Nurse is performing a newborn assessment, which of the following should the nurse identify as
a sign of spina bifida occulta?
Tuft of hair.
A nurse is assessing a client that is 12-hour post-partum, the client’s fundu
...
Nurse is performing a newborn assessment, which of the following should the nurse identify as
a sign of spina bifida occulta?
Tuft of hair.
A nurse is assessing a client that is 12-hour post-partum, the client’s fundus is 2 fingerbreadths
above the umbilicus, deviated to the right of midline, and less firm than previously noted.
Which action should the nurse take?
Assist the client to the restroom to void.
A nurse isteaching a client who is 36 weeks gestation and has a prescription for a non-stress
test. Which of the following statements should the nurse include in her teaching?
You will be offered orange juice and a snack during your test.
A nurse is admitting a client to the labor and delivery unit, when the client states, “My water
just broke.” What is the nurses first action of priority?
Monitor fetal heart rate.
Nurse is developing an educational program for adolescents about nutrition during the third
trimester of pregnancy. Which of the following statements should the nurse include in the
program?
Consume three to fourservings of dairy each day.
Nurse is assessing a client that is 38 weeks gestation during a weekly prenatal visit, which of the
following findings should the nurse report to the doctor?
Weight gain of 2.2 kg (4.8 pounds)
The nurse is providing discharge teaching to the parents of a newborn about using a car seat
properly. Which of the following instructions should the nurse include?
Position the car seat rear facing, in the back seat of the vehicle.
A nurse is preparing to collect a blood specimen from a newborn via heel stick, which of the
following techniques should the nurse use to help minimize the pain?
Place the newborn skin to skin on the mother’s chest.
A nurse is developing a plan for a client who has preeclampsia, and is receiving magnesium
sulfate via continuous IV infusion. Which of the following interventions should the nurse include
in the plan?
Monitor the FHR continuously.
Nurse is caring for a client in labor who is experiencing increased rectal pressure, She is
experiencing contraction that are 2-3 minutes apart, each lasting 80-90 seconds, and a vaginal
examination reveals that her cervix is dilated to 9cm, the nurse should identify that the client is
in which phase of labor?
Transition
A nurse is performing a vaginal exam on a client that reports severe pressure and pain in the
lower back. The nurse notes that the fetal head is in posterior position, the nurse should
identify that which of the following is the best non-pharmacological to perform to relieve the
client’s discomfort?
Counter-Pressure
A nurse is caring for a client who is at 24 weeks gestation and reports daily, mild headaches.
Which of the following should the nurse include in the instructions for the plan of care?
Recommend that the client perform consciousrelaxation techniques daily.
A nurse is teaching a new mom how to bulb syringe to suction her newborn’s secretions, Which
of the following instructions should the nurse include in her teaching?
Stop suctioning when the newborn’s cry sounds clear. (always suction mouth before nose, nose
only if you must)
A nurse is assessing a newborn who is 12 hours old, which of the following clinical
manifestations requires intervention by the nurse?
Substernal chest retractions while sleeping
A nurse is teaching a client about effective breast feeding who is 3 days postpartum, which of
the following information should the nurse include?
Newborn should appear content after each feeding.
Nurse is caring for a client that had uterine hypotonicity and is experiencing post-partum
hemorrhage, which of the following actions is the nurse’s priority?
Massage the client’sfundus.
Nurse is teaching a client who is 24 weeks gestation regarding a 1-hour glucose tolerance test,
which of the following statements should the nurse include in her teaching?
Blood glucose between 130 and 140 is considered a positive screening result.
Nurse is teaching a client who has pre-gestational type 1 diabetes about management during
pregnancy, which of the following statements made by the client, indicates an understanding of
the teaching?
I will continue taking my insulin if I experience nausea and vomiting.
Nurse is assessing late preterm newborn, which of the following manifestation is an indication
of hypoglycemia?
Respiratory distress
Nurse is teaching a group about newborn safety, which of the following statements by a pair is
indicated an understanding of the statement.
I will dress my baby in flame retardant clothing.
Nurse is assessing a client who is in active labor and notes early deceleration in the FHR on the
monitor, the client is at 39 weeks gestation, and is receiving a continuous IV infusion of oxytocin.
Which of the following actions should the nurse take?
Continue monitoring the client.
Nurse is assessing fetal heart tones on a client who is pregnant. The nurse has noted that the
fetal position is left occipital anterior. To which of the following areas of the abdomen should
the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal
heart rate?
Left lower quadrant.
Nurse is assessing a client that received Carboprost for post-partum hemorrhage, which of the
following is an adverse effect of this medication?
Hypertension.
Nurse is assessing a client who is postpartum and has ITP (isiopathic thrombocytopenia
purpura). Which of the following findings should the nurse expect?
Decreased platelet count.
Nurse is performing a vaginal exam for a client who is in active labor and reports back pain,
nurse determines that the client is 8cm dilated, 100% effaced, and -2 station, the fetusis in the
occiput posterior position, Which of the following actions should the nurse take?
Assist the client to the hands and knees position.
Nurse is caring for a client that is at 22 weeks gestation, she reports concern about the blotchy
hyperpigmentation on her forehead. Which of the following actions should the nurse take?
Explain to the client that this is a normal occurrence.
A nurse in a family planning clinic for a client who request oral contraceptives, which of the
following findingsin the client’s history should the nurse recognize as a contraindication to oral
contraceptives?
Cholecystitis, hypertension, migraine headaches
Nurse is caring for a client who is at 40 weeks gestation and is in early labor. The client has a
platelet count of 75,000/mm^3 and isrequesting pain relief. Which of the following treatment
modalities should the nurse anticipate?
Attention-focusing
Nurse is caring for a client that has recently experience perinatal death, which of the following
statements should the nurse make to the client?
I am sad for you.
Nurse is assessing a full-term newborn 15 minutes after birth, which of the following findings
requires intervention by the nurse?
Respiratory rate of 18/min (normal respiratory rate is 30-60)
Nurse is assessing four newborns, which of the following should the nurse report to the
provider?
Newborn that is 18 hours old with a temperature of 37.7 (normal is 36.5-37.5)
Nurse is providing discharge teaching to a client that had cesarean birth 3 days ago, which of the
following instructions should the nurse include?
You can still become pregnant if you are breastfeeding.
Nurse is providing discharge teaching to parents whose newborn has just had a circumcision,
which of the following instructions should the nurse include?
Apply slight pressure with a sterile gauze pad for mild bleeding.
Nurse is providing discharge teaching to a client who is postpartum, for which clinical
manifestation should the nurse tell the client to monitor and report to the provider?
Unilateral breast pain.
Nurse is caring for a newborn that wastransferred 30 minutes after delivery. Which of the
following actions should the nurse take first?
Verify the newbornsidentification.
Nurse is preparing to administer magnesium sulfate at 2g/hr IV, available 20g in 50mL of D5W,
how many mL per hour?
50
The nurse is speaking with a client who is trying to make a decision about uterine tube
occlusion. The client asks, “what effects
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