At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?

A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?

The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?

A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother’s concerns?

Following an amniocentesis, a client verbalizes several concerns. Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mm Hg and her heart rate is 130 beats/minute. Which action should the nurse implement first?

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)

A new parent asks the nurse about an area of swelling on the baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond?

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse’s assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider (HCP) prescribes an oxytocin drip. Which data is most important for the nurse to monitor?

During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?

A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client’s contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?

A client who delivered vaginally 18 hours ago develops a slight fever. The client’s delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and she experienced a third-degree perineal laceration. The nurse should recognize which information poses the greatest risk for developing postpartum endometritis?

The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

What instructions should the nurse provide to a new mother regarding postpartum care and monitoring the newborn’s health?

The day shift nurse reviews the nurse’s notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge health teaching. For each teaching point, indicate whether it is Indicated (appropriate or necessary) or Contraindicated (could be harmful). Each box must have one option selected.

The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)

A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?

The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?