adolescents? (select all that apply)
A) Take iron and calcium supplements daily
B) Gain no more than 15 pounds during the pregnancy
C) Increase food intake by 300 to 400 calorie /day
D) Take folic acid supplement daily
E) Maintain current protein intake
24. The healthcare provides prescribes 10units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
A) uterus soft
B) contraction duration of 100 seconds
C) four contractions in 10 minutes
D) Early deceleration of fetal heart rate
25. A new mother who is breastfeeding her 4-week old infant and has type 1 diabetes, reports that her insulins needs have decreased since the birth of her child. What action should the nurse implement?
A) Inform her that a decrease for insulin occurs while breastfeeding
B) Advice the client to breastfeed more frequently
C) Counsel her to increase her calories retake
D) Schedule an appointment for the client with diabetic nurse educator
26. A diabetic client delivers a full-term large for gestation- age (LGA) infant who is jittery action should the nurse take first?
A) Administer oxygen
B) Feed the infant glucose water (10%)
C) Obtain a blood glucose level
D) Decrees environment stimuli
27. The postpartum admission prescription for a client who delivered a healthy newborn includes one liter of lactated ringers with oxytocin 20units to infuse over 8 hours. How many milliunits /minute is the clients receiving?0.4
28. A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement?
A) Schedule weekly prenatal appointments
B) Contact social services for a temporary shelter
C) Obtain a hemoglobin and hematocrit level
D) Have the client transported to the hospital
29. The nurse is planning a class for pregnant women in the first trimester of pregnancy. Which information is most imported for the nurse to include in the class?
A) Plan rest periods and increase sleep time to an hour per day when fatigue
B) If any vaginal bleeding occurs, notify the healthcare provider immediately
C) Since eating often relieves nausea, carry low fat snacks to eat whenever nausea occurs
D) If morning dizziness occurs, rise slowly and sit on the side of the bed for one minute
30. When assessing a pregnant woman AT 39-weeks gestation who is admitted to labor and delivery which finding is most important to report to the health care provider?
A) + proteinuria
B) 130/70 blood pressure
C) + pedal edema
D) 101.2 oral temperature
31. A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin C drug, how should the nurse respond?
A) “You may be at risk for having a spontaneous miscarriage”
B) “You may have an increased chance of having preeclampsia”
C) “This medication will have no effect on your unborn child”
D) “You may experience postpartum hemorrhaging after delivery”
32. Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client’s medical record lists the client’s religion as Jehovah’s Witness. What action should the nurse take?
A) Prepare to infuse multiple units of fresh frozen plasma
B) Inform the client of the critical need for a blood transfusion
C) Clarify the clients wishes about receiving blood products
D) Obtain consent from the family to infuse packed red blood cells
33. After delivery of a normal infant, the mother tells the nurses that she would like to use oral contraceptive. Which finding in the client’s health history is a contraindication of the use of contraceptives?
A) Previously used intrauterine device (IUD)
B) Reported history of stroke within family
C) Diagnosed with diabetes mellitus 2 years ago
D) Smoked cigarettes prior to becoming pregnant
34. When planning care for a laboring client, the nurse identifies the need to withhold solids food while the client is in labored. What is the most important reasons for this nursing intervention?
A) Nausea occurs from analgesics used during labor
B) Autonomic nervous system stimulation during labor decrease peristalsis
C) An increased risk of aspiration can occur if general anesthesia is needed
D) Gastric emptying time decreases during labor.
35. The parents of a male newborns have signed an informed consent for circumcision. which intervention should the nurse implement upon completion of the circumcision?
A) Place petroleum gauze dressings on the site
B) wrap the infant in warm receiving blankets
C) Give a PRN dose of liquid acetaminophen
D) Offer a pacifier dipped in glucose water
36. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochia flow. On inspection the nurse finds that a perineal hematoma is beginning to form. Which assessment findings show the nurse obtain first?
A) Abdominal contour and bowel sounds
B) Hemoglobin and hematocrit
C) Heart rate and blood pressure
D) Urinary output and IV fluid intake
37. At 6 weeks gestation the rubella titer of a client medication indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?
A) After the client stops breastfeeding
B) Immediately, at 6-weeks gestation to protect fetus
C) After the client reaches 20-weeks gestations
D) Early postpartum within 72 hours of delivery
38. The nurses assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indication that the infant is transitioning well to extrauterine life?
A) Heart rate 220 beats/minute
B) Cries vigorously when stimulated
C) A positive Babinski reflex
D) Flexion of all four extremities
39. A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and cervix dialed 3cm. The nurse’s assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
A) Clients hourly blood pressure
B) Preparation for emergency cesarean birth
C) Intensity, interval, and length of contractions
D) Checking the perineum for bulging
40. The nurse is caring for a newborn who is 18inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10inches. Based on these physical findings, assessment for which condition has the highest priority?
41. 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) When there is no significant vaginal bleeding.
D) After the baby no longer demonstrates acrocyanosis
42. A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, MENOPUR®), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately?
A) Episodes of headache and irritability
B) Nausea and vomiting
C) Rapid increase in abdominal girth
D) Persistent daytime fatigue
43. At 0600 while admitting a woman for a scheduled repeat Caesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
A) Contact the client’s obstetrician
B) Ensure preoperative lab results are available
C) Inform the anesthesia care provider
D) Start prescribed IV with Lactated Ringer’s
44. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30minutes and has a boggy uterus. What action should the nurse implement first?
A) Have the client empty her bladder
B) Inspect the perineum for lacerations
C) Increase oxytocin IV infusion
D) Perform fundal massage until firm
45. A client at 20 weeks gestation comes to antepartum clinic complaining of vaginal warts (human papilloma virus HPV). What information should the nurse provide this client?
A) Termination of the pregnancy should be considered
B) Pregnancy complication are not linked to HPV
C) This client should be treated with acyclovir (Zovirax)
D) The client should be treated with penicillin G.
46. A 33-year-old client at 9 weeks gestation tells the nurse that while she has “cut down,” she still has at least one alcoholic drink every evening before bedtime. What intervention should the nurse implement?
a) Notify child protective services of the client’s illicit drug use and probable child endangerment
b) Praise the client for her actions and offer to discuss ways to decrease consumption even more
c) Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit [Show Less]