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A nurse is assessing a newborn who has a weak cry and is grimacing. The nurse notes a HR of 102/min, blueish extremities, and flaccid muscle tone. APGAR of??A. 4B. 5C. 6D. 7
Pt is 1 day post-vag delivery. The fundus is firm, located 2 fingerbreadths above U and is deviated to the left. Which action should the nurse take first?A. Insert an indwelling urinary catheterB. Notify the practitionerC. Assist the pt to empty her bladderD. Encourage the pt to ambulate
C. Assist the pt to empty her bladder
A nurse is assessing a newborn. Which of the following findings are expected?A. slight yellow skin colorB. breast nodule 6mmC. posterior fontanel larger than the anterior oneD. overlapping suture linesE. lanugo over the shoulders
B. breast nodule 6mm - can be up to 10mmD. overlapping suture linesE. lanugo over the shoulders
Pt has hx of rheumatic heart disease, but no physical symptoms prior to pregnancy. Pt begins to have dyspnea, orthopnea, and pulmonary edema. Which of the following physiological alterations explains this change?A. increased mom wtB. increased blood volumeD. change in hematocrit levelsD. change in heart size
B. increased blood volume
Newborn assessment 12hr after delivery. Which indicates possible neonatal sepsis?A. temperature instabilityB. tachypneaC. hypertonicityD. nasal flaringE. irritability
A. temperature instabilityB. tachypneaX. hypoootonicity & lethargyD. nasal flaringE. irritability
Pt in PP has vag hematoma. Which findings are expected?A. lochia serosa draining from vaginaB. pressure in the vaginaC. intermittent vag painD. yellow exudate draining from vag
B. pressure in the vagina
Nurse is teaching prenatal class about infant safety. Which indicates need for further teaching?A. I will set my hot water heater no higher than 130FB. I will make sure the crib slats are no more than 2 3/8" apartC. I will refrain from using a comforter in the cribD. I will place the infant carrier on the floor when my baby is inside it
A. I will set my hot water heater no higher than 130F - - to avoid burns to the infant, the hot water should be set no higher than 49C or 120F
1 unit = 1000 mUOxytocin is available 30 units per 500mL. At what rate (ml/hr) should the nurse set the infusion pump to deliver 2mU/min?
A nurse is teaching about RhoGAM. Which indicates an understanding?A. I will receive it if my baby is Rh-negB. I will receive it at the time of deliveryC. I will need a second dose when my baby is 6wks oldD. I will need it if I have an amniocentesis
D. I will need it if I have an amniocentesisIt is administered at 28wks GA
Young adult lady asks for contraceptive. Pt has family hx of osteoporosis. Which method is contraindicated? A. combined estrogen-progestin OCB. IUDC. MedroxyprogesteroneD. Norelgesteromin/ethinyl estradiol
A nurse is providing dietary teaching to pt with hyperemesis gravidarum. Which indicates an understanding?A. I should eat to taste instead of trying to balance my mealsB. I will avoid having a snack at bedtimeC. I will have 8oz of hot tea with each mealD. I should pair my sweets with a startch instead of eating them alone
A. I should eat to taste instead of trying to balance my meals
Pregnant pt has epilepsy. Nurse opbserves her having a sz. After turning the pt's head to the side, which of the following actions should the nurse take next?A. Monitor FHRB. Assess uterine activityC. Administer oxygen via nonrebreather maskD. Start a bolus of IV fluids
C. Administer oxygen via nonrebreather mask
A nurse in a clinic is caring for a pt who is at 32wks GA. Which of the following clinical findings should alert the nurse to potential complications?A. fundal height is 34cmB. pt reports diarrhea for 3 daysC. pt reports ankle edemaD. BP is 130/80
B. pt reports diarrhea for 3 daysFundal height should be number of weeks GA +/- 2cm
Pt is being admitted to LD, states "my water just broke." Which of the following is the priority intervention for the nurse to take?A. Perform Nitrazine TestB. Assess the amniotic fluidC. Check cervical dilationD. Monitor FHR
D. Monitor FHR - you're thinking cord prolapse??
A nurse is caring for a pt from different culture. Which indicates a need for intervention?A. Placing belly band lightly over newborn's navelB. Delaying feeding until breast milk comes inC. Waiting to name the newbornD. Using a cradle board to support the newborn
B. Delaying feeding until breast milk comes in
Pt has perinatal death. Which statement by the nurse is good?A. This happens for a reasonB. This must be hard for youC. I understand how you feelD. You're young and will be able to have other children
B. This must be hard for you
Newborn is transferred to nursery 30min after delivery. Which of the following actions should the nurse take first?A. Confirm APGAR scoreB. Verify newborn's identificationC. Administer vitamin K IMD. Determine obstetrical risk factors
B. Verify newborn's identification
Pt had vag delivery and is breastfeeding. Which indicates understanding?A. I will need to eat an additional 330 calories a dayB. I will change my perineal pad at least 2x/dayC. I will massage my uterus daily for 7 daysD. I will breastfeed my baby Q2hrs
A. I will need to eat an additional 330 calories a dayB is 4x/dayC is not necessary on a daily basisD should take cues from infant
Nurse is assessing pt who is 38wks GA. Which finding should the nurse report to the provider?A. BP 136/88B. report of insomniaC. wt gain of 2.2kg (4.8lb)D. report of Braxton-Hicks contractions
C. wt gain of 2.2kg (4.8lb) - in a week
Family recently adopted a newborn. How to help the 7yo accept new brother?A. Allow the kid to hold the babe during bathB. Make sure the kid kisses the babe each nightC. Encourage the kid to sing to soothe the babeD, Switch the kid's room with the nursery
C. Encourage the kid to sing to soothe the babe
Pt is PP with hx of preeclampsia. Upon assessment, the nurse observes petechiae and serosanguineous fluid oozing from the IV site. Which of the following findings should the nurse report?A. Hct 39%B. Serum albumin 4.5g/dLC. WBC count of 9,000D. Platelet count of 50,000
D. Platelet count of 50,000
Pt newly admitted to PACU following c/s. Which is a priority assessment?A. Parent-child attachmentB. PP lochia amountC. Patency of IV catheterD. Quality and quantity of urine output (adsbygoogle = window.adsbygoogle || []).push({});
A nurse has a pt undergoing an oxytocin-stimulated contraction test. 3 contractions in 10 min with late decelerations occuring with 2 of the contractions. Which should she report?A. ReactiveB. Non reactiveC. PositiveD. Negative
C. Positive - indicates an adverse reaction by the fetus
Pt whose labor is not progressing due to shoulder dystocia.A. Apply fundal pressureB. Apply suprapubic pressureC. Place pt in TrendelenburgD. Place pt in Fowler's
B. Apply suprapubic pressure
Pt at normal wt at 10wks GA. Which shows acceptance?A. I will not gain more than 10-15lbsB. I will use new positions during intercourseC. I hope I do not get a dark line up my bellyD. I will not be able to wear my bikini if I get stretch marks
B. I will use new positions during intercourse
A nurse is admitting a pt in labor. She has recently used cocaine. Be looking for?A. Abruptio placentaB. Placenta previaC. PreeclampsiaD. Maternal bradycardia
A nurse is providing d/c teaching to pt who is PP about resuming sexual activity. Which should she include?A. You should use a water soluble gel for lubeB. You can resume sexual activity in 10 daysC. Your physical reaction to sexual stim will not be alteredD. You will not ovulate for 3mos after delivery
A. You should use a water soluble gel for lube
A nurse is providing teaching about nonpharm pain mgmt to a PP pt who is breatfeeding and has engorgement. Which of the following methods should she recommend?A. Cold cabbage leavesB. Modified lanolin creamC. Breast binderD. Breast shells
Prepare for a nonstress test. A. Maintain the pt NPO throughout procedureB. PLace the pt in a supine positionC. Instruct pt to massage the abdomen to stim fetal movementD. Instruct pt to press the provided button each time fetal movement is detected
D. Instruct pt to press the provided button each time fetal movement is detected
Pt in labor is reporting excessive pain. Which requires additional certification or licensure?A. AcupunctureB. AromatherapyC. EffleurageD. Counterpressure
A nurse is caring for pt in labor with ROP position. Pt is dilated 8cm and reports back pain.A. Apply sacral counterpressureB. Perform transcutaneaous electrical nerve stimulationC. Initiate slow-paced breathingD. Assist with biofeedback
A. Apply sacral counterpressure
Pt with hyperemesis grav is receiving IV fluids. Which should be reported?A. BUN 25B. Creatinine 0.8C. Urine output of 240mL in 8hrsD. Weight gain of 0.9kg (2lb) in 24hr
A. BUN 25 - indicates dehydration
Pt in transitional phase of labor is managing pain with breathing techniques. When to change this plan?A. Pt can talk but not walk through contractionsB. Pt increases her rate of breathing to relaxC. Pt requests to move from chair to bedD. Pt reports tingling sensations in her fingers
D. Pt reports tingling sensations in her fingers - indicates hyperventilation and respiratoy alkalosis
A nurse is assessing a newborn who is 24 hr old. Which of the following is an appropriate action for the nurse to take?Vitals: P= 130/min R= 58/min T= 36.60 CLab Results: pH 7.3 PCO3 28 mmHg PO2 62Progress Notes: Irregular respirations, feeding difficulties, lethargy
Obtain a blood glucose level
A nurse is providing discharge instructions to a client whose infant was circumcised using the clamp technique. Which of the following responses by the client indicates an understanding of the teaching?A. I will apply the diaper loosely if bleeding occursB. I will put petroleum jelly around the glans during each diaper changeC. I will wipe off any yellow exudate that forms on glansD. I will remove the plastic ring after 7 days
B. I will put petroleum jelly around the glans during each diaper change
A nurse in a provider's office is assessing a client who is breastfeeding and reports a fever and body aches. Which of the following additional clinical findings is associated with mastitis?A. Pink shiny nipples and visible rash (candidiasis)B. Burning or stinging of the breast during feedings (candidiasis)C. Unilateral breast pain with tendernessD. Firm areolae with flattened nipples (engorgement and poor latching)
C. Unilateral breast pain with tenderness
A nurse is caring for a client who is at 38 weeks of gestation and is in labor. the nurse notes late decelerations on the fetal monitor. (Order the steps of the process)
Reposition the client on her side(elevate client's legs)Increase the maintenance IV solutionPalpate the uterus to assess for tachysystoleAdminister oxygen via face mask at 8 L/min
A nurse providing education about car seat safety to the parents of a newborn. Which of the following should the nurse include in the teaching?A. Secures the care seat harness at the newborn's waistB. Install the car seat facing forward in the car's back seatC. Position the newborn in the car seat at a 45 angleD. Obtain approval from the hospital staff before purchasing the car seat
C. Position the newborn in the car seat at a 45 angle
A nurse is caring for a client who is in preterm labor at 32 weeks of gestation and is receiving magnesium sulfate 2g IV for tocolytic therapy. The nurse should report which of the following findings to the provider?A. RR of 12/minB. Absent DTRsC. Report of hot flashesD. Calcium of 9.5
A nurse on an antepartum unit is reviewing the assessment findings of four clients who were in the third trimester of pregnancy. Which of the following assessment findings is the highest priority?A. Gestational Diabetes and FBGLevel of 120B. Report of epigastirc painC. Hgb of 10Report of urinary frequency and burning upon urination
B. A client who is reporting epigastric pain (the worry is preeclampsia)
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?A. I will get injections of it once a day until my labor stopsB. My blood sugar may be low while I'm on itC. I will have blood tests because my potassium might decreaseD. My BP may increase
C. I will have blood tests because my potassium might decrease
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?A. Assessment of dilatation and effacementB. Leopold C. Sterile speculum examD. Nitrazine test
A nurse is caring a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and requires notification to the provider?A. Late decellsB. Baseline variablityC. Cessation of uterine dilationD. Prolonged active phase of labor
A nurse on a postpartum unit is caring for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following assessment findings should the nurse expect to find?A. Decrease platelet countB. Increased ESRC. Low megakaryocytesD. High WBC
A. Decrease platelet countB unrelatedC would be increasedD N/A
A nurse is caring for a client who is at 32 weeks gestation and has gonorrhea. The infection places the client at increased risk for which of the following during pregnancy?A. Excessive bleedingB. OligohydramniosC. PROMD. Proteinuria
C. Premature rupture of membranes
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The fetal monitor shows uterine contractions every 6 minutes, lasting 20 to 25 seconds, and an FHR of 150/min. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?A. Decreased uterine contractionsB. Increase in hgb levelsC. Reduced respiratory distress in newbornD. Increased production of antibodies in newborn
C. Reduced respiratory distress in newborn
A nurse is assessing a fetal heart monitor tracing of a client receiving oxytocin at 10milliunits/min. Uterine contractions are noted every 60 to 90 seconds . After turning the client to the side-lying position, which of the following actions should the nurse take next?A. d/c medB. prepare to administer terbutalineC. administer oxygenD. increase the maintenance IV fluid rate
A nurse is teaching the mother of a newborn about erythromycin ophthalmic ointment 0.5%. Which of the following should be included in the teaching?A. We'll need your consentB. It is required by law that newborns receive this treatmentC. We'll administer it 3hr after birthD. We administer it for HPV prophylaxis
B. It is required by law that newborns receive this treatment
A nurse is caring for a client who is in active labor and reports back pain. The nurse performs a vaginal exam and determines the client is 8 cm dilated, 100% effaced, and -2 station. The fetus is in the occiput posterior position. Which of the following is an appropriate nursing intervention?A. Perform effleurageB. Place pt in lithotomyC. Assist the client to the hands and knees positionD. Apply a fetal scalp electrode
C. Assist the client to the hands and knees position
A nurse is caring for a client who is in labor and has ruptured membranes and one inch of the umbilical cord protruding into the vagina. After calling for assistance, which of the following is a priority nursing action? A. Place a rolled towel beneath one of the hipsB. Apply internal upward pressure to the presenting part C. Administer oxygenD. Increase IV infusion rate
B. Apply internal upward pressure to the presenting part
A nurse on the newborn unit is planning discharge for four clients. Which of the following newborns will require care beyond that of a standard follow-up visit with the provider after delivery?A. A newborn being sent home 22 hr after birth B. A newborn at 38GAC. A newborn who is bottle feedingD. Twin newborns with APGARS of 8/9
A A newborn being sent home 22 hr after birth
A client who is pregnant presents to a prenatal clinic for her first visit. She tells the nurse that her last normal menstrual period began Oct 13. Using Nagele's rule, the nurse should determine the client's estimated date of delivery as which of the following? A. July 6B. July 13C. July 20 D. July 27
A nurse is performing an admission assessment on a newborn who is large for gestational age (LGA). Which of the following findings indicates a need for further assessment? A. heel stick BG of 50B. RR of 50C. jitteriness D. acrocyanosis
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? A. Warn the heel prior to punctureB. Request a prescription for IM analgesicC. Use a manual lance blade to pierce the skinD. Swaddle the newborn after the heel puncture
D. Swaddle the newborn after the heel puncture
A nurse is conducting an initial prenatal visit for a client who is at 6 weeks of gestation. Which of the following laboratory tests should be performed at this time? A. 24-hr urine for proteinB. GBS cultureC. 3-hr glucose toleranceD. Rubella titer
A nurse is providing education for a client who is in her third trimester and is schedule for a biophysical profile. The nurse should tell the client that which of the following variables is included in the test? A. GAB. L/S ratioC. Amniotic fluid indexD. Doppler flow analysis
A nurse is observing a mother caring for her newborn who is crying. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior? A. Lays the newborn across and lap and gently swaysB. Places the babe in the crib in a prone positionC. Offers the babe a pacifier dipped in milkD. Prepares a bottle of milk with rice cereal
B. Places the babe in the crib in a prone position
A nurse is providing family planning education to a client who has decided to use a diaphragm. Which of the following should the nurse include in the plan of care? A. You should replace it Q3yrsB. You should leave the diaphragm in place for at least 6 hours after intercourse.C. You should use an oil based lubeD. You should insert it when your bladder is full
B. You should leave the diaphragm in place for at least 6 hours after intercourse.a - replace Q2yrs |
A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor
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