Exam Review
- A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering?Select all that apply:(SATA)A)Antibiotic ointment to both eyesB)Hepatitis B immunizationC)Lidocaine gel to the umbilical stumpD)Haemophilus influenzae type b immunizationE)Vitamin K injection
- A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)(SATA)A)Vernix in the folds and creasesB)Abundant lanugoC)Positive Moro reflexD)Cracked peeling skinE)Short soft fingernails
- A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?A)Accidental lacerationsB)Respiratory distressC)HypothermiaD)Acrocyanosis
- A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?A)Cocaine useB)Blunt force traumaC)HypertensionD)Cigarette smoking
Exam Review
- A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?A)Inwardly turned foot on the affected sideB)Absent plantar reflexesC)Lengthened thigh on the affected sideD)Asymmetric thigh folds
- A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?A)“The cause might be too short or infrequent feedings.”B)“It is due to the newborn’s loss of the influence of the maternal hormones.”C)“This might be related to your baby having 3 stools a day.”D)“You might want to offer water supplements between feedings.”
- A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?A)DyspneaB)HeadachesC)NervousnessD)Tremors
- A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?A)5B)6C)7D)8E)9
Exam Review
- A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?A)Administer oxygen by non-rebreather mask at 5 L/minB)Obtain laboratory study of prothrombin and partial thromboplastin timeC)Methylergonovine 0.2 mg IM nowD)Insert an indwelling urinary catheter
- A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?A)Rapid decline in human chorionic gonadotropin (hCG) levelsB)Irregular fetal heart rateC)Excessive uterine enlargementD)Profuse, clear vaginal discharge
- 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.
- A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SGA)Observe for meconium in respiratory secretions.B)Monitor for hyperthermia.C)Identify manifestations of anemia.D)Monitor for hyperglycemia.
Exam Review
- A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?A)A client who is experiencing preterm labor at 26 weeks of gestation.B)A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation.C)A client who has a post-term pregnancy at 42 weeks of gestation.D)A client who is experiencing fetal death at 32 weeks of gestation.
- A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?A)Cocaine use.B)Blunt force trauma.C)Hypertension.D)Cigarette smoking.
- A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?A)“There is no need to worry about that. Most forms of hearing loss are not inherited.”B)“We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”C)“The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”D)“Look at how she looks at you when you speak. That’s a good sign.”
- A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?A)Prepare the newborn for transport to the NICU.B)Call the provider to further assess the newborn.C)Ask another nurse to verify the heart rate.D)Document this as an expected finding.
Exam Review
- A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?A)48/minB)22/minC)100/minD)110/min
- An 8-pound 15-ounce baby born at 35 weeks’ gestation would be described using which terminology? Select all that apply.A)Small for gestational ageB)TermC)PretermD)Average for gestational ageE)Post term
- A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?A)Place a finger at the base of the newborn’s toes.B)Turn the newborn’s head quickly to one side.C)Hold the newborn vertically allowing one foot to touch the table surface.D)Perform a sharp hand clap near the infant.
- 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 can push the baby to the room in a wheeled bassinet.B)If you show me your photo identification, you can take the infant.C)Have the mother ring, and I will take the baby to the room.D)You may carry your grandchild to the room.
Exam Review
- A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 97.6°F. Which of the following is the priority nursing action?A)Witness the signature for informed consent for surgery.B)Initiate IV access.C)Insert an indwelling urinary catheter.D)Prepare the abdominal and perineal areas.
- A nurse is caring for a client who is 1 hour postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?A)Notify the client’s provider.B)Increase the frequency of fundal massage.C)Encourage the client to empty her bladder.D)Document the findings and continue to monitor the client.
- A nurse is monitoring a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are full and warm to palpation. Which of the following interpretations of these findings should the nurse make?A)Additional interventions not indicated at this time.B)Application of a heating pad to the breasts is indicated.C)The client should be advised to remove her nursing bra.D)The client is exhibiting early indications of mastitis.
- A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?A)PreeclampsiaB)Puerperal infectionC)Anaphylactoid syndrome of pregnancyD)Disseminated intravascular coagulation