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    Exam Review

    1. A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
      A)
      Increase the client's fluid intake.
      B)
      Prepare to administer oxytocic medication.
      C)
      Palpate the client's uterine fundus.
      D)
      Assist the client on a bedpan to urinate.
    2. A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
      A)
      Less than 2.5 cm of rubra lochia on perineal pad
      B)
      Client report of increased thirst
      C)
      Fundus palpable to right of midline
      D)
      Client report of frequent uterine contractions
    3. A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?
      A)
      Initiate early feeding.
      B)
      Suction excess mucus with a bulb syringe.
      C)
      Prepare for an exchange blood transfusion.
      D)
      Begin phototherapy.
    4. A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?
      A)
      Caput succedaneum
      B)
      Pilonidal dimple
      C)
      Cephalhematoma
      D)
      Molding
    Page 1 of 16

    Exam Review

    1. A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide?
      A)
      "There are so many variables that you'll have to ask your obstetrician."
      B)
      "The primary consideration is what type of incision was performed this time."
      C)
      "A repeat cesarean birth is safer for both you and your baby."
      D)
      "It's too soon for you to be worrying about this now."
    2. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?
      A)
      Place an identification bracelet.
      B)
      Administer eye prophylaxis.
      C)
      Administer vitamin K.
      D)
      Dry the skin.
    3. A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)
      (SATA)
      A)
      "I'll make sure his diaper is loose in the front."
      B)
      "I'll apply petroleum jelly to his penis with diaper changes."
      C)
      "I'll expect the plastic ring to fall off by itself within a week."
      D)
      "I'll call the doctor if I see any bleeding."
      E)
      "I'll wash his penis with warm water and mild soap each day."
    4. A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?
      A)
      "You may carry your grandchild to the room."
      B)
      "Have the mother call and I will take the baby to the room."
      C)
      "If you show me your photo identification, you can take the infant."
      D)
      "You can push the baby to the room in a wheeled bassinet."
    Page 2 of 16

    Exam Review

    1. A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?
      A)
      "I should place my baby's crib next to the heater to keep him warm during the winter."
      B)
      "I should pad the mattress in my baby's crib so that he will be more comfortable when he sleeps."
      C)
      "I should remove extra blankets from my baby's crib."
      D)
      "I will place my baby on his stomach when he is sleeping."
    2. A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?
      A)
      The client is immune to the rubella virus.
      B)
      The client requires a rubella vaccination at this time.
      C)
      The client requires a rubella immunization following delivery.
      D)
      The client is not experiencing a rubella infection at this time.
    3. A nurse is completing discharge instructions for a new mother and her newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make?
      A)
      "Your baby should wet 6 to 8 diapers per day."
      B)
      "Your baby should sleep at least 6 hours between feedings."
      C)
      "Your baby should burp after each feeding."
      D)
      "Your baby should have a wake cycle of 30 to 60 minutes after each feeding."
    4. A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
      A)
      Dorsogluteal
      B)
      Vastus lateralis
      C)
      Deltoid
      D)
      Ventrogluteal
    Page 3 of 16

    Exam Review

    1. A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
      A)
      This is a cephalohematoma which can occur spontaneously.
      B)
      A caput succedaneum will subside in a few days.
      C)
      Mongolian spots can be found on the skin of many newborns.
      D)
      This is a telangiectatic nevus and no treatment is needed.
    2. A nurse is caring for a client who is postpartum and has a prescription for Rho (D) Immunoglobulin. The nurse should verify which of the following prior to administration?
      A)
      Client is Rh negative and the newborn is Rh positive.
      B)
      Client is Rh positive and the newborn is Rh negative.
      C)
      Client is Rh positive and the newborn is Rh positive.
      D)
      Client is Rh negative and the newborn is Rh negative.
    3. A nurse is providing teaching about the Dietary Approaches to Stop Hypertension (DASH) diet to a client who has hypertension. Which of the following instructions should the nurse include?
      A)
      Consume ten percent of total calories from saturated fat.
      B)
      Consume foods that are high in calcium.
      C)
      Increase intake of refined carbohydrates.
      D)
      Limit sodium intake to 3,200 milligrams per day.
    4. A nurse is planning care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?
      A)
      Offer the client a selection of beverages at each meal.
      B)
      Inform the client that a weight gain of 2.3 kg (5 lb) per week is expected.
      C)
      Arrange for someone to remain with the client for 30 min after meals.
      D)
      Encourage the client to participate in developing dietary goals.
    Page 4 of 16

    Exam Review

    1. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about recognizing hyperglycemia. Which of the following manifestations should the nurse include in the teaching?
      A)
      Anxiety
      B)
      Hyperventilation
      C)
      Cool skin
      D)
      Metallic taste
    2. A nurse is teaching a client who reports wanting to lose weight about behavioral modifications. Which of the following statements should the nurse include in the teaching?
      A)
      "Set your weight loss goal to 2.5 pounds per week."
      B)
      "Make sure to drink water with our meals."
      C)
      "Meal replacement shakes can cause weight gain."
      D)
      "Your biggest meal of the day should be breakfast."
    3. A nurse is reviewing the laboratory results for a client who started a weight loss program 3 months ago. Which of the following findings is an indication that the program has been effective?
      A)
      Increased glycosylated hemoglobin
      B)
      Increased LDL
      C)
      Increased cholesterol
      D)
      Increased HDL
    4. A nurse is providing follow-up care with a client who participated in a class about improving bone health. Which of the following client statements should the nurse identify as an understanding of the teaching?
      A)
      "I have included fortified milk, fatty fish, and cheese into my diet each day."
      B)
      "I increased my intake of orange juice, lean meats, and egg whites."
      C)
      "I have been taking 500 micrograms per day of vitamin A supplement."
      D)
      "I take an 800-milligram calcium supplement with my breakfast every day."
    Page 5 of 16

    Exam Review

    1. A nurse is caring for a client who has a pressure injury and is assessing the client's dietary intake. Which of the following factors should the nurse identify as a barrier to wound healing?
      A)
      Decreased fat intake
      B)
      Decreased vitamin C intake
      C)
      Increased protein intake
      D)
      Increased caloric intake
    2. A nurse is caring for a client who follows a vegan diet. The nurse should identify that the client is at risk for which of the following deficiencies?
      A)
      Magnesium
      B)
      Vitamin C
      C)
      Vitamin D
      D)
      Folic acid
    3. A nurse is providing teaching about dietary modifications to a client who has cholecystitis. The nurse should include which of the following foods as appropriate for the client's diet?
      A)
      Blueberry muffins
      B)
      Graham crackers
      C)
      2% milk
      D)
      Ground beef
    4. A nurse is caring for a client who has a major burn injury and is receiving total parenteral nutrition. Which of the following laboratory tests is the priority for the nurse to use to confirm the client is receiving adequate nutrition?
      A)
      Magnesium
      B)
      Folic acid
      C)
      Prealbumin
      D)
      Transferrin
    Page 6 of 16