The nurse is preforming an assessment on a client who is at 38 weeks gestation and notes that the fetal heart rate is 174 beats/ min. On the basis of this
... [Show More] finding, what is the PRIORITY nursing action?
A) Document the finding
B) Check the mothers heart rate
C) Notify the HCP
D) Tell the client the fetal HR is normal
C
A client arrives to the clinic for the first prenatal assessment. She tells the nurse that the first day of her menstrual period was October 19, 2014. Using Nageles Rule, which expected date of delivery should the nurse document in the client's chart?
A) July 12, 2014
B) July 26, 2015
C) August 12, 2015
D) August 26, 2015
B
The nurse has preferred a non stress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document the finding?
A) Normal
B) Abnormal
C) The need for further evaluation
D) That findings were difficult to interperet
A
The home care nurse visits a pregnant client who has had a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the HCP?
A) Urinary Output has increased
B) Dependent edema has resolved
C) Blood pressure reading is at the prenatal baseline
D) The client complains of a headache and blurred vision
D
The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that FURTHER TEACHING IS NEEDED if the client makes which statement?
A) "I will need to increase my insulin dosage during the first 3 months of pregnancy."
B) "My insulin dose will likely need to be increased during the second and third trimesters."
C) "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy."
D) "My insulin needs should return to normal within 7-10 days after birth if I am bottle feeding."
A
The nurse in the labor room is caring for a client in the active stage of the first phase of labor (latent phase). The nurse is assessing the fetal patterns and notices a late deceleration on the monitor strip. What is themes appropriate nursing action?
A) Administer oxygen via face mask
B) Place the mother in a supine position
C) Increase the rate of oxytocin (pitocin) intravenous infusion
D) Document the findings and continue to monitor the fetal patterns
A
The maternity nurse is preparing for the administration of a client in the third trimester pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the HCP's prescriptions and should question which prescription?
A) Prepare the client for an ultrasound
B) Obtain equipment for a manual pelvic examination
C) Prepare to draw a hemoglobin and hematocrit blood sample
D) Obtain equipment for external electronic fetal heart rate
B
The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?
A) Lethargy
B) Sleepiness
C) Constant crying
D) Cuddles when being held
C
The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the PRIORITY nursing consideration for this newborn?
A) Developmental delays because of excessive size
B) Maintaining safety because of low blood glucose levels
C) Choking because of impaired suck and swallow reflexes
D) Elevated body temperature because of excess fate and glycogen
B
The nurse is caring for a client with preeclampsia. The client is receiving an IV infusion of magnesium sulfate. When gathering items to be available for the client, which HIGHEST PRIORITY item should the nurse obtain?
A) Tongue blade
B) Percussion hammer
C) Potassium chloride injection
D) Calcium gluconate injection
D
A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is preforming assessments every 30 minutes. Which finding would be of MOST concern to the nurse?
A) Urinary output of 20 mL
B) Deep tendon reflexes of 2+
C) Fetal HR of 120 beats/ min
D) Respiratory rate of 10 breaths/ min
D
An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in preforming to assess for evidence of birth trauma?
A) Palpate the clavicles for a fracture
B) Auscultate the heart for a cardiac defect
C) Blanch the skin for evidence of jaundice
D) Preform Ortolani's maneuver for hip dislocation
A
During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. The nurse evaluates that teaching has been effective when the woman states:
A) "I will need to eat 600 more calories per day because I am pregnant."
B) "I can continue with the same diet as before pregnancy as long as it is well balanced."
C) "Diet and insulin needs change during pregnancy."
D) "I will plan my diet based on results of urine glucose testing."
C
The nurse should assist the laboring woman into a hands-and-knees position when __________.
A) the occiput of the fetus is in a posterior position
B) the fetus is at or above the ischial spines
C) the fetus is in a vertex presentation
D) the membranes rupture
A
To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are __________.
A)PPH and infection
B) multiple gestation and PPH
C) uterine tetany and overproduction of oxytocin
D) retained placental fragments and infection
D [Show Less]