A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
Reports increased urinary output
Diaphoresis
Reports blurred vi
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A nurse is assessing a client who has gestational diabetes and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
Reports increased urinary output
Diaphoresis
Reports blurred vision
Shallow respirations
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Administer penicillin G 2.4 million units IM to the client
Instruct the client to schedule an annual pelvic examination
Tell the client she will start medication for HIV immediately after delivery
Report the client’s condition to the local health department
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
Depression
Polyuria
Hypotension
Urticaria
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
“I can administer oxytocin 4 hours after the insertion of the medication”
“You will need a full bladder prior to the insertion of the medication” - no need to empty bladder first
“Remain in a side-lying position for 15 minutes after the medication is inserted”
“An antacid will be given 20 minutes prior to the insertion of the medication”
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
Administer antiviral medication
Schedule an ultrasound examination
Administer Haemophilus influenza type b vaccine
Schedule an indirect Coombs’ test
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
Apply a cool back for 10 minutes to the heel prior to the puncture
Request a prescription for IM analgesic
Use a manual lace blade to pierce the skin
Place the newborn skin to skin on the mother’s chest
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?
Insert two gloved fingers into the vagina and apply upward pressure to the presenting part
Wrap the visible cord tightly with sterile, dry gauze
Apply oxygen to the client at 2 L/min via nasal cannula
Place the client in the lithotomy position and apply fundal pressure
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption? Which of the following laboratory tests should the nurse expect the provider to prescribe?
Kleihauer-Betke test
Progesterone serum level
Lecithin/sphingomyelin (L/S) ration
Maternal Alpha-fetoprotein (AFP)
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?
Abruptio placenta
Placenta previa
Preeclampsia
Maternal bradycardia
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?
2+ deep tendon reflex
Proteinuria of 200mg in a 24-hr specimen
Polyuria
Blurred vision
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family’s 7-year-old child in accepting the new family member?
Allow the sibling to hold the newborn during a bath - quizlet
Make sure the sibling kisses the newborn each night
Obtain a gift from the newborn to present to the sibling
Switch the sibling’s room with the nursery
A nurse is assessing a client who is receiving morphine via IV bolus following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer?
Fentanyl
Butorphanol
Naloxone
Meperidine
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
“I should increase my protein intake to 60 grams each day”
“I should drink 2 liters of water each day”
“I should increase my overall daily caloric intake by 300 calories”
“ I should take 600 micrograms of folic acid each day”
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
Acrocyanosis
Transient strabismus
Jaundice -quizlet
Caput succedaneum
A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior?
Lays the newborn across her lab and gently sways - quizlet
Places the newborn in the crib in a prone position
Offers the newborn a pacifier dipped in formula
Prepares a bottle of formula mixed with rice and cereal
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?
“obtain an informed consent prior to obtaining the specimen”
“collect at least 1 milliliter of urine for the test”
“ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen” – quizlet
“premature newborns may have false negative tests due to immature development of the liver enzymes”
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse’s priority?
Check the client’s capillary refill
Massage the client’s fundus
Insert an indwelling urinary catheter for the client
Prepare the client for a blood transfusion
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestation should the nurse expect? Select all that apply
Yellow sclera
Acrocyanosis
Posterior fontanel larger than the anterior fontanel.- no anterior bigger than posterior
Positive Babinski reflex
Two umbilical arteries visible
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?
Wipe the newborn’s eyes from the inner canthus outward
Wash the newborn’s neck by lifting the newborn’s chin
Cleanse the skin around the newborn’s umbilical cord stump
Wash the newborn’s legs and feet
Clean the newborn’s diaper area
A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?
Hypertension
Hypothermia
Constipation
Muscle weakness
A nurse is caring for a client who is 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?
Five the client orange juice
Elevate the client’s legs
Have the client change positions - quizlet
Establish IV access
A nurse is caring for a client who is 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
Determine progression of dilation and effacement
Perform leopolds maneuvers - quizlet
Complete a sterline speculum exam
Prepare a nitrazien paper test
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
A client who is at 11 weeks of gestation and reports abdominal cramping -quizlet
A client who is at 15 weeks of gestation and reports tingling and numbness in right hand
A client who is at 20 weeks of gestation and reports constipation for the past 4 days
A client who is 8 weeks of gestation and reports having three bloody noses in the past week
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?
Excessive bleeding
Oligohydramnios
Premature rupture of membranes -quizlet
Proteinuria
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
A newborn who is 26 hr old and has erythema toxicum on his face
A newborn who is 32 hr old and has not passed a meconium stool
A newborn who is 12 hr old and has pink-tinged urine
A newborn who is 18 hr old and has an axillary temperature of 37.7 C (99.9 F)
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?
Administer asprin for pain
Maintain the client on bed rest- quizlet
Massage the affected leg every 12 hours
Apply cold compresses to the affected calf
A nurse is providing discharge teaching to a client who has a cesarean birth 3 days ago. Which of the following instructions should the nurse include?
“you can resume sexual activity in 1 week”
“you won’t need to do kegel exercises since you had a cesarean”
“you can still become pregnant if you are breastfeeding” - quizlet
“you are safe to start adding sit-ups to your exercise routine in 2 weeks”
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect?
Heart rate 154/min
Axillary temperature 36
Respiratory rate 58/min
Length 43 cm
Weight 2,600 g (5 lb 12 oz)
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
Deep tendon reflexes 4+
Fundal height 14 cm
Urine protein 2+
FHR 152/min
A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider?
Hemoglobin 10g/dL
WBC count 10,000/mm3
Platelets 250,000/mm3
Fasting blood glucose 90 mg/dL
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Feed the newborn 1 oz of water every 4 hours
Apply lotion to the newborn’s skin three times per day
Remove all clothing from the newborn except the diaper - quizlet
Discontinue therapy if the newborn develops a rash
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse’s priority following the procedure?
Check the client’s temperature
Observe for uterine contractions
Administer Rh0(D) immune globulin
Monitor the FHR
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?
Fundal height 34 cm
Report of decreased fetal movement
Report of occasional ankle swelling
BP 110/80 mm Hg
A nurse is admitting a client to the labor and delivery unit when the clients states, “My water just broke.” Which of the following interventions is the nurse’s priority?
Perform nitrazine testing
Assess the fluid
Check cervical dilation
Begin FHR monitoring
A nurse is caring for a client who is a 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests?
Biophysical profile – quizlet
Amniocentesis
Cordocentesis
Kleihauer-Betke test
A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr?
50 mL/hr
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provder?
BUN 25 mg/dL
Serum creatinine 0.8 mg/dL
Urine output of 280 mL within 8 hr
Urine negative for ketones
A nurse is assessing a late preterm newborn. Which of the following manifestations in an indication of hypoglycemia?
Hypertonia
Increased feeding
Hyperthermia
Respiratory distress
A nurse in a provider’s office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?
Singleton pregnancy
BMI of 20
Maternal age 32 years
Pregestational diabetes mellitus - quizlet
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client’s medical record, which of the following should the nurse report to the provider?
1-hr glucose tolerance test 120
Hematocrit 34
Fundal height measurement 30
Fetal heart rate (FHR) 110
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Substernal retractions
Acrocyanosis
Overlapping suture lines
Head circumference 33 cm (13 in)
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client’s head to one side, which of the following actions should the nurse take immediately after the seizure?
Monitor the FHR
Assess uterine activity
Administer oxygen via a nonrebreather mask
Start a bolus of IV fluids
A nurse is providing teaching about nonpharmacological pain management to a client is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?
Cold cabbage leaves
Purified lanolin cream
A snug-fitting support bra
Breast shells
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?
Lochia serosa vaginal drainage
Vaginal pressure
Intermittent vaginal pain
Yellow exudate vaginal drainage
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil
Popliteal angle of 90 degrees
Creases over the entire foot sole
Raised areolas with 3 to 4 mm buds
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn. Which of the following client statements indicates an understanding of the teaching?
“my sister will be able to carry my baby from the nursery to my room when she arrives”
The nurse will match my wrist band to my baby’s crib card when they bring him to me”
“the person who comes to take my baby’s pictures will be wearing a photo identification badge”
“My baby doesn’t need to wear the electronic security bracelet when he’s in my room”
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?
Report of visual disturbances
Report of tingling of the fingers
Report of urinary frequency
Report of leg cramps
A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching.
“ I will not gain more than 15 to 20 pounds during my pregnancy”
“ I will likely need to use alternative positions for sexual intercourse”
“I’m glad I had a breast reduction years ago, so they will not enlarge with my pregnancy”
“I’m glad I have a light complexion and will not get any stretch marks”
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?
Decreased uterine contractions
An increase in the client’s hemoglobin levels
A reduction in respiratory distress in the newborn
Increased production of antibodies in the newborn
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity?
Calcium gluconate
Hydralazine
Medroxyprogesterone acetate
Methylergonovine
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects?
Client reports nausea
Urinary output of 40 mL/hr
Respiratory rate 10/min
Client reports feeling flushed
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the following oxytocin infusion and should be reported to the provider?
Late decelerations
Moderate variability of the FHR
Cessation of uterine dilation
Prolonged active phase of labor
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
“The test should take 10 to 15 minutes to complete”
“You will lay in a supine position throughout the test”
“You should not eat or drink for 2 hours before the test”
“You should press the handheld button when you feel your baby moving”
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect?
Bruising over the buttocks
Hard nodules on the roof of the mouth
Petechiae over the head
Bilateral periauricular papilomas
A nurse is transporting a newborn back to the patient’s room following a procedure. Which of the following actions should the nurse take?
Verify that the parent’s identification band matches the newborn’s identification band
Scan the newborn’s identification band to verify their identity
Check the newborn’s security tag number to ensure it matches the newborn’s medical record
Match the newborn’s date and time of birth to the information in the parent’s medical record
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practice should the nurse include in the plan of care?
Protect the client’s head and feet from cold air
Bathe the client within 12 hr following birth
Ambulate the client within 24 hr following birth
Offer the client a glass of cold milk with her first meal
A change nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopolds maneuvers?
Picture with the hands on the babys butt
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
Monitor the client’s blood pressure every hour
Restrict the total hourly intake of 200 mL
Monitor the FHR continuously
Administer protamine sulfate for manifestations of toxicity
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?
Blood pressure 136/88 mm Hg
Report insomnia
Weight gain of 2.2 kg (4.8 lb)
Report of Braxton Hicks contractions
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
To estimate the fetal weight
To locate a pocket of fluid
To determine multiparity
To prescreen for fetal anomalies
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