Maternity Questions

Maternity 1Maternity - Antepartum 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. The nursing student is preparing to teach a prenatal class about fetal circulation. Which statement should be included in the teaching plan? 1. "One artery carries oxygenated blood from the placenta to the fetus." 2. "Two arteries carry oxygenated blood from the placenta to the fetus." 3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 4. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta." 3. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." A pregnant client tells the clinic nurse that she wants to know the gender of her baby as soon as it can be determined. The nurse understands that the client should be able to find out the gender at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent 1. The appearance of the fetal external genitalia The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the mother's heart rate. 3. Notify the health care provider (HCP). 4. Tell the client that the fetal heart rate is normal. 3. Notify the health care provider (HCP). The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." The nursing instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus o 1. Allows for fetal movement o 2. Surrounds, cushions, and protects the fetus o 3. Maintains the body temperature of the fetus o 4. Can be used to measure fetal kidney function A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be most appropriate? 1. "Has either of you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Do either of you have diabetes mellitus?" 4. "Do either of you have problems with high blood pressure?" 2. "Do you plan to have any other children?" The nurse should include which statement to a pregnant client found to have a gynecoid pelvis? 1. "Your type of pelvis has a narrow pubic arch." 2. "Your type of pelvis is the most favorable for labor and birth." 3. "Your type of pelvis is a wide pelvis, but has a short diameter." 4. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery." 2. "Your type of pelvis is the most favorable for labor and birth." Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? 1. It cushions and protects the baby. 2. It maintains the temperature of the baby. 3. It is the way the baby gets food and oxygen. 4. It prevents all antibodies and viruses from passing to the baby. 3. It is the way the baby gets food and oxygen. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding? 1. 22 cm 2. 30 cm 3. 36 cm 4. 40 cm 2. 30 cm The nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. Which are probable signs of pregnancy? Select all that apply. Maternity 2 11. 12. 13. 14. 15. 16. 17. 18. 19. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography o 1. Ballottement o 2. Chadwick's sign o 3. Uterine enlargement o 4. Braxton Hicks contractions A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Inform the client that these contractions are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition. 3. Inform the client that these contractions are common and may occur throughout the pregnancy. The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client? 1. Total abstinence from sexual intercourse is necessary during the entire pregnancy. 2. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. 3. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy. 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor. 4. A cesarean section will be necessary if vaginal lesions are present at the time of labor. The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus 1. A softening of the cervix A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19, 2014. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2014 2. July 26, 2015 3. August 12, 2015 4. August 26, 2015 2. July 26, 2015 The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action? 1. Auscultate for fetal heart sounds. 2. Assess the cervix for compressibility. 3. Palpate the abdomen for fetal movement. 4. Initiate a gentle upward tap on the cervix. 4. Initiate a gentle upward tap on the cervix. A pregnant client asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 2. 8 and 10 3. 10 and 12 4. 14 and 18 4. 14 and 18 The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which finding concerns the nurse and indicates the need for follow-up? 1. Quickening 2. Braxton Hicks contractions 3. Fetal heart rate of 180 beats/minute 4. Consistent increase in fundal height 3. Fetal heart rate of 180 beats/minute The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? Maternity 3 20. 21. 22. 23. 24. 25. 26. 27. 28. 1. Strict bed rest is required after the procedure. 2. Hospitalization is necessary for 24 hours after the procedure. 3. An informed consent needs to be signed before the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen. 3. An informed consent needs to be signed before the procedure. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the emergency department at the maternity center immediately." 4. "Use tampons if the discharge is bothersome, but to be sure to change the tampons every 2 hours." 2. "The vaginal discharge may be bothersome, but is a normal occurrence." The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? 1. Normal 2. Abnormal 3. The need for further evaluation 4. That findings were difficult to interpret 1. Normal A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery 1. A normal test result A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice? 1. Hematocrit 38% 2. Glucose 86 mg/dL 3. Hemoglobin 9.1 g/dL 4. White blood cell count 12,400 cells/mm3 3. Hemoglobin 9.1 g/dL A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell that client that which exercise is safest? 1. Swimming 2. Scuba diving 3. Low-impact gymnastics 4. Bicycling with the legs in the air 1. Swimming A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy and the client asks the nurse about the procedure. How should the nurse respond to the client? 1. "The procedure takes about 2 hours." 2. "It will be necessary to drink 1 to 2 quarts of water before the examination." 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." 4. "Gel is spread over the abdomen, and a round disk transducer will be moved over the abdomen to obtain the picture." 3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? 1. "I should wear panty hose." 2. "I should wear support hose." 3. "I should wear flat nonslip shoes that have good support." 4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours." 4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours." A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps? 1. "Bend your foot toward your body while flexing the knee when the cramps occur." 2. "Bend your foot toward your body while extending the knee when the cramps occur." 3. "Point your foot away from your body while flexing the knee when the cramps occur." 4. "Point your foot away from your body while extending the knee when the cramps occur." 2. "Bend your foot toward your body while extending the knee when the cramps occur." The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? 1. "I will record the number of movements or kicks." 2. "I need to lie flat on my back to perform the procedure." 3. "If I count fewer than 10 kicks in a 2-hour period I should count the kicks again over the next 2 hours." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks." 2. "I need to lie flat on my back to perform the procedure." Maternity 4 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. The nurse is providing instructions regarding treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction? 1. "I should avoid straining during bowel movements." 2. "I can gently replace the hemorrhoids into the rectum." 3. "I can apply ice packs to the hemorrhoids to reduce the swelling." 4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." 4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink." The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide? 1. Avoid wearing a bra. 2. Wash the breasts with warm water and keep them dry. 3. Wear tight-fitting blouses or dresses to provide support. 4. Wash the nipples and areolar area daily with soap, and massage the breasts with lotion. 2. Wash the breasts with warm water and keep them dry. The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? 1. Increase in pulse rate 2. Increase in blood pressure 3. Frequent bowel elimination 4. Decrease in red blood cell production 1. Increase in pulse rate The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? 1. "I should avoid between-meal snacks." 2. "I should lie down for an hour after eating." 3. "I should use spices for cooking rather than using salt." 4. "I should avoid eating foods that produce gas and fatty foods." 4. "I should avoid eating foods that produce gas and fatty foods." The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider? 1. Urinary output has increased. 2. Dependent edema has resolved. 3. Blood pressure reading is at the prenatal baseline. 4. The client complains of a headache and blurred vision. 4. The client complains of a headache and blurred vision. The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I should stay on the diabetic diet." 2. "I should perform glucose monitoring at home." 3. "I should avoid exercise because of the negative effects on insulin production." 4. "I should be aware of any infections and report signs of infection immediately to my health care provider." 3. "I should avoid exercise because of the negative effects on insulin production." The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura 4. Evidence of bleeding, such as in the gums, petechiae, and purpura The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Generalized edema 5. Increased pulse rate 6. Increased respiratory rate o 1. Proteinuria o 2. Hypertension o 4. Generalized edema 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? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2. "My insulin dose will likely need to be increased during the second and third trimesters." 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4. "My insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding." 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? Maternity 5 39. 40. 41. 42. 43. 44. 45. 46. 47. 1. Therapeutic abortion is required. 2. She will have to stay at home until treatment is completed. 3. Medication will not be started until after delivery of the fetus. 4. Isoniazid plus rifampin (Rifadin) will be required for 9 months. 4. Isoniazid plus rifampin (Rifadin) will be required for 9 months. The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I should increase my sodium intake during pregnancy." 2. "I should lower my blood volume by limiting my fluids." 3. "I should maintain a low-calorie diet to prevent any weight gain." 4. "I should drink adequate fluids and increase my intake of high-fiber foods." 4. "I should drink adequate fluids and increase my intake of high-fiber foods." The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? 1. A client who has a history of intravenous drug use 2. A client who has a significant other who is heterosexual 3. A client who has a history of sexually transmitted infections 4. A client who has had one sexual partner for the past 10 years 1. A client who has a history of intravenous drug use A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1. "I will watch for the evidence of the passage of tissue." 2. "I will maintain strict bed rest throughout the remainder of the pregnancy." 3. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." 4. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding." 2. "I will maintain strict bed rest throughout the remainder of the pregnancy." The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida 2. The client has a history of cardiac disease 3. The client's hemoglobin level is 13.5 g/dL 4. The client is a 20-year-old primigravida of average weight and height 2. The client has a history of cardiac disease The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2. "Meat does not provide iron and should be avoided." 3. "The iron is best absorbed if taken on an empty stomach." 4. "On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement." 3. "The iron is best absorbed if taken on an empty stomach." A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client?Refer to chart. 1. "You should avoid all school-age children during pregnancy." 2. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." 4. "Be sure to tell the health care provider in 2 weeks as additional screening will be prescribed during your second trimester." 3. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? 1. "I will drink 8 oz of water with each meal." 2. "I will eat three servings of cracked wheat bread each day." 3. "I will eat two saltine crackers before I get up each morning." 4. "I will eat fresh fruits and vegetables for snacks and for dessert each day." 4. "I will eat fresh fruits and vegetables for snacks and for dessert each day." The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? 1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." 2. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low." 3. "The low levels of estrogen and progesterone increase the release of the follicle-stimulating hormone and luteinizing hormone." 4. "The high levels of estrogen and progesterone promote the release of the follicle-stimulating hormone and luteinizing hormone." 1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." The nurse encourages a pregnant human immunodeficiency virus (HIV)–positive client to report any early signs of vaginal discharge or perineal tenderness to the health care provider immediately. The client asks the nurse about the importance of this action, and the nurse responds by telling the client which accurate statement? 1. "This is necessary to relieve anxiety for the pregnant client." 2. "This is necessary to eliminate the need for further uncomfortable screenings." Maternity 6 48. 49. 50. 51. 52. 53. 54. 55. 56. 3. "This is necessary to minimize the financial cost of caring for an HIV-positive client." 4. "This is necessary to assist in identifying potential infections that may need to be treated." 4. "This is necessary to assist in identifying potential infections that may need to be treated." A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client? 1. "You should not worry about your baby's condition after the delivery because complications are rare." 2. "Your baby will probably need to spend a few days in the neonatal intensive care unit after delivery." 3. "You will not have any problems if you follow all the advice the health care provider has given you." 4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." 4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." The nurse is performing an assessment on a pregnant client at 16 weeks of gestation. On assessment, the nurse expects the fundus of the uterus to be located at which area? 1. At the umbilicus 2. Just above the symphysis pubis 3. At the level of the xiphoid process 4. Midway between the symphysis pubis and the umbilicus 4. Midway between the symphysis pubis and the umbilicus The clinic nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to the risk of abruptio placentae if which information is obtained on assessment? 1. The client is 28 years of age. 2. This is the second pregnancy. 3. The client has a history of hypertension. 4. The client performs moderate exercise on a regular daily schedule. 3. The client has a history of hypertension. During a prenatal visit, a nurse is explaining dietary management to a client with pre-existing diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? 1. "Diet and insulin needs change during pregnancy." 2. "I will plan my diet based on the results of urine glucose testing." 3. "I will need to eat 600 more calories every day because I am pregnant." 4. "I can continue with the same diet as before pregnancy, as long as it is well balanced." 1. "Diet and insulin needs change during pregnancy." The clinic nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instructions? 1. "It is best that I rest lying on my side to promote blood return to the heart." 2. "I need to avoid excessive weight gain to prevent increased demands on my heart." 3. "I need to try to avoid stressful situations because stress increases the workload on the heart." 4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." 4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason? 1. Reduce excessive maternal stress and fatigue. 2. Help the mother prepare for labor and delivery. 3. Avoid exposure to potential pathogens and resulting infections. 4. Prepare the 18-month-old child for maternal separation during hospitalization. 1. Reduce excessive maternal stress and fatigue. The nurse is instructing a pregnant client regarding measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? 1. Milk 2. Potatoes 3. Cantaloupe 4. Whole-grain cereal 4. Whole-grain cereal The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? 1. Milk 2. Yogurt 3. Bananas 4. Leafy green vegetables 4. Leafy green vegetables A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observation made by the nurse during the assessment indicates a need for further teaching? 1. The client is wearing sneakers. 2. The client is wearing knee-high hose. 3. The client is wearing flat shoes with rubber soles. 4. The client is wearing pants with an elastic waistband. 2. The client is wearing knee-high hose. Maternity 7 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. A pregnant client visits a clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instructions? 1. "I should wear flat-heeled shoes." 2. "I should sleep on a firm mattress." 3. "I should try to maintain good posture." 4. "I should do more exercises to strengthen my back muscles." 4. "I should do more exercises to strengthen my back muscles." A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? 1. "The test is a procedure that will require an informed consent to be signed." 2. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 3. "The test is done to see if the baby can handle the stress of labor, and that medicine is given to make the uterus contract." 4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen." 4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen." The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? 1. Consume a low-fiber diet. 2. Drink 8 glasses of water per day. 3. Use a Fleet enema when the episodes occur. 4. Take a mild stool softener daily in the evening. 2. Drink 8 glasses of water per day. A pregnant client in the prenatal clinic is scheduled for a biophysical profile. The client asks the nurse what this test involves. The nurse should make which appropriate response? 1. "This test measures your ability to tolerate the pregnancy." 2. "This test measures amniotic fluid volume and fetal activity." 3. "This test measures your cardiac status and ability to tolerate labor." 4. "This test only measures the amount of amniotic fluid present in the uterus." 2. "This test measures amniotic fluid volume and fetal activity." The nurse in the prenatal clinic is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, would alert the nurse to a potential psychosocial problem? 1. "I don't like dairy products." 2. "I will continue drinking my afternoon milkshake." 3. "I'm not used to eating so much food, but I will try." 4. "I only want to gain 10 pounds because I want to have a small, petite baby." 4. "I only want to gain 10 pounds because I want to have a small, petite baby." The nurse in the prenatal clinic is conducting a session about nutrition to a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? 1. Eat only when hungry. 2. Eliminate snacks during the day. 3. Avoid meals in fast-food restaurants. 4. Monitor for appropriate weight gain patterns. 4. Monitor for appropriate weight gain patterns. The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? 1. Hard cheese 2. Dried fruits 3. Creamed spinach 4. Fresh-squeezed orange juice 2. Dried fruits The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item? 1. Milk 2. Tea 3. Coffee 4. Orange juice 4. Orange juice A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. The nurse determines that the client is experiencing which type of abortion? 1. Septic 2. Inevitable 3. Incomplete 4. Threatened 2. Inevitable The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion? 1. Age of 35 years Maternity 8 67. 68. 69. 70. 71. 72. 73. 74. 75. 2. History of syphilis 3. History of genital herpes 4. History of diabetes mellitus 2. History of syphilis The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? 1. Checking for edema 2. Monitoring daily weight 3. Monitoring the apical pulse 4. Monitoring the temperature 3. Monitoring the apical pulse The nurse reviews the laboratory results for a client with a suspected ectopic pregnancy. The nurse would expect which result of the beta subunit of human chorionic gonadotropin (β-hCG) if the client had an ectopic pregnancy? 1. Not present 2. Present in low levels 3. Present in high levels 4. Within normal limits 2. Present in low levels The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? 1. The client's last baby weighed 10 pounds at birth. 2. The client's previous deliveries were by cesarean birth. 3. The client has a family history of cardiovascular disease. 4. The client is 5 feet 3 inches in height and weighs 165 pounds. 1. The client's last baby weighed 10 pounds at birth. The nurse is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? 1. Increased insulin 2. Increased caloric intake 3. Decreased protein intake 4. Decreased insulin 1. Increased insulin The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply. 1. Vaginal bleeding 2. Excessive fetal activity 3. Excessive nausea and vomiting 4. Larger-than-normal uterus for gestational age 5. Elevated levels of human chorionic gonadotropin (hCG) o 1. Vaginal bleeding o 3. Excessive nausea and vomiting o 4. Larger-than-normal uterus for gestational age o 5. Elevated levels of human chorionic gonadotropin (hCG) The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid? 1. Pork 2. Cheese 3. Chicken 4. Green leafy vegetables 4. Green leafy vegetables A client reports to the health care clinic and says that it has been 6 weeks since her last menstrual period. The nurse performs a pregnancy test and should expect to note the presence of which hormone in the blood test results if the client is pregnant? 1. Estrogen 2. Progesterone 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG) 4. Human chorionic gonadotropin (hCG) A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2015, and ended the menses on March 14, 2015. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is which date? 1. January 14, 2014 2. January 21, 2014 3. December 21, 2015 4. December 14, 2015 4. December 14, 2015 The prenatal clinic nurse asks a coassigned nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if he or she makes which statement? 1. "An increase in pulse rate occurs." 2. "A decrease in blood volume occurs." Maternity 9 76. 77. 78. 79. 80. 81. 82. 83. 84. 3. "A decrease in cardiac output occurs." 4. "The systolic and diastolic blood pressures increase by 20 mm Hg." 1. "An increase in pulse rate occurs." The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply. 1. Viruses 2. Bacteria 3. Nutrients 4. Medications 5. Antibodies o 1. Viruses o 3. Nutrients o 4. Medications o 5. Antibodies A client who is 8 weeks pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the symptoms? 1. Eating a high-fat diet 2. Increasing fluids with meals 3. Eating a high-carbohydrate diet 4. Eating dry crackers before arising 4. Eating dry crackers before arising The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy. Home care for this client should include which measure? 1. Increase daily calories to ensure weight gain. 2. Maintain a supine position during rest periods. 3. Restrict visitors who may have an active infection. 4. Avoid becoming concerned about placing stress on the heart. 3. Restrict visitors who may have an active infection. A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? 1. Monitor for fetal movement. 2. Monitor the maternal blood glucose. 3. Instruct the client to maintain complete bed rest. 4. Instruct the client to restrict dietary sodium and any food items that contain sodium. 1. Monitor for fetal movement. A maternity unit nurse is developing a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? 1. Restrict food and fluids. 2. Reduce external stimuli. 3. Monitor blood glucose levels. 4. Maintain the client in a supine position. 2. Reduce external stimuli. A client with severe preeclampsia is admitted to the maternity department. Which room assignment would be most appropriate for this client? 1. A private room across from the elevator 2. A semiprivate room across from the nurses' station 3. A private room two doors away from the nurses' station 4. A semiprivate room with another client who enjoys watching television 3. A private room two doors away from the nurses' station A couple is seen in the fertility clinic. After several tests, it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse would indicate a need for further information about the procedure? 1. "Ova and sperm are collected and allowed to incubate." 2. "A fertilized ovum is transferred into the woman's uterus." 3. "The procedure is a method of medically assisted reproduction." 4. "The procedure is performed using artificial insemination of sperm instilled through the vagina." 4. "The procedure is performed using artificial insemination of sperm instilled through the vagina." The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse plans care, knowing that this type of pelvis has which characteristic? 1. Is heart-shaped 2. Has a flat shape 3. Has an oval shape 4. Is a normal female pelvis 2. Has a flat shape The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks of gestation. Which information should the nurse discuss with the client? Select all that apply. 1. Plan induction at 35 weeks. 2. Plan amniocentesis at this time. 3. Schedule biophysical profile immediately. Maternity 10 85. 86. 87. 88. 89. 90. 91. 92. 93. 4. Plan for weekly non-stress test at 32 weeks. 5. Obtain nutritional counseling with a dietitian. o 4. Plan for weekly non-stress test at 32 weeks. o 5. Obtain nutritional counseling with a dietitian. A nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid? 1. Cheese 2. Spinach 3. Potatoes 4. Bananas 2. Spinach The nurse is caring for a client with preeclampsia. The client is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? 1. Tongue blade 2. Percussion hammer 3. Potassium chloride injection 4. Calcium gluconate injection 4. Calcium gluconate injection A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client? 1. Costovertebral angle pain 2. Pain, itching, and vaginal discharge 3. Absence of any signs and symptoms 4. Proteinuria, hematuria, edema, and hypertension 2. Pain, itching, and vaginal discharge The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? 1. October 7 2. October 16 3. November 7 4. November 16 4. November 16 The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness? 1. A full bladder 2. Emotional instability 3. Insufficient iron intake 4. Compression of the vena cava 4. Compression of the vena cava A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? 1. "I can douche anytime I want." 2. "I can wear my tight-fitting jeans." 3. "I should avoid the use of condoms." 4. "I should wear underwear with a cotton panel liner." 4. "I should wear underwear with a cotton panel liner." The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? 1. "Most children do not receive the vaccine until they are 5 years of age." 2. "You are still susceptible to rubella, so your toddler should receive the vaccine." 3. "It is not advised for children of pregnant women to be vaccinated during their mother's pregnancy." 4. "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." 4. "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." A clinic nurse is explaining the changes in the integumentary system that occur during pregnancy to a client and should tell the client that which change may persist after she gives birth? 1. Epulis 2. Chloasma 3. Telangiectasia 4. Striae gravidarum 4. Striae gravidarum A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement? 1. "I should drink 12 glasses of fruit juices and milk every day." 2. "I should drink 8 to 10 glasses of fluid a day, and I can drink as many diet soft drinks as I want." 3. "I should drink 12 glasses of fluid a day, and I can include the coffee or tea that I drink in the count." 4. "I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water." 4. "I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water." Maternity 11 94. A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction? 1. "I should cook meat thoroughly." 2. "I should drink unpasteurized milk only." 3. "I should avoid contact with materials that are possibly contaminated with cat feces." 4. "I should avoid touching mucous membranes of the mouth or eyes while handling raw meat." 2. "I should drink unpasteurized milk only." 95. A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging in the 130/90 mm Hg range. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? 1. "My vision the past 2 days has been really fuzzy." 2. "The swelling in my hands and ankles has gone down." 3. "I had heartburn yesterday after I ate some spicy foods." 4. "I had a headache yesterday, but I took some acetaminophen (Tylenol) and it went away." 1. "My vision the past 2 days has been really fuzzy." 96. A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? 1. Urinary output of 20 mL 2. Deep tendon reflexes of 2+ 3. Fetal heart rate of 120 beats/min 4. Respiratory rate of 10 breaths per minute 4. Respiratory rate of 10 breaths per minute 97. The nurse is reviewing fetal development with a client who is at 36 weeks gestation. Which statements describe the characteristics that develop in a fetus at this time? Select all that apply. 1. Eyelids begin to fuse. 2. Fetal heart begins to beat. 3. The fetal skin is transparent. 4. The fetus weighs approximately 1200 g. 5. The fetus is approximately 42 to 48 cm long. 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1 o 5. The fetus is approximately 42 to 48 cm long. o 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1 98. A client who has just been told that she is pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response? 1. "Your baby's heart right now consists of two parallel tubes, so we can't hear it today." 2. "Your baby's heart right now is beginning to partition into four chambers and has begun to beat, so we should be able to hear it with a Doppler." 3. "Your baby's heart right now is beginning to partition into four chambers and has begun to beat, so we should be able to hear it with a fetoscope." 4. "Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine." 4. "Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine." 99. During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate. Which finding would the nurse note as normal? 1. 80 beats/minute 2. 100 beats/minute 3. 150 beats/minute 4. 180 beats/minute 3. 150 beats/minute 100. The clinic nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Of the following interventions, which should the nurse list as having the lowest priority in planning nursing care for this client? 1. Assess blood pressure. 2. Discuss the need for hospitalization. 3. Assess deep tendon reflexes and edema. 4. Teach the importance of keeping track of a daily weight. 2. Discuss the need for hospitalization. 101. During a woman's prenatal visit, the nurse is measuring fundal height. The nurse knows that the woman is at 20 weeks' gestation. Based on this information, the nurse expects the fundus to be found at what area of the abdomen? 1. At the umbilicus 2. At the xiphoid process 3. Midway between the umbilicus and the xiphoid process 4. Midway between the symphysis pubis and the umbilicus 1. At the umbilicus 102. The nurse is teaching a woman in her first trimester measures to alleviate nausea and vomiting. Which statement by the woman would indicate that further teaching is required? 1. "I will avoid fried foods." 2. "I will eat five or six small meals a day." Maternity 12 103. 104. 105. 106. 107. 108. 109. 110. 111. 3. "I will contact the clinic if the vomiting does not subside." 4. "I will eat dry crackers after arising out of bed in the morning." 4. "I will eat dry crackers after arising out of bed in the morning." The nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant woman to describe the process of quickening. Which statement if made by the student indicates an understanding of this term? 1. "It is the thinning of the lower uterine segment." 2. "It is the fetal movement that is felt by the mother." 3. "It is the irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated." 2. "It is the fetal movement that is felt by the mother." The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? 1. "I don't like my figure anymore. My clothes are all too tight." 2. "I don't like my breasts anymore. These silver lines are ugly." 3. "I don't like my stomach anymore. That brown line is disgusting." 4. "I don't like my face any more. I always look like I have been crying." 4. "I don't like my face any more. I always look like I have been crying." The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority? 1. Pain 2. Disturbed body image 3. Insufficient fluid volume 4. Inability to tolerate activity 3. Insufficient fluid volume The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, would indicate an understanding of the instructions? 1. "Iron supplements will give me diarrhea." 2. "Meat does not provide iron and should be avoided." 3. "The iron is best absorbed if taken on an empty stomach." 4. "My body has all the iron it needs, and I don't need to take supplements." 3. "The iron is best absorbed if taken on an empty stomach." A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse would be most appropriate and supportive to the woman? 1. "You should avoid all school-age children during pregnancy." 2. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3. "Be sure to tell the health care provider on your next prenatal visit, but there is little risk in the second trimester." 4. "You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed." 4. "You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed." A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse should plan to tell the client? 1. "You will be isolated from your newborn infant after delivery." 2. "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." 3. "There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions, and if any are present, a cesarean delivery will be needed." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions, and if any are present, a cesarean delivery will be needed." A pregnant woman is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? 1. The breasts become stretched because of the weight gain. 2. The increased metabolic rate causes the breasts to become larger. 3. The breast changes occur because of the secretion of estrogen and progesterone. 4. Cortisol secreted by the adrenal glands plays a role in increasing the size and appearance of the breasts. 3. The breast changes occur because of the secretion of estrogen and progesterone. The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action? 1. Contracting and then consciously relaxing different muscle groups 2. Massaging the abdomen during contractions, using both hands in a circular motion 3. Instructing her partner to stroke or massage a tightened muscle by the use of touch 4. Contracting an area of the body, such as an arm or leg, and then concentrating on letting tension go from the rest of the body 2. Massaging the abdomen during contractions, using both hands in a circular motion During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, would indicate an understanding of the proper nutritional measures to minimize this problem? 1. "I will drink 8 ounces of water with each meal." 2. "I will eat three servings of cracked wheat bread each day." 3. "I will eat two saltine crackers before I get up each morning." 4. "I will eat fresh fruits and vegetables for snacks and for dessert each day." Maternity 13 4. "I will eat fresh fruits and vegetables for snacks and for dessert each day." 112. A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, would indicate that she understands her needs? 1. "My weight gain is not important." 2. "I should avoid stressful situations." 3. "I should rest by lying on my back." 4. "There is no restriction on people who visit me." 2. "I should avoid stressful situations." 113. The nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. The nurse understands that which hormone is responsible for the development of this sign? 1. Prolactin 2. Estrogen 3. Progesterone 4. Human chorionic gonadotropin 2. Estrogen 114. A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse tell the woman? 1. Uterine contractions are stimulated by Leopold's maneuvers. 2. An external fetal monitor is attached, and the woman ambulates on a treadmill until contractions begin. 3. The uterus is stimulated to contract by the administration of small amounts of oxytocin (Pitocin) or by nipple stimulation. 4. Small amounts of oxytocin (Pitocin) are administered during internal fetal monitoring to stimulate uterine contractions. 3. The uterus is stimulated to contract by the administration of small amounts of oxytocin (Pitocin) or by nipple stimulation. 115. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider (HCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the HCP has documented the results as negative. How should the nurse interpret this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean delivery 1. A normal test result 116. A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information? 1. The woman has the herpes simplex virus (HSV). 2. This woman has contracted an airborne disease. 3. The neonate will definitely develop this disease after birth. 4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test. 4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test. 117. In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to do to elicit the most accurate responses to the questions that refer to sexually transmitted infections? 1. Establish a therapeutic relationship. 2. Use specific closed-ended questions. 3. Omit these types of questions because they are highly personal. 4. Apologize for the embarrassment that these questions will cause the client. 1. Establish a therapeutic relationship. 118. The clinic nurse is teaching a pregnant woman about the warning signs in pregnancy. Which, if identified as a warning sign by the woman, would indicate a need for further education? 1. Rapid weight gain 2. Visual disturbances 3. Generalized or facial edema 4. Presence of irregular painless contractions 4. Presence of irregular painless contractions 119. The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Based on this finding, which nursing action is most appropriate? 1. Document the temperature. 2. Notify the health care provider. 3. Retake the temperature by the rectal route. 4. Inform the client that the temperature is elevated and antibiotics may be required. 1. Document the temperature. 120. A 39-week-gestation pregnant client calls the maternity unit stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which would be the best response made by the nurse? 1. "Six to eight fetal movements in a 24-hour period are adequate to determine that the fetus is healthy." 2. "Fetal movement is a sign of fetal health. Even if the amount has decreased, the fetus is still healthy." 3. "Continue to count fetal movements for the next 24 hours and call your health care provider if the number of movements continues to decrease." 4. "Fetal movements do not decrease as a woman nears term; therefore you should be seen by your health care provider for further evaluation." 4. "Fetal movements do not decrease as a woman nears term; therefore you should be seen by your health care provider for further evaluation." 121. A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for Maternity 14 122. 123. 124. 125. 126. 127. 128. 129. observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths per minute, and temperature is 99° F. The nurse plans care based on which interpretation? 1. The woman requires further evaluation for preterm labor. 2. The woman is suffering from an intestinal bacterial infection. 3. The woman is exhibiting signs and symptoms of gestational hypertension. 4. The woman needs instruction on pelvic tilts to decrease her lower back pain. 1. The woman requires further evaluation for preterm labor. The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers the client's 1-hour oral glucose tolerance test (OGTT) result to be 163 mg/dL. Which would be the nurse's best response to the client? 1. "Your OGTT results indicate that your baby is at high risk for macrosomia and special considerations may be necessary at delivery." 2. "Your OGTT results are within normal limits, but continuing your prenatal visits remains essential to monitor fetal growth and development." 3. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." 4. "Your OGTT results indicate that you are positive for gestational diabetes. You will be scheduled for a dietitian consultation to plan your daily dietary intake." 3. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternal nurse's priority will be to assess for which complication? 1. Placenta previa 2. Polyhydramnios 3. Abruptio placentae 4. Gestational hypertension 3. Abruptio placentae The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action? 1. Notify the health care provider. 2. Prepare the client for labor induction. 3. Place the fetal heart monitor on the client in order to do a nonstress test (NST). 4. Provide the client with information regarding warning signs and symptoms of pregnancy and discharge her to home. 3. Place the fetal heart monitor on the client in order to do a nonstress test (NST). A client in week 35 of her pregnancy is placed on the fetal heart monitor (FHM) for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes what conclusion regarding the NST? 1. The fetal heart rate (FHR) is positive, with a baseline of 130 beats/min, moderate variability, and no decelerations. 2. The FHR is reactive, with a baseline of 130 beats/min, moderate variability, and no decelerations. 3. The FHR is nonreactive, with a baseline of 130 beats/min, moderate variability, and small episodic decelerations. 4. The FHR is negative, with a baseline of 130 beats/min, moderate variability, and no decelerations. 2. The FHR is reactive, with a baseline of 130 beats/min, moderate variability, and no decelerations. The charge nurse on a labor and delivery unit has numerous admissions of laboring clients and must transfer one of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client would be the most appropriate one to transfer? 1. The 36-year-old, gravida I, para 0 client who is at 24 weeks' gestation and is being monitored for preterm labor 2. The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding 3. The 40-year-old, gravida III, para 0 client who is at 38 weeks' gestation and is complaining of decreased fetal movement 4. The 29-year-old, gravida I, para 0 client who is at 42 weeks' gestation and had a biophysical profile score of 5 earlier today 2. The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding A nurse working in an infertility clinic reviews the medical history of a 35-year-old woman who is currently taking fertility medications and is planning a pregnancy. Which medication, if present in the client's history, would indicate a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate? 1. Methyldopa 2. Folic acid (Folvite) 3. Phenytoin (Dilantin) 4. Bupropion (Wellbutrin SR) 3. Phenytoin (Dilantin) A nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which is a characteristic of placenta previa? 1. A tender and rigid uterus 2. Painless, bright red vaginal bleeding 3. Greenish discoloration of the amniotic fluid 4. Vaginal bleeding accompanied by abdominal pain 2. Painless, bright red vaginal bleeding A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 1. 5 weeks 2. 9 weeks Maternity 15 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 3. 13 weeks 4. 18 weeks 4. 18 weeks A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present? 1. Soft uterus 2. Abdominal pain 3. Nontender uterus 4. Painless vaginal bleeding 2. Abdominal pain A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider. The nurse should tell the woman to call the health care provider if which occurs? 1. Urine tests negative for protein. 2. Fetal movements are more than four per hour. 3. Weight increases by more than 1 pound in a week. 4. The blood pressure reading is ranging between 122/80 and 132/88 mm Hg. 3. Weight increases by more than 1 pound in a week. A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? 1. Apply heat to the affected area. 2. Take acetaminophen (Tylenol) every 4 hours. 3. Self-administer calcium carbonate tablets three times daily. 4. Purchase a chewable antacid that contains calcium and take a tablet with each meal. 1. Apply heat to the affected area. A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur? 1. She will feel some pain during the procedure. 2. She will be placed in a supine left side-lying position. 3. She will feel some pressure when the vaginal probe is moved. 4. She will need to drink 2 quarts of water to attain a full bladder. 3. She will feel some pressure when the vaginal probe is moved. A nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What is the nurse's best response? 1. "Prolactin stimulates the secretion of milk, which is called lactogenesis." 2. "Oxytocin stimulates the secretion of milk, which is called lactogenesis." 3. "Progesterone stimulates the secretion of milk, which is called lactogenesis." 4. "Testosterone stimulates the secretion of milk, which is called lactogenesis." 1. "Prolactin stimulates the secretion of milk, which is called lactogenesis." A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates a need for further teaching? 1. "I need to stay on the diabetic diet." 2. "I will perform glucose monitoring at home." 3. "I cannot exercise because of the negative effects on insulin production." 4. "I will report signs of infection immediately to my health care provider." 3. "I cannot exercise because of the negative effects on insulin production." The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. What is the best response by the nurse? 1. "It causes the cessation of menstruation." 2. "It is pain that occurs during ovulation." 3. "It is the presence of tissue outside the uterus that resembles the endometrium." 4. "It is also known as primary dysmenorrhea and causes lower abdominal discomfort." 3. "It is the presence of tissue outside the uterus that resembles the endometrium." A client calls the health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse should expect which hormone to be present in the urine? 1. Estrogen 2. Progesterone 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG) 4. Human chorionic gonadotropin (hCG) The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the purpose of estrogen. Which response should the nurse give the client for the purpose of estrogen? 1. It maintains and relaxes the uterine lining for implantation. 2. It stimulates metabolism of glucose and converts the glucose to fat. 3. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. 4. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. 4. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the gender of the fetus is determined by Maternity 16 140. 141. 142. 143. 144. 145. 146. 147. 148. which weeks? 1. 6 to 8 2. 8 to 10 3. 13 to 16 4. 20 to 22 3. 13 to 16 The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was and the client reports February 9, 2015. Using Nägele's rule, the nurse determines what is the estimated date of confinement (delivery)? 1. October 7, 2015 2. October 16, 2015 3. November 7, 2015 4. November 16, 2015 4. November 16, 2015 A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which is the most appropriate nursing action? 1. Instruct the client to avoid walking. 2. Assess for signs of venous thrombosis. 3. Instruct to elevate the legs throughout the day. 4. Tell the client that this is normal during pregnancy. 2. Assess for signs of venous thrombosis. A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/min. Which nursing action is appropriate? 1. Document the findings. 2. Notify the health care provider (HCP). 3. Inform the client that everything is normal and fine. 4. Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate. 2. Notify the health care provider (HCP). A nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures? 1. "I do not need to abstain from sexual intercourse." 2. "I need to use vaginal creams after I douche every day." 3. "I need to douche and perform a sitz bath three times a day." 4. "It may be necessary to have a cesarean section for delivery." 4. "It may be necessary to have a cesarean section for delivery." A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate? 1. "You will not be able to breast-feed the baby until 6 months after delivery." 2. "Breast-feeding is allowed after the baby has been vaccinated with immune globulin." 3. "Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby." 4. "Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery." 2. "Breast-feeding is allowed after the baby has been vaccinated with immune globulin." A nurse is collecting data from a client who is at 32 weeks gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)? 1. 22 cm 2. 28 cm 3. 32 cm 4. 40 cm 3. 32 cm A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should the nurse implement? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Instruct the client that these are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition. 3. Instruct the client that these are common and may occur throughout the pregnancy. A nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. What should the nurse determine that this sign indicates? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin (hCG) in the urine 4. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus 1. A softening of the cervix A nursing instructor asks a nursing student to describe the process of quickening. Which statement by the student indicates an understanding of this term? 1. "It is the thinning of the lower uterine segment." 2. "It is the fetal movement that is felt by the mother." Maternity 17 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 3. "It is irregular painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated." 2. "It is the fetal movement that is felt by the mother." A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make? 1. Between 6 and 8 weeks 2. Between 8 and 10 weeks 3. Between 12 and 14 weeks 4. Between 16 and 20 weeks 4. Between 16 and 20 weeks A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? 1. Immunization with rubella 2. Retesting rubella titer during pregnancy 3. Antibiotics to be taken throughout the pregnancy 4. Counseling the mother regarding therapeutic abortion 2. Retesting rubella titer during pregnancy A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? 1. "The exercises will help reduce backaches." 2. "The exercises will help prevent ankle edema." 3. "The exercises will help prevent urinary tract infections." 4. "The exercises will help strengthen the pelvic floor in preparation for delivery." 4. "The exercises will help strengthen the pelvic floor in preparation for delivery." The nurse in a health care clinic is instructing a client how to perform kick counts. Which statement made by the client indicates a need for further teaching? 1. "I should lie on my back to perform the procedure." 2. "I will use a clock or a timer and record the number of movements or kicks." 3. "I should count the fetal movements for 30 to 60 minutes three times a day." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks." 1. "I should lie on my back to perform the procedure." A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client? 1. "The test is an invasive procedure and requires that you sign an informed consent." 2. "The fetus is challenged by uterine contractions to obtain the necessary information." 3. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." 4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." A nurse provides teaching regarding how to relieve discomfort to a client in her second trimester of pregnancy that is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching? 1. "When I get home I should lie on my left side, with my feet in a dorsiflexed position." 2. "I should soak in a tub bath of hot water when I get home and then perform pelvic tilt exercises." 3. "When I get home I should lie on my right side, with my feet elevated on a pillow, and put a heating pad on my back." 4. "When I get home I should lie on the floor, with my legs elevated onto a couch, and turn my hips and knees at right angles." 4. "When I get home I should lie on the floor, with my legs elevated onto a couch, and turn my hips and knees at right angles." A pregnant client calls the nurse at the health care provider's office and reports that she has noticed a thin, colorless, vaginal drainage. Which information is most appropriate for the nurse to provide to the client? 1. Come to the clinic immediately. 2. The vaginal discharge may be bothersome, but is a normal occurrence. 3. Report to the emergency department at the maternity center immediately. 4. Use tampons if the discharge is bothersome but be sure to change the tampons every 2 hours. 2. The vaginal discharge may be bothersome, but is a normal occurrence. The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result? 1. Normal findings 2. Abnormal findings 3. The need for further evaluation 4. That the findings on the monitor were difficult to interpret 1. Normal findings A pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. Which activity should the nurse tell the client to perform when the cramps occur? 1. Dorsiflex the foot while flexing 2. Dorsiflex the foot while extending 3. Plantar flex the foot while flexing 4. Plantar flex the foot while extending 2. Dorsiflex the foot while extending The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching? 1. "Cool sitz baths will help in relieving the discomfort." 2. "I should perform Kegel exercises as you have instructed." Maternity 18 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 3. "I should apply heat packs to the hemorrhoids to help them shrink." 4. "I can apply ice packs to the hemorrhoids to assist in relieving discomfort." 3. "I should apply heat packs to the hemorrhoids to help them shrink." The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food should the nurse instruct the client to eat to supplement the dietary source of calcium? 1. Dried fruits 2. Hard cheese 3. Creamed spinach 4. Fresh squeezed orange juice 1. Dried fruits A nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food should the nurse encourage the client to consume because it is highest in folic acid? 1. Rice 2. Cheese 3. Chicken 4. Green leafy vegetables 4. Green leafy vegetables A pregnant client asks the nurse about the type of exercises that are allowable during pregnancy. Which exercise should the nurse instruct the client to engage in? 1. Swimming 2. Water skiing 3. Downhill skiing 4. Aerobic exercising 1. Swimming A pregnant client reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. A sputum culture is obtained, andMycobacterium tuberculosis is identified in the sputum. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis? 1. The need for therapeutic abortion is required. 2. Medication will not be started until after delivery of the fetus. 3. Isoniazid plus rifampin (Rifadin) will be required for a total of 9 months. 4. The newborn must receive medication therapy immediately following birth. 3. Isoniazid plus rifampin (Rifadin) will be required for a total of 9 months. The nurse provides home care instructions to a pregnant client with a history of cardiac disease. Which statement made by the client indicates a need for further teaching? 1. "It is best that I rest on my left side to promote blood return to the heart." 2. "I need to avoid excessive weight gain to prevent increased demands on my heart." 3. "I need to try to avoid stressful situations because stress increases the workload on the heart." 4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." 4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." A nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which sign/symptom indicating that this problem has not yet resolved? 1. Pink mucous membranes 2. Increased vaginal secretions 3. Complaints of daily headaches and fatigue 4. Complaints of increased frequency of voiding 3. Complaints of daily headaches and fatigue The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk? 1. Presence of cats in the home 2. Number of sexual partners during pregnancy 3. Exposure to children with rashes or gastrointestinal symptoms 4. History of high fevers or unusual rashes during the first 6 weeks of pregnancy 1. Presence of cats in the home A nurse is preparing to care for a client being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which is the priority nursing action? 1. Assessing for edema 2. Monitoring daily weight 3. Monitoring the apical pulse 4. Monitoring the temperature 3. Monitoring the apical pulse A nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data should alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? 1. The client's last baby weighed 10 lb at birth. 2. The client has a family history of type 1 diabetes. 3. The client is 5 feet, 3 inches tall and weighs 165 lb. 4. The client's previous deliveries were by cesarean section. 1. The client's last baby weighed 10 lb at birth. A nurse is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that which may be required during the second half of pregnancy? 1. Increased insulin Maternity 19 169. 170. 171. 172. 2. Decreased insulin 3. Increased caloric intake 4. Decreased caloric intake 1. Increased insulin A nurse is providing instructions about taking iron supplements to a pregnant client. The nurse determines that the client understands the instructions if the client states she will take the supplements with which drink? 1. Tea 2. Milk 3. Coffee 4. Orange juice 4. Orange juice A nurse is assisting the health care provider to perform Leopold's maneuvers on a pregnant client. Which action should the nurse perform before the procedure? 1. Ask the client to urinate. 2. Ask the client to drink 8 oz of water. 3. Locate the fetal heart tones with a fetoscope. 4. Warm the sonogram gel before placing it on the client's abdomen. 1. Ask the client to urinate. A nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be least likely at risk for the development of thrombophlebitis in the postpartum period? 1. A 35-year-old client who reports that she smokes 2. A 26-year-old client with a family history of thrombophlebitis 3. A 37-year-old client in her fourth pregnancy who is overweight 4. A 22-year-old client in her first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis 2. A 26-year-old client with a family history of thrombophlebitis The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should determine that the client needs further teaching if the client believes which is true about nutrition during pregnancy? 1. Iron supplements should be taken throughout pregnancy. 2. Calcium intake should be increased for the duration of the pregnancy. 3. Pregnancy greatly increases the risk of malnourishment for the mother. 4. The maternal diet significantly influences fetal growth and development. 3. Pregnancy greatly increases the risk of malnourishment for the mother. Maternity - Intrapartum 1. 2. 3. 4. 5. A nursing student is assigned to care for a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement is correct regarding the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava 3. Connects the umbilical vein to the inferior vena cava The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida II who has just been diagnosed with dead fetus syndrome 4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood 3. A gravida II who has just been diagnosed with dead fetus syndrome The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 3. The cervix is dilated completely. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin (Pitocin) intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns. 1. Administer oxygen via face mask. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11 g/dL 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 cells/mm3 2. Fetal heart rate of 180 beats/minute Maternity 20 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the –1 station. This documented finding indicates that the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the iliac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis 3. 1 cm above the ischial spine A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 3. Increased efficiency of contractions The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations 4. Variable decelerations A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees 1. Supine position with a wedge under the right hip The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques. 1. Notify the health care provider (HCP). The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions. 2. Assess the baseline fetal heart rate. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity." 4. "My contractions will increase in duration and intensity." Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure 3. Fetal heart rate pattern The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids 2. Rest between contractions Maternity 21 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin (Pitocin). 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present. 2. Discontinue the infusion of oxytocin (Pitocin). The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding 2. Uterine tenderness The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring. 2. Obtain equipment for a manual pelvic examination. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery 1. Delivery of the fetus The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypertonic 4. Preterm labor 1. Hypotonic The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate 4. Persistent nonreassuring fetal heart rate The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is thepriority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely. 1. Provide pain relief measures. The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer ampicillin 1 g as an intravenous piggyback every 6 hours. 3. Perform a vaginal examination every shift. The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor 2. Monitoring the fetal heart rate Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the intravenous flow rate. 2. Place the client in a high Fowler's position. Maternity 22 26. 27. 28. 29. 30. 31. 32. 33. 34. 3. Continue the oxytocin (Pitocin) drip if infusing. 4. Administer oxygen, 8 to 10 L/minute, via face mask. 4. Administer oxygen, 8 to 10 L/minute, via face mask. The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age. o 4. Bright red vaginal bleeding o 5. Soft, relaxed, nontender uterus o 6. Fundal height may be greater than expected for gestational age. The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately. 2. Place the client in Trendelenburg's position. A nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? 1. The client's fear 2. The client's fatigue 3. The client's inability to control the situation 4. The client's inability to cope with the situation 1. The client's fear The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation. Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1. Hematuria 2. Prolonged clotting times 3. Increased platelet count 4. Swelling of the calf of one leg 5. Petechiae, oozing from injection sites, and hematuria o 1. Hematuria o 2. Prolonged clotting times o 5. Petechiae, oozing from injection sites, and hematuria The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1. Forceps delivery 2. Schultz presentation 3. Hypotonic contractions 4. Weak bearing-down efforts 1. Forceps delivery The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1. Bear down. 2. Hold her breath. 3. Breathe rapidly. 4. Push with each contraction. 3. Breathe rapidly. The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? 1. "It is the application of pressure to the sacrum to relieve a backache." 2. "It is a form of biofeedback to enhance bearing-down efforts during delivery." 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 4. "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest." 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse plan to assess and document the fetal heart rate? 1. Hourly 2. Every 15 minutes 3. Every 30 minutes 4. Before each contraction 2. Every 15 minutes The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1. Noting whether the heart rate is greater than 140 beats/min Maternity 23 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 2. Placing the diaphragm of the Doppler on the mother's abdomen 3. Palpating the maternal radial pulse while listening to the fetal heart rate 4. Performing Leopold's maneuver first to determine the location of the fetal heart 3. Palpating the maternal radial pulse while listening to the fetal heart rate The nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? 1. Increased urinary output 2. A fetal heart rate of 90 beats/min 3. Three contractions occurring within a 10-minute period 4. Adequate resting tone of the uterus palpated between contractions 2. A fetal heart rate of 90 beats/min The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which intervention is implemented before initiating the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside 3. Continuous electronic fetal monitoring The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation 4. Placental separation During the intrapartum period, a nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1. Stimulate the labor process. 2. Prevent dehydration and hypoxemia. 3. Avoid the necessity of a cesarean delivery. 4. Eliminate the need for analgesic administration. 2. Prevent dehydration and hypoxemia. A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1. Measure fundal height. 2. Attach electronic fetal monitoring. 3. Prepare the client for a possible cesarean section. 4. Visually examine the perineum and vaginal opening. 1. Measure fundal height. The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Administer magnesium sulfate intravenously. 4. Assess the blood pressure and fetal heart rate. 2. Clear and maintain an open airway. A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted? 1. Back pain 2. Abdominal pain 3. Painful vaginal bleeding 4. Painless vaginal bleeding 4. Painless vaginal bleeding A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment finding would indicate the presence of concealed bleeding? 1. Back pain 2. Heavy vaginal bleeding 3. Increase in fundal height 4. Early deceleration on the fetal heart monitor 3. Increase in fundal height The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? 1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 2. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. 3. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min. 1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal? 1. Light green, with no odor Maternity 24 45. 46. 47. 48. 49. 50. 51. 52. 53. 2. Clear and dark amber-colored 3. Thick and white, with no odor 4. Pale straw-colored, with flecks of vernix 4. Pale straw-colored, with flecks of vernix A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/min and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1. Contact the obstetrician. 2. Continue to monitor the client. 3. Report the FHR to the anesthesiologist. 4. Prepare for imminent delivery of the fetus. 2. Continue to monitor the client. The nurse is developing a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Keep the room semi-dark. 2. Initiate seizure precautions. 3. Pad the side rails of the bed. 4. Avoid environmental stimulation. 5. Allow out-of-bed activity as tolerated. o 1. Keep the room semi-dark. o 2. Initiate seizure precautions. o 3. Pad the side rails of the bed. o 4. Avoid environmental stimulation. The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the mother's reflexes 2. Taking the mother's temperature 3. Taking the mother's apical pulse 4. Monitoring the mother's blood pressure 4. Monitoring the mother's blood pressure A nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? 1. Assess the fetal heart rate. 2. Check the client's temperature. 3. Change the pads under the client. 4. Check the client's respiratory rate. 1. Assess the fetal heart rate. The goal for a woman with partial premature separation of the placenta is, "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, would indicate that this goal has been achieved? 1. No accelerations of FHR 2. Short-term variability present 3. Variable decelerations present 4. Fetal heart rate (FHR) of 170 to 180 beats/min 2. Short-term variability present The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? 1. A 2. B 3. C 4. D 1. A The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate decelerations? 1. Prepare the client for a cesarean delivery. 2. Monitor the fetal heart rate every 30 minutes. 3. Encourage an upright or side-lying maternal position. 4. Increase the rate of the oxytocin (Pitocin) infusion every 10 minutes. 3. Encourage an upright or side-lying maternal position. The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client? 1. Assess for signs and symptoms of labor. 2. Assess the client's temperature every 2 hours. 3. Schedule a daily ultrasound to assess fetal movement. 4. Schedule a non-stress test every 4 hours to assess fetal well-being. 1. Assess for signs and symptoms of labor. The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1. Fentanyl 2. Morphine sulfate Maternity 25 54. 55. 56. 57. 58. 59. 60. 61. 62. 3. Butorphanol tartrate 4. Meperidine hydrochloride (Demerol) 3. Butorphanol tartrate The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1. Chest pain 2. A rigid abdomen 3. A soft and boggy uterus 4. Complaints of severe abdominal pain 4. Complaints of severe abdominal pain The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1. Exhaustion 2. Valsalva maneuver 3. Involuntary grunting 4. Fear of losing control 4. Fear of losing control A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for throughout the client's labor? 1. Anxiety 2. Hemorrhage 3. Low self-esteem 4. Postpartum infection 4. Postpartum infection Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? 1. Slow the intravenous (IV) rate. 2. Continue the oxytocin (Pitocin) drip. 3. Place the client in a high Fowler's position. 4. Administer oxygen at 8 to 10 L/min via face mask. 4. Administer oxygen at 8 to 10 L/min via face mask. A pregnant 39-week-gestation gravida 1 para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B Streptococcus(GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action? 1. Provide the client with instructions on how to push. 2. Prepare the labor room and the client for an imminent delivery. 3. Call the HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 4. Call the health care provider (HCP) to the labor and delivery unit to perform a delivery. 3. Call the HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP). A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? 1. Perform an abdominal prep on the client. 2. Prepare the delivery room for a vaginal delivery. 3. Explain to the client why a cesarean delivery is necessary. 4. Call the health care provider to obtain a prescription for an antiviral medication. 3. Explain to the client why a cesarean delivery is necessary. The nurse caring for a client in labor notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which best describes minimal variability? 1. FHR fluctuations are lasting more than 15 seconds. 2. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate. 3. FHR fluctuations are lasting more than 15 seconds. 4. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate. 1. FHR fluctuations are lasting more than 15 seconds. After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1. Reposition the laboring woman to knee-chest. 2. Assess the vagina and cervix with a gloved hand. 3. Notify the health care provider of the need for an amnioinfusion. 4. Document the description of the fetal bradycardia in the nursing notes. 2. Assess the vagina and cervix with a gloved hand. On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies is which category of decelerations? 1. Episodic, late decelerations that indicate uteroplacental insufficiency 2. Periodic, early decelerations and indicative of fetal head compression 3. Periodic, variable decelerations and an indication of cord compression 4. Episodic, early decelerations that may be a result of maternal hypotension 2. Periodic, early decelerations and indicative of fetal head compression Maternity 26 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1. Prepare for delivery. 2. Administer a tocolytic. 3. Administer an opioid antagonist. 4. Turn the woman to a lateral position. 5. Increase the rate of the intravenous infusion. 6. Administer oxygen by face mask at 10 L/minute. o 4. Turn the woman to a lateral position. o 5. Increase the rate of the intravenous infusion. o 6. Administer oxygen by face mask at 10 L/minute. The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? 1. "The medication will only affect you and your pain level when given during a contraction." 2. "The medication will provide the most optimal relief when it is given while your pain level is highest." 3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4. "You will experience a lower incidence of adverse effects from the medication when administered during a contraction." 3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." On March 10, 2015, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7, 2014. The nurse plans care based on which interpretation? 1. The client is possibly in preterm labor. 2. The fetus may not be viable at delivery. 3. The client may require labor augmentation. 4. The fetus is at high risk for shoulder dystocia. 1. The client is possibly in preterm labor. The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and would expect to note which prescribed treatment for this condition? 1. Increased hydration 2. Oxytocin (Pitocin) infusion 3. Administration of a tocolytic medication 4. Administration of a medication that will provide sedation 2. Oxytocin (Pitocin) infusion Which newborn is most at risk for a brachial plexus injury? 1. A term infant with a history of a forceps-assisted delivery 2. A term infant delivered via primary cesarean section for malpresentation 3. A large for gestational age infant with a history of shoulder dystocia at delivery 4. A 36-week preterm infant delivered vaginally after preterm rupture of membranes 3. A large for gestational age infant with a history of shoulder dystocia at delivery A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider (HCP) has prescribed an epidural block. Which nursing intervention would be implemented after the epidural block has been placed? 1. Palpate the bladder at frequent intervals. 2. Encourage the woman to walk to progress the labor. 3. Assess the blood pressure frequently for hypertension. 4. Encourage the woman to assume a supine position after the epidural has been placed. 1. Palpate the bladder at frequent intervals. A nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? 1. Administer oxygen to the woman. 2. Transport the woman to the delivery room. 3. Place an external fetal monitor on the woman. 4. Exert upward pressure against the presenting part using a gloved hand. 4. Exert upward pressure against the presenting part using a gloved hand. A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1. Contact the health care provider. 2. Place the mother in a Trendelenburg position. 3. Administer oxygen to the client by face mask. 4. Document the findings and continue to monitor fetal patterns. 4. Document the findings and continue to monitor fetal patterns. The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1. Stop the oxytocin infusion. 2. Check the client's blood pressure. 3. Check the client for bladder distention. 4. Place the client in a side-lying position. 1. Stop the oxytocin infusion. A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which is documented in the client's record? 1. The contractions are regular. Maternity 27 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 2. The membranes have ruptured. 3. The cervix is completely dilated. 4. The client begins to expel clear vaginal fluid. 3. The cervix is completely dilated. A nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding the nurse should prepare for which appropriate nursing action? 1. Administering oxygen via face mask 2. Placing the mother in a supine position 3. Increasing the rate of the intravenous (IV) oxytocin (Pitocin) infusion 4. Documenting the findings and continuing to monitor the fetal patterns 1. Administering oxygen via face mask A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of the infusion needs to be decreased? 1. Increased urinary output 2. A fetal heart rate of 180 beats/min 3. Three contractions occurring in a 10-minute period 4. Adequate resting tone of the uterus palpated between contractions 2. A fetal heart rate of 180 beats/min A nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action? 1. Determine the fetal heart rate. 2. Provide peripads for the client. 3. Take the client's blood pressure. 4. Note the amount, color, and odor of the amniotic fluid. 1. Determine the fetal heart rate. A nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse should document these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation 4. Placental separation A nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse should ensure that which is implemented before the beginning of the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside 3. Continuous electronic fetal monitoring A nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should assess that the amniotic fluid is normal if it has which characteristics? 1. Clear and dark amber color 2. Light green color with no odor 3. Thick white color with no odor 4. Straw-colored, with flecks of vernix 4. Straw-colored, with flecks of vernix A nurse is developing a plan of care for a client experiencing dystocia, and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? 1. Monitoring fetal status 2. Providing comfort measures 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor 1. Monitoring fetal status A nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? 1. Maternal fatigue 2. The passage of meconium 3. Coordinated uterine contractions 4. Progressive changes in the cervix 2. The passage of meconium A nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely. 1. Provide pain relief measures. A nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. Maternity 28 83. 84. 85. 86. 87. 88. 89. 3. Find the closest telephone and page the health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately. 2. Place the client in Trendelenburg's position. A nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action? 1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. 2. Turn the client on her back and administer oxygen by face mask at 8 to 10 L/min. 3. Turn the client on her side and administer oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client on her back and administer oxygen by nasal cannula at 2 to 4 L/min. 1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery 1. Delivery of the fetus A nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing? 1. Hypotonic 2. Precipitate 3. Hypertonic 4. Preterm labor 1. Hypotonic A nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes and have a duration of 35 seconds. Using this information, what is the most appropriate action for the nurse to take? 1. Prepare for imminent delivery. 2. Continue to monitor the client. 3. Report the findings to the obstetrician. 4. Report the FHR to the anesthesiologist on call. 2. Continue to monitor the client. A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the most appropriate nursing action? 1. Sit the client in a high Fowler's position. 2. Call the pharmacy for a tocolytic medication. 3. Get intravenous (IV) therapy equipment and solution from the storage area. 4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. 4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. The purpose of a vaginal examination is to specifically assess the status of which findings? Select all that apply. 1. Station 2. Dilation 3. Effacement 4. Bloody show 5. Contraction effort o 1. Station o 2. Dilation o 3. Effacement A nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 4. Painless, bright red vaginal bleeding 5. Increased uterine resting tone on fetal monitoring o 1. Uterine tenderness o 2. Acute abdominal pain o 3. A hard, "board-like" abdomen o 5. Increased uterine resting tone on fetal monitoring Maternity - Newborn 1. 2. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer 3. Drying the infant with a warm blanket The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? Maternity 29 3. 4. 5. 6. 7. 8. 9. 10. 11. 1. Bring the infant to the clinic. 2. This is a normal occurrence. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues. 1. Bring the infant to the clinic. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the health care provider (HCP). 3. Document the findings. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of a barrel chest and acrocyanosis 1. Tachypnea and retractions The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently. 2. Continue to breast-feed every 2 to 4 hours. 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? 1. Lethargy 2. Sleepiness 3. Constant crying 4. Cuddles when being held 3. Constant crying The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz 4. Head circumference appropriate for gestational age 2. Abnormal palmar creases The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern. 4. Monitor the newborn's response to feedings and weight gain pattern. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection. 4. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches. o 4. Monitor skin temperature closely. o 5. Reposition the newborn every 2 hours. o 6. Cover the newborn's eyes with eye shields or patches. The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely Maternity 30 12. 13. 14. 15. 16. 17. 18. 19. 20. 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment 2. Maintaining standard precautions at all times while caring for the newborn The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen 2. Maintaining safety because of low blood glucose levels Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery." 4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." 4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Early decelerations of the fetal heart rate 3. Uterine hyperstimulation A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which finding is noted on assessment? 1. Proteinuria of 3+ 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Serum magnesium level of 6 mEq/L 2. Respirations of 10 breaths/minute The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes o 1. Flushing o 4. Depressed respirations o 5. Extreme muscle weakness The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling ointment." 3. "I need to administer the eye ointment within 1 hour after delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs." 1. "I will flush the eyes after instilling the ointment." A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine (Nubain) 2. Betamethasone (Celestone) 3. Rho(D) immune globulin (RhoGAM) 4. Dinoprostone (Cervidil vaginal insert) 2. Betamethasone (Celestone) Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes 2. Blood pressure Maternity 31 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. The nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular 2. Intratracheal An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone (Celestone) 4. Meperidine hydrochloride (Demerol) 1. Naloxone Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility 4. Being affected by Rh incompatibility Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the health care provider who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease 4. Peripheral vascular disease A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client regarding care of her infant. Which client statement indicates the need for further instruction? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Notify the health care provider. 4. Cover the ears with gauze pads. 3. Notify the health care provider. The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? 1. "The cord will fall off in 1 to 2 weeks." 2. "Alcohol may be used to clean the cord." 3. "I should cleanse the cord two or three times a day." 4. "I need to fold the diaper above the cord to prevent infection." 4. "I need to fold the diaper above the cord to prevent infection." The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? 1. Lethargy 2. Irritability 3. Higher-than-normal birth weight 4. A greater-than-normal appetite when feeding 2. Irritability The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? 1. The mother bathes the newborn infant after a feeding. 2. The mother states that she would gather all supplies before the bath is started. 3. The mother states that she would never leave the newborn infant in the tub of water alone. 4. The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist. 1. The mother bathes the newborn infant after a feeding. A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1. Positive for HIV 2. Indicates the presence of maternal infection Maternity 32 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 3. Indicates that the newborn will develop AIDS later in life 4. Positive for acquired immunodeficiency syndrome (AIDS) 2. Indicates the presence of maternal infection A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? 1. A rectal thermometer 2. A blood pressure cuff 3. A specific gravity urinometer 4. A bottle of sterile normal saline 4. A bottle of sterile normal saline The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1. "I should retract the foreskin and clean the penis every time I change the diaper." 2. "I need to retract the foreskin and clean the penis every time I give my infant a bath." 3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning." 3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." The nurse is preparing to instruct a client in how to bathe a newborn. Which statement should the nurse include in the instruction? 1. "Begin with the eyes and face." 2. "Begin with the feet and work upward." 3. "Do the back side first, and then the front side." 4. "Start with the chest, move to the face, and then finish the rest of the body." 1. "Begin with the eyes and face." The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select? 1. The gluteal muscle 2. The lower aspect of the rectus femoris muscle 3. The medial aspect of the upper third of the vastus lateralis muscle 4. The lateral aspect of the middle third of the vastus lateralis muscle 4. The lateral aspect of the middle third of the vastus lateralis muscle The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1. Make a loud, abrupt noise to startle the newborn. 2. Stimulate the ball of the foot of the newborn by firm pressure. 3. Stimulate the perioral cavity of the newborn infant with a finger. 4. Stimulate the pads of the newborn infant's hands by firm pressure. 1. Make a loud, abrupt noise to startle the newborn. A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? 1. Applying lotions to exposed newborn skin 2. Assessing skin integrity and fluid status of the newborn 3. Having minimal contact with the newborn to prevent stimulation 4. Advising the mother to limit the newborn's oral intake during phototherapy 2. Assessing skin integrity and fluid status of the newborn The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should mostappropriately document which Apgar score for the newborn? 1. 3 2. 5 3. 7 4. 10 2. 5 The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? 1. Document the findings. 2. Contact the health care provider. 3. Apply an oxygen mask to the newborn infant. 4. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes. 1. Document the findings. Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1. Peripads 2. Tape measure 3. Reflex hammer 4. Blood pressure cuff 4. Blood pressure cuff Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response? 1. "The medication provides pain relief during labor." 2. "The medication will help prevent any nausea and vomiting." Maternity 33 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 3. "The medication will assist in increasing the contractions." 4. "The medication prevents respiratory depression in the newborn infant." 1. "The medication provides pain relief during labor." The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1. Initiate an intravenous (IV) line on the newborn infant. 2. Place the newborn infant on a cardiorespiratory monitor. 3. Place the newborn infant in the radiant warmer incubator. 4. Administer oxygen via resuscitation bag to the newborn infant. 4. Administer oxygen via resuscitation bag to the newborn infant. The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding? 1. One artery 2. Two veins 3. Two arteries 4. One artery and one vein 3. Two arteries The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding? 1. Loose stools 2. High-pitched cry 3. Vigorous feeding habits 4. A copper-colored skin rash 4. A copper-colored skin rash The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1. Radiation 2. Convection 3. Conduction 4. Evaporation 3. Conduction The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes an Apgar score of 6. On the basis of this score, what should the nurse determine? 1. The newborn requires vigorous resuscitation. 2. The newborn is adjusting well to extrauterine life. 3. The newborn requires some resuscitative interventions. 4. The newborn is having some difficulty adjusting to extrauterine life. 3. The newborn requires some resuscitative interventions. A nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? 1. Selective placement of the infant 2. Periodic well-baby examinations 3. Phenylketonuria (PKU) testing at birth 4. Administration of an antibiotic for an umbilical cord staphylococcal infection 2. Periodic well-baby examinations The nurse is preparing to bathe a 1-day-old newborn. Which action should the nurse avoid when performing the procedure? 1. Immersing the newborn in water 2. Supporting the newborn's body during the bath 3. Ensuring that the water temperature is warm 4. Ensuring that the water temperature does not exceed 100° F 1. Immersing the newborn in water On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? 1. At 1 minute after birth and 5 minutes after birth 2. Immediately at birth, 3 minutes after birth, and 10 minutes after birth 3. At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth 4. At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta 1. At 1 minute after birth and 5 minutes after birth The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score? 1. 3 2. 5 3. 7 4. 10 4. 10 The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the heart rate is within normal range if which heart rate is noted on assessment? 1. 80 beats/min 2. 90 beats/min Maternity 34 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 3. 130 beats/min 4. 180 beats/min 3. 130 beats/min The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding? 1. A depressed anterior fontanel 2. A soft and flat anterior fontanel 3. An anterior fontanel measuring 1 cm 4. An anterior fontanel measuring 7 cm 2. A soft and flat anterior fontanel The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1. A suture split greater than 1 cm 2. A hard, rigid, immobile suture line 3. Swelling of the soft tissues of the head and scalp 4. Edema resulting from bleeding below the periosteum of the cranium 4. Edema resulting from bleeding below the periosteum of the cranium The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? 1. Inside the abdominal cavity and under the skin 2. Inside the abdominal cavity and under the dermis 3. Outside the abdominal cavity and not covered with a sac 4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane 4. Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant? 1. 10 to 20 mL 2. 30 to 90 mL 3. 75 to 100 mL 4. 90 to 150 mL 4. 90 to 150 mL A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks the nurse to explain the diagnosis. On what description should the nurse plan to base the response? 1. Gastric contents regurgitate back into the esophagus. 2. The esophagus terminates before it reaches the stomach. 3. Abdominal contents herniate through an opening of the diaphragm. 4. A portion of the stomach protrudes through the esophageal hiatus of the diaphragm. 1. Gastric contents regurgitate back into the esophagus. The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? 1. Excessive oral secretions 2. Bowel sounds heard over the chest 3. Hiccups and spitting up after a meal 4. Coughing, wheezing, and short periods of apnea 4. Coughing, wheezing, and short periods of apnea An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? 1. Hepatitis B vaccine given within 24 hours after birth 2. Immune globulin (IG) given as soon as possible after delivery 3. Hepatitis B immune globulin (HBIG) given within 14 days after birth 4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth 4. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth The nurse is caring for a newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL. How should the nurse interpret this laboratory value? 1. A normal value 2. Lower than normal 3. Higher than normal 4. Requiring health care provider notification 1. A normal value The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant? 1. Presence of a cephalhematoma 2. Infant blood type of O negative 3. Birth weight of 8 pounds 6 ounces 4. A negative direct Coombs' test result 1. Presence of a cephalhematoma The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis? 1. Monitoring the urine for blood 2. Monitoring the urinary output pattern Maternity 35 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 3. Testing for contractures of the extremities 4. Stimulating for reflex responses in the extremities 4. Stimulating for reflex responses in the extremities Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route? 1. Erythromycin 2. Tetracycline 1% 3. Phytonadione (Vitamin K) 4. Measles-mumps-rubella vaccination 3. Phytonadione (Vitamin K) The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference? 1. Wrap the tape measure around the infant's head, and measure just below the eyebrows. 2. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. 3. Place the tape measure under the infant's head at the base of the skull, and wrap around to the front just below the eyes. 4. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth. 2. Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows. The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? 1. Thin and gelatinous, with increased subcutaneous fat 2. Thin and gelatinous, with increased amounts of brown fat 3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat 4. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat 3. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Cover the ears with gauze pads. 4. Notify the health care provider (HCP). 4. Notify the health care provider (HCP). The nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1. Urinary output 2. Total bilirubin levels 3. Blood glucose levels 4. Hemoglobin and hematocrit levels 3. Blood glucose levels An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? 1. Palpate the clavicles for a fracture. 2. Auscultate the heart for a cardiac defect. 3. Blanch the skin for evidence of jaundice. 4. Perform Ortolani's maneuver for hip dislocation. 1. Palpate the clavicles for a fracture. The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which would the nurse expect to note in the neonate? 1. Tremors 2. Bradycardia 3. Flaccid muscles 4. Extreme lethargy 1. Tremors An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action? 1. Elevates the gastrostomy tube 2. Tapes the gastrostomy tube to the bed linens 3. Attaches the gastrostomy tube to low suction 4. Connects the gastrostomy to the feeding pump 1. Elevates the gastrostomy tube Which would be considered a normal finding in a newborn less than 12 hours old? 1. Grunting respirations 2. Heart rate of 190 beats/min 3. Bluish discoloration of the hands and feet 4. A yellow discoloration of the sclera and body 3. Bluish discoloration of the hands and feet The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. 1. Retinopathy 2. Hypoglycemia 3. Fractured clavicle Maternity 36 71. 72. 73. 74. 75. 76. 77. 78. 4. Hyperbilirubinemia 5. Congenital heart defect 6. Necrotizing enterocolitis o 2. Hypoglycemia o 3. Fractured clavicle o 5. Congenital heart defect A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1. Determine Apgar score. 2. Auscultate the heart rate. 3. Thoroughly dry the newborn. 4. Take the newborn's rectal temperature. 3. Thoroughly dry the newborn. The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. 1. Call bell 2. Feeding pump 3. Vital sign machine 4. Phototherapy lights 5. Intravenous (IV) pump o 4. Phototherapy lights o 5. Intravenous (IV) pump Which would be considered a normal finding in a newborn less than 12 hours old? 1. Grunting respirations 2. Heart rate of 190 beats/minute 3. Bluish discoloration of the hands and feet 4. A yellow discoloration of the sclera and body 3. Bluish discoloration of the hands and feet Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. 1. Grunting respirations 2. Presence of vernix caseosa 3. Heart rate of 190 beats/minute 4. Anterior fontanelle measuring 5.0 cm 5. Bluish discoloration of hands and feet 6. A yellow discoloration of the sclera and body o 1. Grunting respirations o 3. Heart rate of 190 beats/minute o 6. A yellow discoloration of the sclera and body A nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation? 1. The infusion rate needs to be increased. 2. The magnesium sulfate is effective. 3. The woman is experiencing cerebral edema. 4. The woman is experiencing magnesium excess. 4. The woman is experiencing magnesium excess. Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter? 1. Lochial flow 2. Urine output 3. Temperature 4. Blood pressure 4. Blood pressure A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? 1. Reinforce the dressing. 2. Document the findings. 3. Contact the health care provider. 4. Swab the drainage and send the sample to the laboratory for culture. 3. Contact the health care provider. A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment that is used and how it functions to assist their newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition. 1. Encourage the parents to touch their newborn. Maternity 37 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. Butorphanol tartrate is prescribed for a client in labor. The nurse understands that this medication is prescribed to achieve which outcome? 1. Providing pain relief 2. Promoting fetal lung maturity 3. Increasing uterine contractions 4. Decreasing uterine contractions 1. Providing pain relief A client experiencing preterm labor at the 29th week of gestation has been admitted to the hospital. The client has a prescription to receive betamethasone. The nurse understands that the medication has which action? 1. Stops the uterine contractions 2. Prevents spontaneous delivery 3. Promotes maturation of the fetal lungs 4. Accelerates the growth rate of the fetus 3. Promotes maturation of the fetal lungs A client with preeclampsia is receiving magnesium sulfate. The nurse should assess the client closely for which sign of magnesium toxicity? 1. Proteinuria 2. Presence of deep tendon reflexes 3. Respiratory rate of 10 breaths/min 4. Serum magnesium level of 5 mEq/L 3. Respiratory rate of 10 breaths/min A nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. The nurse plans to explain to the parents that which is the purpose of the medication? 1. Help the newborn to see more clearly. 2. Ensure the sterility of the conjunctiva in the newborn. 3. Guard against infection acquired during intrauterine life. 4. Protect the newborn from contracting an eye infection during birth. 4. Protect the newborn from contracting an eye infection during birth. A nurse has a routine prescription to administer an injection of phytonadione (vitamin K) to the newborn. Before giving the medication, the nurse explains to the mother that this medication has which function? 1. Stimulating the liver to produce vitamin K 2. Preventing clotting abnormalities in the newborn 3. Preventing vitamin deficiency of fat-soluble vitamins 4. Supplementing the infant, because breast milk and formula are low in vitamin K 2. Preventing clotting abnormalities in the newborn A client in preterm labor is being started on intravenous magnesium sulfate to stop the contractions. The nurse should checks to ensure that which medication is available as an antidote if needed? 1. Vitamin K 2. Magnesium oxide 3. Calcium gluconate 4. Aluminum hydroxide 3. Calcium gluconate A nurse gave an intramuscular dose of methylergonovine (Methergine) to a client following delivery of an infant. The nurse determines that this medication had the intended effect if which finding is noted? 1. Decreased pulse rate 2. Increased urine output 3. Improved uterine tone 4. Increased blood pressure 3. Improved uterine tone The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and should note that the heart rate is normal if which rate is noted? 1. A heart rate of 100 beats/min 2. A heart rate of 140 beats/min 3. A heart rate of 180 beats/min 4. A heart rate of 190 beats/min 2. A heart rate of 140 beats/min The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and should determine that the respiratory rate is normal if which respiratory rate is noted? 1. A respiratory rate of 20 breaths/min 2. A respiratory rate of 40 breaths/min 3. A respiratory rate of 70 breaths/min 4. A respiratory rate of 80 breaths/min 2. A respiratory rate of 40 breaths/min The nurse is performing an assessment on a newborn. The nurse is preparing to measure the head circumference of the newborn. Which procedure should the nurse use to perform this procedure? 1. Wrap the paper tape around the newborn's head, and measure just above the eyebrows. 2. Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. 3. Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn's mouth. 4. Place the paper tape under the newborn's head at the base of the skull, and wrap around to the front, just above the eyes. 2. Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. Maternity 38 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the Moro reflex? 1. Clap hands or slap the mattress. 2. Stimulate the perioral cavity with a finger. 3. Stimulate the ball of the infant's foot with firm pressure. 4. Stimulate the pads of the infant's hands with firm pressure. 1. Clap hands or slap the mattress. The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection which site should the nurse should select? 1. The gluteal muscle 2. The lower aspect of the rectus femoris muscle 3. The medial aspect of the upper third of the vastus lateralis muscle 4. The lateral aspect of the middle third of the vastus lateralis muscle 4. The lateral aspect of the middle third of the vastus lateralis muscle The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate? 1. 20 to 40 breaths/min 2. 40 to 60 breaths/min 3. 70 to 80 breaths/min 4. 80 to 100 breaths/min 2. 40 to 60 breaths/min The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low set. Which nursing action is most appropriate initially? 1. Document the findings. 2. Arrange for hearing testing. 3. Cover the ears with gauze pads. 4. Notify the health care provider (HCP). 4. Notify the health care provider (HCP). A nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly? 1. The client begins to wash the newborn by starting with the eyes and face. 2. The client cleans the newborn's ears and then moves to the eyes and the face. 3. The client washes the arms, chest, and back, followed by the neck, arms, and face. 4. The client washes the entire newborn's body and then washes the eyes, face, and scalp. 1. The client begins to wash the newborn by starting with the eyes and face. A nurse is providing instructions to a client regarding cord care for her newborn. Which statement made by the client indicates a need for further teaching? 1. "The cord will fall off in 1 to 2 weeks." 2. "I should clean the cord two or three times a day." 3. "Alcohol may be used if prescribed to clean the cord." 4. "I need to fold the diaper above the cord to prevent infection." 4. "I need to fold the diaper above the cord to prevent infection." The nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instruction should the nurse provide to the mother? 1. Increase the frequency of the breast-feeding. 2. Stop the breast-feedings and switch to bottle-feeding permanently. 3. Provide bottled water feedings between the breast-feeding sessions. 4. Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently. 1. Increase the frequency of the breast-feeding. A nurse is monitoring a newborn that was born to a client who abuses alcohol. Which finding should the nurse expect to note when assessing this newborn? 1. Lethargy 2. Irritability 3. Higher than normal birth weight 4. A greater than normal appetite when feeding 2. Irritability A nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest, with acrocyanosis 1. Tachypnea and retractions The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/min; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well-flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score? 1. 7 2. 9 Maternity 39 99. 3. 8 4. 10 2. 9 Which are modes of heat loss in the newborn? Select all that apply. 1. Radiation 2. Urination 3. Convection 4. Conduction 5. Evaporation o 1. Radiation o 3. Convection o 4. Conduction o 5. Evaporation Maternity - Postpartum 1. 2. 3. 4. 5. 6. 7. A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week. o 2. Pregnancy needs to be avoided for 1 to 3 months. o 3. The vaccine is administered by the subcutaneous route. o 4. Exposure to immunosuppressed individuals needs to be avoided. o 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding." 1. "You will need to bottle-feed your newborn." A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience." 1. "What can I do for you?" The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately." 1. "We want to attend a support group." The nurse evaluates the ability of a hepatitis B–positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding. 2. The mother holds the newborn properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks." 1. "I will begin abdominal exercises immediately." After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? Maternity 40 8. 9. 10. 11. 12. 13. 14. 15. 16. 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record. 2. Support the mother in her reaction to the newborn infant. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation 2. Hemorrhage The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids. 4. Increase hydration by encouraging oral fluids. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided. 3. Instruct the client to request help when getting out of bed. The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum 1. 3 days postpartum The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume 1. Client pain level The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily." o 1. "I should wear a bra that provides support." o 2. "Drinking alcohol can affect my milk supply." o 3. "The use of caffeine can decrease my milk supply." o 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily." The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding. 1. The diet should include additional fluids. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots. 2. Massage the fundus until it is firm. The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor Maternity 41 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 4. The client with lochia that is red and has a foul-smelling odor When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids. 3. Notify the health care provider. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive 3. Heavy The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4° F 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute 2. An increase in the pulse rate from 88 to 102 beats/minute The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump. o 1. Wear a supportive bra. o 2. Rest during the acute phase. o 3. Maintain a fluid intake of at least 3000 mL. o 4. Continue to breast-feed if the breasts are not too sore. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast-feeding." 4. "I should wash my nipples daily with soap and water." 4. "I should wash my nipples daily with soap and water." The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses 3. Enlarged, hardened veins A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask. 4. Administer oxygen, 8 to 10 L/minute, by face mask. The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position. 3. Notify the health care provider (HCP). The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths Maternity 42 27. 28. 29. 30. 31. 32. 33. 34. 35. 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels 2. Encouraging fluid intake The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation 1. Changes in vital signs The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings. 3. Prepare an ice pack for application to the area. On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Elevate the client's legs. 2. Document the findings. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots. 3. Massage the fundus until it is firm. On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed." 4. "Foods and fluids that will increase urine alkalinity should be consumed." The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, would indicate the need for further assessment related to this form of depression? 1. The mother is caring for the infant in a loving manner. 2. The mother demonstrates an interest in the surroundings. 3. The mother constantly complains of tiredness and fatigue. 4. The mother looks forward to visits from the father of the newborn. 3. The mother constantly complains of tiredness and fatigue. A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? 1. Massage the breasts, applying gentle pressure on the areolas with the thumb and forefinger. 2. Have the mother grasp her areola between the thumb and forefinger and tug firmly to get the nipple to protrude. 3. Encourage taking a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude. 4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp. 4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp. A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? 1. "Mastitis usually involves both breasts." 2. "Mastitis can occur at any time during breast-feeding." 3. "Mastitis usually is caused by wearing a supportive bra." 4. "Mastitis is most common for women who have breast-fed in the past." 2. "Mastitis can occur at any time during breast-feeding." The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? 1. Elevate her legs. 2. Remain on bed rest. 3. Ambulate frequently. 4. Apply warm, moist packs to the legs. 3. Ambulate frequently. The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider (HCP). Maternity 43 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 4. Assess for hypovolemia and notify the health care provider (HCP). The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, would indicate a complication related to a laceration of the birth canal? 1. Presence of dark red lochia 2. Palpation of the uterus as a firm contracted ball 3. The saturation of more than one peripad per hour 4. Palpation of the fundus at the level of the umbilicus 3. The saturation of more than one peripad per hour The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instructions? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours." 2. "I need to stop breast-feeding until this condition resolves." A postpartum client with deep vein thrombosis is being treated with anticoagulant therapy. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for which symptoms? 1. Dysuria, ecchymosis, and vertigo 2. Epistaxis, hematuria, and dysuria 3. Hematuria, ecchymosis, and vertigo 4. Hematuria, ecchymosis, and epistaxis 4. Hematuria, ecchymosis, and epistaxis After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1. "I will probably need my mother to help me with housekeeping." 2. "Because I am so sore, I will nurse the baby while lying on my side." 3. "My husband and I will not have intercourse until the stitches are healed." 4. "The only medications I will take are prenatal vitamins and stool softeners." 4. "The only medications I will take are prenatal vitamins and stool softeners." The nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Administration of anticoagulants 2. Elevation of the affected extremity 3. Ambulation eight to ten times daily 4. Application of ice packs to the affected area 2. Elevation of the affected extremity A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/min. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, what is the nurse's next action? 1. Reassure the client. 2. Monitor fundal height. 3. Apply perineal pressure. 4. Prepare the client for surgery. 4. Prepare the client for surgery. The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instructions? 1. "I need to take the antibiotics as prescribed." 2. "I need to take warm sitz baths to promote healing." 3. "I need to apply warm compresses to provide comfort." 4. "I need to isolate the infant for 48 hours after beginning the antibiotics." 4. "I need to isolate the infant for 48 hours after beginning the antibiotics." A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? 1. Lack of power about the situation 2. Grieving because of the loss of the baby 3. Lack of knowledge regarding what occurred 4. Concern about the loss of the baby and personal health 4. Concern about the loss of the baby and personal health The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." 3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." The nursing student is assigned to care for a client in the postpartum unit. The coassigned nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an Maternity 44 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. understanding of this method? 1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1. The mother is observed talking to the newborn. 2. The mother performs cord care for the newborn. 3. The mother verbalizes discomfort with the new role of motherhood. 4. The mother requests that the nurse feed the newborn because she is feeling fatigued. 4. The mother requests that the nurse feed the newborn because she is feeling fatigued. The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned with the presence of subinvolution if which occurs? 1. The presence of afterpains 2. Retained placental fragments from delivery 3. An oral temperature of 99.0° F following delivery 4. Increased estrogen and progesterone levels as noted on laboratory analysis 2. Retained placental fragments from delivery The nurse is monitoring a postpartum client who is at risk of developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, would support a diagnosis of postpartum endometritis? 1. Abdominal tenderness and chills 2. Increased perspiration and appetite 3. Maternal oral temperature of 100.2° F 4. Uterus two fingerbreadths below midline and firm 1. Abdominal tenderness and chills Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? 1. Limit fluid intake. 2. Maintain the client in a supine position. 3. Ask family members to care for the newborn. 4. Encourage the client to take pain medication as prescribed. 4. Encourage the client to take pain medication as prescribed. The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? 1. Monitoring the vital signs 2. Palpating the uterine fundus 3. Auscultating the bowel sounds 4. Assessing the amount of drainage on the peripad 2. Palpating the uterine fundus The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action? 1. Massage the uterus until firm. 2. Take the client's blood pressure. 3. Contact the health care provider (HCP). 4. Assess the amount of drainage on the peripad. 1. Massage the uterus until firm. The postpartum unit nurse is developing a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? 1. Use a low-pitched voice to speak to the infant. 2. Encourage the mother to hold the infant when the infant cries. 3. Encourage the parents to allow the infant to sleep in the parental bed. 4. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged. 2. Encourage the mother to hold the infant when the infant cries. The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? 1. "If I experience any sweating during the night, I should call the health care provider." 2. "If I have uterine cramping while breast-feeding, I should contact the health care provider." 3. "If I'm still having bloody vaginal drainage in a week, I should contact the health care provider." 4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider." 4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider." A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the fundus. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position. 3. Cover the client with a warm blanket. The postpartum unit nurse has provided information regarding performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that the sitz bath will promote which action? Maternity 45 56. 57. 58. 59. 60. 61. 62. 63. 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Assist in healing and provide comfort. 4. Assist in healing and provide comfort. A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1. Massaging the uterus 2. Pushing gently on the uterus 3. Assisting the woman to urinate 4. Rechecking the uterus in 1 hour 5. Checking for a distended bladder 6. Calling the delivery room to schedule an abdominal hysterectomy o 1. Massaging the uterus o 3. Assisting the woman to urinate o 5. Checking for a distended bladder A woman infected with the human immunodeficiency virus (HIV) has given birth to a normal-appearing infant, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates a need for further instruction? 1. "I'm going to breast-feed my baby starting right away." 2. "I need to wash my hands before and after bathroom use." 3. "My baby needs to be on antiviral medications for the next 6 weeks." 4. "I am going to contact some support groups listed in my take-home material to help me with everything I'll have to deal with when I get home." 1. "I'm going to breast-feed my baby starting right away." The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area? 1. A 2. B 3. C 4. D 4. D A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The unit nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1. Postpartum infection 2. Maternal attachment 3. Maternal overexertion 4. Postpartum newborn-mother bonding 3. Maternal overexertion A postpartum care unit nurse is reviewing the records of 4 new mothers admitted to the unit. The nurse determines that which mother would be least likely at risk for developing a puerperal infection? 1. A mother who had ten vaginal exams during labor 2. A mother with a history of previous puerperal infections 3. A mother who gave birth vaginally to a 3200 gram infant 4. A mother who experienced prolonged rupture of the membranes 3. A mother who gave birth vaginally to a 3200 gram infant A postpartum unit nurse is preparing to care for a client who has just delivered a healthy newborn. In the immediate postpartum period what is the recommended frequency for the nurse to assess the client's vital signs? 1. Every hour for the first 2 hours and then every 4 hours 2. Every 30 minutes during the first hour and then every hour for the next 2 hours 3. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4. Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours 4. Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain. 2. Ask the client about pain in the calf area. The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation? 1. Sunlight for 3 days 2. Scratching the injection site 3. Pregnancy for 2 to 3 months after the vaccination 4. Sexual intercourse for 2 to 3 months after the vaccination 3. Pregnancy for 2 to 3 months after the vaccination Maternity 46 64. 65. 66. 67. 68. 69. 70. 71. On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instructions? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed." 4. "Foods and fluids that will increase urine alkalinity should be consumed." A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statement by the client would indicate the need for further instructions? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? 1. The mother has cracked nipples and feeds the infant with a supplemental bottle. 2. The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast. 3. The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister. 4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow. 4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow. The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at the lowest risk for development of postpartum thromboembolic disorders? 1. A 39-year-old woman who reports that she smokes 2. A 26-year-old woman with a family history of thrombophlebitis 3. A 37-year-old woman in her fourth pregnancy who is overweight 4. A 22-year-old woman with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis 2. A 26-year-old woman with a family history of thrombophlebitis The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1. "I should apply my antiembolism stockings after breakfast." 2. "I should avoid prolonged standing or sitting in one position." 3. "I should perform regularly scheduled exercise such as walking." 4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area." 1. "I should apply my antiembolism stockings after breakfast." The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction? 1. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider." 2. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis." 3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." 4. "I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings." 3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the health care provider. 2. Assess the client's vital signs. 3. Gently message the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution. 3. Gently message the uterine fundus. After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How would the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used. 1. An 8-hour post–vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr. 2. A 12-hour post–cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 3. A 48-hour post–cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener. 4. A 24-hour post–vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin). o 2. A 12-hour post–cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. o 4. A 24-hour post–vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin). Maternity 47 1. 1. An 8-hour post–vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr. o 3. 3. A 48-hour post–cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener. A client who is a gravida III, para III had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a level of 6 on pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used. 1. Prenatal vitamin 1 tablet orally daily 2. Docusate sodium (Colace) 100 mg orally 3. Ketorolac (Toradol) 30 mg by intravenous push over 3 minutes 4. Ampicillin sodium (Ampicillin) 1 g intravenous (IV) piggyback over 60 minutes o 3. Ketorolac (Toradol) 30 mg by intravenous push over 3 minutes o 4. Ampicillin sodium (Ampicillin) 1 g intravenous (IV) piggyback over 60 minutes o 2. Docusate sodium (Colace) 100 mg orally o 1. Prenatal vitamin 1 tablet orally daily A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider needs to be notified of the finding. 3. The client is experiencing normal lochia discharge. A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1. Pump both breasts and discard the milk. 2. Bottle-feed the infant on a temporary basis. 3. Breast-feed from the left breast and gently pump the right breast. 4. Stop breast-feeding from both breasts until this condition resolves. 3. Breast-feed from the left breast and gently pump the right breast. The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You will need a second vaccination at your 6-week postpartum visit." 2. "You should avoid sexual intercourse for 2 weeks after the administration of the vaccine." 3. "You should not become pregnant for 1 to 3 months after the administration of the vaccine." 4. "You should avoid heat and extreme temperature changes for a week after the administration of the vaccine." 3. "You should not become pregnant for 1 to 3 months after the administration of the vaccine." A nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis? 1. A primigravida with a normal spontaneous vaginal delivery 2. A gravida II who delivered vaginally following an 18-hour labor 3. A client experiencing an elective cesarean delivery at 38 weeks' gestation 4. An adolescent experiencing an emergency cesarean delivery for fetal distress 4. An adolescent experiencing an emergency cesarean delivery for fetal distress A nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching? 1. "I can begin abdominal exercises immediately." 2. "I need to notify the health care provider if I develop a fever." 3. "I can't lift anything heavier than my newborn for at least 2 weeks." 4. "I need to turn on my side and push up with my arms to get out of bed." 1. "I can begin abdominal exercises immediately." A nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation 2. Hemorrhage The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back, with her knees and legs flat and straight. 2. Ask the client to urinate and empty her bladder. The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs? 1. Hourly for the first 2 hours and then every 4 hours o 72. 73. 74. 75. 76. 77. 78. 79. 80. Maternity 48 81. 82. 83. 84. 85. 86. 87. 88. 89. 2. 30 minutes during the first hour and then every hour for the next 2 hours 3. 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours 4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day? 1. 100 2. 300 3. 500 4. 1000 3. 500 The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Arriving home and activities are increased 2. Breast-feeding The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase? 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client is self-focused and talks to others about labor." 4. "The client is self-focused and talks to others about labor." The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding? 1. Accepting the client's feelings 2. Acknowledging the client's apprehension 3. Assisting the client with giving the baths to allow her to become more at ease 4. Leaving the infant with the client so that she will be required to provide the care 4. Leaving the infant with the client so that she will be required to provide the care The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? 1. Apply a heating pad to breasts for comfort. 2. Wear a breast shield to correct nipple inversion. 3. Wear a supportive brassiere continuously for 72 hours. 4. Use the manual breast pump provided to express milk. 3. Wear a supportive brassiere continuously for 72 hours. The postpartum client who had a vaginal delivery of a healthy newborn has a prescription for a sitz bath. The nurse should tell the client that the sitz bath will provide which effect? 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Promote healing and provide comfort. 4. Promote healing and provide comfort. A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss? 1. A temperature of 100.4º F 2. An increased pulse rate of 88 to 102 beats/min 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/min 2. An increased pulse rate of 88 to 102 beats/min A nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours." 2. "I need to stop breast-feeding until this condition resolves." A nurse is monitoring the client for signs of postpartum depression. Which would indicate the need for further assessment related to this form of depression? 1. The client is caring for the infant in a loving manner. 2. The client demonstrates an interest in the surroundings. 3. The client constantly complains of tiredness and fatigue. 4. The client looks forward to visits from the father of the newborn. 3. The client constantly complains of tiredness and fatigue. Maternity 49 90. 91. 92. 93. 94. 95. The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis? 1. Afterpains 2. Increased estrogen levels 3. Increased progesterone levels 4. Retained placental fragments from delivery 4. Retained placental fragments from delivery The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should plan to take which action first? 1. Massage the uterus until firm. 2. Take the client's blood pressure. 3. Ask the client about the presence of pain. 4. Recheck the amount of drainage on the peripad. 1. Massage the uterus until firm. When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? 1. Offer only one breast at each feeding. 2. Massage distended areas as the infant nurses. 3. Cleanse nipples with a mild antibacterial soap before and after infant feedings. 4. Express and discard milk from the affected breast at the first signs of mastitis. 2. Massage distended areas as the infant nurses. Which instructions should a nurse provide to a client following delivery regarding care of the episiotomy site to prevent infection? Select all that apply. 1. Report a foul-smelling discharge. 2. Take a warm sitz baths three times a day. 3. Change the perineum pads three times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation. o 1. Report a foul-smelling discharge. o 2. Take a warm sitz baths three times a day. o 4. Use warm water to rinse the perineum after elimination. o 5. Wipe the perineum from front to back after voiding and defecation. A nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply. 1. Wear a supportive bra between feedings. 2. Avoid breast-feeding during the time of breast engorgement. 3. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. 4. Apply moist heat to both breasts for about 20 minutes before a feeding. 5. Massage the breasts gently during a feeding, from the outer areas to the nipples. o 1. Wear a supportive bra between feedings. o 3. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. o 4. Apply moist heat to both breasts for about 20 minutes before a feeding. o 5. Massage the breasts gently during a feeding, from the outer areas to the nipples. On the second postpartum day, a client complains of burning, urgency, and frequency of urination. A urinalysis is obtained, and the results indicate the presence of a urinary tract infection. Which measures should the nurse instruct the client to take regarding the prevention and treatment of the infection? Select all that apply. 1. Urinate frequently throughout the day. 2. Wipe the perineal area from front to back after urinating. 3. Fluid intake should be increased to at least 3000 mL/day. 4. Prescribed medication must be taken until it is completed. 5. Foods and fluids that will increase urine alkalinity should be consumed. o 1. Urinate frequently throughout the day. o 2. Wipe the perineal area from front to back after urinating. o 3. Fluid intake should be increased to at least 3000 mL/day. o 4. Prescribed medication must be taken until it is completed.