Exam Review
- What would the nurse document after assessing a neonate born at 38 weeks' gestation who weighs 8 lb 13.1 oz (4,017 g)?A)Appropriate for gestational age, term.B)Large for gestational age, term.C)Large for gestational age, preterm.D)Appropriate for gestational age, preterm.
- A postpartum client is being treated with subcutaneous heparin for deep vein thrombosis of the left calf. Which client assessment is of most concern to the nurse?A)Presence of varicose veins.B)Dyspnea when breastfeeding.C)Pulse of 92 beats/min.D)Blood pressure of 136/88 mm Hg.
- The nurse reviews results of a 28 week fetal ultrasound that reveals a small for gestational age fetus and a low implanted placenta. The nurse will plan teaching for which pregnancy complication?A)Placental abruption.B)Placenta accreta.C)Preterm labor.D)Placenta previa.
- A pregnant client is receiving magnesium sulfate to prevent eclampsia via a continuous intravenous infusion. Hourly assessments are recorded. Which assessment findings lead the nurse to stop the infusion immediately? Select all that apply.(SATA)A)Client is alert and oriented × 4.B)Absent deep tendon reflexes (DTR).C)Serum magnesium value of 6 mg/dL.D)Urine output of 10 mL/hr.E)Glasgow Coma Scale (GCS) of 10.F)Respiratory rate of 10 breaths per minute.
Exam Review
- The nurse is teaching a group of new mothers regarding the benefits of breastfeeding. Which factor would have a significant effect on the success of breastfeeding?A)Distribution of erectile tissue in the nipples.B)Amount of milk products consumed during pregnancy.C)Viewpoint of the client's family towards breastfeeding.D)Age of the client at the time of delivery.
- The nurse and student are discussing clients who are laboring on the unit. Which clients would the nurse encourage to attempt a vaginal birth after having a cesarean section? Select all that apply.(SATA)A)A client who had rupture of membranes 26 hours ago.B)A client with a current separation of symphysis pubis.C)A client who had a cesarean section because of placenta previa.D)A client who had a cesarean section because of a breech presentation.E)A client who was positive for Group B streptococcal infection.F)A client who has a gynecoid shaped pelvis.
- The nurse and student are discussing clients who are laboring on the unit. Which clients would the nurse encourage to attempt a vaginal birth after having a cesarean section? Select all that apply.(SATA)A)A client who had rupture of membranes 26 hours ago.B)A client with a current separation of symphysis pubis.C)A client who had a cesarean section because of placenta previa.D)A client who had a cesarean section because of a breech presentation.E)A client who was positive for Group B streptococcal infection.F)A client who has a gynecoid shaped pelvis.G)A client with a traditional cesarean incision.
- After an emergency cesarean birth, the client tells the nurse that she was hoping for a natural childbirth but is glad that she and her baby are healthy. Which postpartum phase of adjustment does this statement reflect?A)Taking-in.B)Taking-hold.C)Working-through.D)Letting-go. . .
Exam Review
- A nurse is conducting discharge teaching with a pregnant client at 32 weeks' gestation admitted to the facility with preterm labor that has been arrested. The nurse determines that the teaching was successful based on which client statement?A)It's safe for me to do any type of activity at home.B)I need to remain on strict bed rest when I go home.C)My contractions will be a lot stronger than the ones I have now when I go into labor.D)I need to do a fetal kick count each day while at home.
- The nurse is educating a client about postpartum complications. Which complication will be included for a primipara with a second-degree perineal laceration and repair?A)Difficulty voiding spontaneously.B)Delayed onset of milk production.C)Maladaptive bonding with the newborn.D)Posterior vaginal varicosities.
- The provider orders magnesium sulfate to treat a primigravida client's severe pre-eclampsia. The medication is available as 60 grams of magnesium sulfate in 1000 mL of lactated ringer's at a rate of 4 grams/hr. What is the starting rate of the infusion? Record numerical answers only. Round the answer to the nearest whole number.
- The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on the left breast, a temperature of 38.2°C, and malaise. The nurse notes a local area on the same breast to be red and warm to touch. The nurse calls the healthcare provider to report which suspected issue?A)Mastitis.B)Plugged milk duct.C)Unilateral engorgement.D)Breast yeast infection.
Exam Review
- The nurse is caring for a client in labor whose fetus is in an occiput posterior position. Which intervention would the nurse use to reduce this client's discomfort?A)Place the client in a prone position.B)Apply ice packs to the lower back.C)Massage the lower back.D)Place the client in the Trendelenburg position.
- The nurse is caring for a client with the following assessment data: Fetal Assessment: Experiencing early decelerations, Fetal heart rate of 140 beats/min in the right lower quadrant; Maternal Assessment: Presenting part floating. What is the correct interpretation of these findings?A)Amniotomy should be implemented.B)The mother is in the second stage of labor.C)The fetus is demonstrating signs of distress.D)The client needs to be immediately prepped for a Cesarean birth.
- The nurse is caring for a primigravida at 42 weeks' gestation with the following assessment data recorded in the patient's record: Cervix 2 cm dilated, Cervix 70A)Amniotomy should be implemented.B)The mother is in the second stage of labor.C)The fetus is demonstrating signs of distress.D)Cesarean birth is anticipated.
- A client had undergone suction curettage for the removal of a hydatidiform mole (gestational trophoblastic disease). What would the nurse emphasize when planning for the client's discharge?A)The reasons for postponing another pregnancy for at least three months.B)The necessity of at least six weeks of follow-up care.C)The risk factors for the development of another hydatidiform mole.D)The basis for chemotherapy if the human chorionic gonadotropin levels decrease.
Exam Review
- Which complication would the nurse consider for a client with a fetus in a breech presentation?A)Stronger contractions, indicating progression of labor.B)Nonreassuring fetal signs, indicating prolapse of the cord.C)Rapid dilation of the cervix, indicating precipitate labor.D)Cessation of contractions, indicating overstretching of the uterus.
- A pregnant client presents with painless bleeding caused by placenta previa at 37 weeks' gestation. Which assessment is the most important for the nurse to perform?A)Measurement of fundal height.B)Digital vaginal examination for dilation.C)Assessment of maternal temperature.D)Monitor fetal heart rate and contraction patterns.
- A pregnant client has a history of chronic hypertensive disease. Which medication would the nurse not expect to be prescribed for this client?A)Labetalol.B)Digoxin.C)Warfarin.D)Nitroglycerin.
- A pregnant client late in the second trimester comes to the emergency department with a report of painless, bright red vaginal bleeding. The client states, "It started all of a sudden and now it seems to have stopped.”. What action is the priority for this client on admission?A)Prepare the client for an immediate cesarean birth.B)Perform a vaginal examination.C)Ultrasound assessment.D)Assess uterine contractions by intrauterine pressure catheter (IUPC).
Exam Review
- The nurse is caring for a postpartum client with suspected uterine atony. Which interventions would the nurse initiate to improve the patient's status? Select all that apply.A)Increase intravenous fluid replacement.B)Insert an indwelling urinary catheter.C)Monitor deep tendon reflexes.D)Initiate a peri-pad count.E)Perform a fundal massage.F)Administer tocolytic therapy.
- A client with diabetes in the second trimester of pregnancy, notes that the usual dose of insulin to maintain blood glucose levels has been increasing over the last few weeks. What would the nurse explain to the client about insulin during pregnancy?A)Insulin resistance develops because of human placental lactogen hormone and other hormones.B)The fetus is using insulin to maintain adequate blood glucose levels in utero.C)An increase in circulating blood volume during pregnancy makes insulin less available.D)The change in diet causes an increased need for insulin to maintain normal blood glucose levels.
- During a home visit, the nurse learns that a new mother is experiencing breast engorgement. What would the nurse recommend to help alleviate this problem?A)Having her apply lanolin cream to each breast.B)Encouraging her to wear a firm-fitting bra.C)Decreasing her fluid intake to below 500 ml per 24 hours.D)Discontinuing breastfeeding for 24 hours.
- What is the priority nursing action when caring for a client who has had an amniotomy and the fetal heart rate immediately decreases from 140 to 80 beats/min?A)Administer oxygen.B)Increase the intravenous fluids.C)Inspecting the vagina.D)Placing the client in the knee-chest position.