1. The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor. What maternal prescription is most important in prevent... [Show More] ing this fetus from developing respiratory distress syndrome?
a. terbutaline (Brethine) 0.25 mg SubQ Q15 mins x 3
b. Betamethasone (Celestone) 12 mg deep IM
c. Butorphanol 1 mg IV push q2h PRN pain
d. Ampicillin 1-gram IV push q8h
2. A primigravida client confides in the nurse that her sister told her that she should eliminate all salt once she is at 26 weeks’ gestation because it will eliminate fluid retention and swelling. How should the nurse respond?
a. Salt foods lightly during cooking but add no additional salt at the table.
b. eliminate all added salt from the diet to improve kidney function during pregnancy
c. limit grain, meat and milk products which are significant sources of sodium
d. use canned food products to obtain salt because it is easier to monitor salt intake
3. A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?
b. brain damage
c. poor appetite
4. The mother of a breastfeeding 24 hr old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is “doing it right.” She tells the nurse, “I just know my daughter is not getting enough to eat.” What response would be best for the nurse to make?
a. feed your baby hourly until you feel confident that your child is receiving enough milk
b. don’t worry, soon your milk will come in, and you will feel how full your breasts are
c. since you are so concerned, you should probably supplement breastfeeding with formula
d. if your baby’s urine is straw-colored, she is getting enough milk*
5. A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment finding warrants immediate intervention by the nurse?
a. the onset of uterine contractions
b. leaking amniotic fluid
c. fetal heart rate 60 beats/min*
d. ruptured amniotic membrane
6. A client at 40-weeks’ gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. What information is most important for the nurse to obtain first?
a. the estimated amount of fluid
b. time the membranes ruptured
c. color and consistency of the fluid
d. any odor noted when membranes ruptured.
7. A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action should the nurse take first?
a. assess the urine for proteinuria
b. record the finding on a flowsheet
c. obtain blood pressure reading
d. notify the healthcare provider
8. 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 butterfly, small gauge needle to do a venous puncture on the hand
b. draw blood from the infant's antecubital vein using a small gauge needle
c. use a small gauge needle to puncture the vastus lateralis
d. use a lancet to puncture the outer lateral aspect of the heel *
9. A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
a. postpartum psychosis
b. hard, painful uterine afterpains
c. placenta accreta
d. disseminated intravascular coagulation*
10. A primigravida client receives a prescription for an infusion of oxytocin (Pitocin) at 12 milliunits/minute. The available solution is ringers lactated 1,000 ml with Piton 10 units. The nurse should program the infusion pump to deliver how many ml/hour?
11. A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some “heart damage.” The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client’s history, which nursing diagnosis has the highest priority?
a. sleep deprivation
b. risk for infection
c. fluid volume excess *
d. nausea and vomiting
12. collard greens
13. A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse’s assessment reveals approximately 30 ml of bright red vaginal bleeding, FHR of 130 to 140 beats/min, no contraction, and no complaints of pain. What is the most likely case of this client’s bleeding?
a. placenta previa
b. a ruptured blood vessel in the vaginal vault
c. normal bloody show indicating initiation of labor
d. abruptio placenta
14. A client at 26 weeks gestation recently indicated a yellow discharge from her right breast. How should the nurse respond?
a. you need to wear a good support bra
b. you need to discuss this with your HCP
c. you probably have an infection
d. this is normal *
15. 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 HCP?
a. +1 pedal edema
b. 130/70 blood pressure
c. 101.2 F oral temp *
d. +1 proteinuria
16. When performing the daily head to toe assessment of a one-day old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
a. review maternal medical records for blood type and Rh factor
b. prepare the newborn for phototherapy
c. evaluate cord blood Coombs’ test results
d. measure bilirubin levels using transcutaneous bilirubinometer
17. A pregnant client mentions in her history that she changes a cat’s litter box daily. Which test should the nurse anticipate the HCP to prescribe?
a. Biophysical profile
b. TORCH screening
c. Fern Test
18. Assessment findings of a 3-hour old newborn include: axillary temperature of 97.7 F, heart rate of 140 beats/min with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement?
a. record findings in electronic medical record
b. obtain venous blood sample for glucose level
c. attach a pulse oximeter on the heel
d. place the infant under the radiant warmer
19. Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?
a. pudendal block
b. epidural block
c. saddle block
d. paracervical block
20. A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?
a. that is called a caput succedaneum. it will absorb and cause no problems*
b. that is called a cephalohematoma. it can cause jaundice as it is absorbed
c. that is called a cephalohematoma. it will cause no problems
d. that is called a caput succedaneum. it will have to be drained
21. A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the hospital. Which instruction should the nurse include in the discharge teaching plan?
a. breastfeed infant every 4 hours
b. monitor skin and eyes for yellow tinge
c. reposition the infant every 2 hours
d. change diapers every hour
22. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/min, respiratory rate 16 breaths/min, and blood pressure 130/74. What action should the nurse implement?
a. administer a PRN dose of acetaminophen
b. report heart rate to HCP
c. document the vital signs in the record
d. assess the perineum for excessive lochia
23. 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 E drug. How should the nurse respond?
a. you may have an increased chance of having preeclampsia
b. this medication will have no effect on your unborn child
c. you may experience postpartum hemorrhage after delivery
d. you may be at higher risk for having a spontaneous miscarriage *
24. A pregnant woman who is at 10-weeks’ gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client?
a. an amniocentesis conducted at 24 weeks’ gestation confirms or denies Down Syndrome in the fetus
b. maternal serum Human Chorionic Gonadotropic (HCG) can identify Down Syndrome at 6 weeks of gestation
c. Weekly fundal height measurements are a noninvasive method used to check for Down Syndrome
d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome *
25. A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, menopur) and HCG. Which side effect should the nurse tell the client to report immediately?
a. persistent daytime fatigue
b. rapid increase in abdominal girth
c. nausea and vomiting
d. episodes of headache and irritability
26. The HCP prescribes 10 units/L of oxytocin (Pitocin) via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
a. early decelerations of FHR
b. uterus is soft
c. Four contractions in 10 minutes
d. contraction duration of 100 seconds *
27. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority should the nurse address to ensure the newborn’s survival?
a. fluid balance
c. heat loss
d. bleeding tendencies
28. One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first?
a. check the differential, since the WBC is normal for this client *
b. notify the HCP, since this finding is indicative of infection
c. assess the client’s temperature, pulse and respirations q4h
d. assess the clients perineal area for signs of perineal hematoma
29. The nurse is performing a newborn assessment. Which symptom, if present in a newborn would indicate respiratory distress?
a. respiratory rate of 50 breaths per min
b. flaring of the nares *
c. shallow and irregular respirations
d. abdominal breathing with synchronous chest movement
30. The nurse is caring for a client following an emergency cesarean delivery under a general anesthesia. Which assessment finding, occurring in the first 8 hours after delivery, is more critical and requires immediate intervention?
a. mild nausea and anorexia
b. uterine atony *
c. a positive Homan’s sign
d. Respiratory rate 12
31. The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision?
a. give a PRN dose of liquid acetaminophen
b. wrap the infant in warm receiving blankets
c. place petrolatum gauze dressings on the site *
d. offer a pacifier dipped in glucose water
32. The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?
a. palpate the client’s bladder
b. check the pH of the vaginal fluid
c. determine cervical dilation
d. review the FHR pattern *
33. A 26-week gestation primigravida who is carrying twins is seen in the clinic today. Her final height is measured at 29 cm. Based on these findings, what action should the nurse implement?
a. notify the HCP of the finding
b. schedule the client for a biophysical profile
c. document the finding in the medical record
d. request another nurse measure the fundus
34. A client at 34 weeks gestation is scheduled to travel for business using a commercial airline. Which instruction is most important for the nurse to provide this client?
a. explore the availability of medical care at the destination site
b. request an aisle seat in a row that is not designated as an exit row *
c. perform ankle flexion and extension several times throughout the trip
d. wear non-constricting clothing to prevent edema of the feet and hands
35. Following a precipitous labor, a postpartum client has a continuous trickling of bright red blood from her vagina. Her uterus is firm, and her vital signs are within normal limits. The nurse determines that this sign may indicate which condition?
a. expected course in the fourth stage of labor
b. a full urinary bladder
c. early postpartum hemorrhage
d. the laceration on the cervix *
36. The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority?
37. A postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client?
a. RhoGAM is not necessary unless all her pregnancies are Rh-positive
b. RhoGAM prevents maternal antibody formation for future Rh-positive babies
c. the mother should receive RhoGAM when the baby is Rh-negative
d. the R-positive factor from the fetus threatens her blood cells *
38. A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per minute. What intervention is most important for the nurse to perform?
a. encourage the client to empty her bladder *
b. determine the maternal pulse rate
c. instruct the client to drink a glass a juice
d. place the client in a supine position
39. Vaginal examination reveals that a laboring clients’ cervix is dilated to 2 cm, 70% effaced, with the presenting part at -2 stations. The client tells the nurse, “I need my epidural now! This hurt!” the nurses’ response to the client should be based on what information?
a. the client should be dilated to at least 8 cm before receiving an epidural
b. the baby needs to be at a zero station before an epidural can be administered
c. Administering an epidural at this point would slow the labor process *
d. the client will need to be catheterized before the epidural can be administered.
40. A client at 38 weeks gestation presents to the labor and delivery unit in active labor. Based on which assessment finding should the nurse notify the surgery team to prepare for a primary cesarean section?
a. treated ten days ago for Chlamydia
b. Group Beta Strep positive
c. Positive western blot for HIV
d. active herpes lesions on the perineum
41. A 6 weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?
a. immediately, at six weeks gestation to protect this fetus
b. early postpartum within 72 hours of delivery
c. after the client stops breastfeeding
d. after the client reaches 20-weeks’ gestation
42. The nurse is receiving a report for a laboring client who arrived in the ER with ruptured membranes that the client did not recognize. What is the priority nursing action to implement when the client is admitted to the labor and delivery suite.
a. Prepare to start at IV *
b. take the clients temp
c. begin a pad count
d. monitor amniotic fluid for meconium
43. A laboring client with gestation diabetes is receiving an IV infusion with regular insulin at five units/hour. The IV solution contains 100 units of regular insulin in 250 ml of 0.9% normal saline. The nurse should program the infusion pump to deliver how many ml/hours?
44. The nurse is conducting a 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. combined estrogen- progesterone oral contraceptives
b. breastfeed exclusively at least every 3 to 4 hours
c. condoms and contraceptive foam or gel
d. rhythm method (natural family planning)
45. A full-term infant is admitted to the newborn nursery 2 hours after delivery. The delivery record indicates that the mother is positive for HIV and received zidovudine AZT IV during labor. What action should the nurse implement?
a. ensure that AZT is given within 6 hours after birth
b. assess for the presence of the Moro reflex
c. collect venous specimen for serum glucose level
d. obtain consent for the Hep B vaccine
46. In determining the one-minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has a loud cry with stimulation, good muscle tone and his color is acrocyanotic. What Apgar score should the nurse assign?
b. 9 **
47. A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
a. complaints of feeling tired all the time
b. presence of amenorrhea for 2 months
c. visualization of implantation by vaginal ultrasound
d. maternal blood serum tests positive for alpha-fetoprotein
48. Four clients at full term present to the labor and delivery unit at the same time. which client should the nurse assess first?
a. primipara with vaginal show and leaking membranes
b. primipara with burning on urination and urinary frequency
c. multipara scheduled for a non-stress test and biophysical profile
d. multipara with contractions occurring every 3 minutes
49. A primigravida at 40 weeks gestation is contracting q2 minutes and her cervix is 9 cm dilated and 100% effaced. The FHR is 120 beats/minute. The client is screaming, and her husband is alarmed. Which intervention should the nurse implement?
a. notify the rapid response team
b. have delivery table set up *
c. ask the husband to step out
d. administer a PRN narcotic
50. The nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine demise protocol and identification procedures. What action is most important for the nurse to take?
a. Explain reasons consent for an infant autopsy is needed
b. create a memory box of a baby’s footprints and photographs
c. determine if the mother desires a visit from the clergy
d. encourage the mother to hold and spend time with her baby * [Show Less]