Which nursing diagnosis has the highest priority for a postpartum client who has developed disseminated intravascular coagulopathy (DIC) A. Anticipating Grieving B. High risk for infection C. Risk for deficient fluid vol
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Which nursing diagnosis has the highest priority for a postpartum client who has developed disseminated intravascular coagulopathy (DIC) A. Anticipating Grieving B. High risk for infection C. Risk for deficient fluid volume D. Spiritual Distress 2. A newly delivered 9lb 4 ounce baby boy exhibits of respiratory distress. The nurse obtains a blood sample to assess the infant for which of the following? A. Hypoglycemia B. Pneumonia C. Sepsis D. Hyperbilirubinemia 3. The nurse explains to the client in premature that betamethesome is given to: A. Stop uterine contractions B. Prevent infection C. Assist with fetal lung maturity D. Prevent cervical dilation 4. The onset of late decelerations on the fetal monitor should lead the nurse to suspect which condition? A. Head compression B. Cord compression C. Close uterine contractions D. Decreased uteroplacental blood flow 5. The nurse receives a call for postpartum who delivered 7 days ago. The client report having increase bleeding. The nurse suspect late postpartum hemorrhage, which is most commonly caused by which of the following? A. Uterine Atony B. Disseminated intravascular coagulopathy C. Retained Placental fragments D. Lacerations 6. Which of the following clients have the greatest risk for developing postpartum hemorrhage? A. A client who gave birth to a boy weighing 5lb 2 ounces B. A 17 year old client C. A client who is diagnosed with endometritis D. A client experimenting uterine atony 7. A client is ordered heparin 2,500 units SQQD for treatment of thrombophlebitis. On hand is Heparin 5,000 units/ml. How many millimeters will the nurse administer? A. 0.5 ml B. 1ml C. 2ml D. 2.5 ml 8. Which nursing intervention is appropriate in the care of an infant with respiratory distress syndrome? A. Perform a complete gestational age assessment B. Perform chest physiotherapy C. Suction mcconium from airway as needed D. Maintain a neutral thermal environment this answer is also correct 9. A client who baby is jaundice ask, “How will those lights help my baby? Which statement by the nurse is accurate? A. “The lights prevent more bilirubin from being released into your baby’s body” B. “Exposing the skin to the air helps get rid ofjaundice” C. “The lights help convert bilirubin to a form that the baby can get rid of” D. “The lights release a substance that attacks the bilirubin in the body and destroys it” 10. While feeding an infant the nurse notes white patches over the germsand buccal cavity, the nurse’s next best intervention would be” A. Document findings as normal B. Further evaluate to no yeast infection C. Prepare to give vitamin K D. Assess maternal history for Herpes 11. The nurse is evaluating a client receiving magnesium sulfate. What clinical manifestations indicate that the medication is working? A. Blood pressure 128/76 B. Serum magnesium level reaches 2.2 MEQ/L C. Contractions are steady at a frequency of every four minutes D. There is an absence of seizure activity 12. A client in active labor is receiving an epidural, while it is being administered. Which of the following should the nurse consider as the highest priority? A. Checking uterine contractions for an increase in strength B. Positioning the mother flat in be, preventing spinal headache C. Telling the mother that she will have an increase in urinary output D. Monitoring mother’s blood pressure for hypotension 13. The post cesarean section client has the following for breakfast ½ grapefruit 4 ounces prune juice 1 pint cottage cheese ½ pint of skim milk 1 ounce of apple juice 2 ounce container of jello What is the total intake to be included on the intake and output sheet? A. 350 ml B. 450 ml C. 550 ml D. 650 ml 14. What are the expected findings of a second day postpartum client? A. Yellowish white lochia and fundus three fingerbreadths below the umbilicus B. Red lochia with small clots and fundus midline and two fingerbreadths below the umbilicus C. Pinkish brown lochia fundus midline and four fingerbreadths below the umbilicus D. A large amount of bright red lochia with large clots and fundus midline at the umbilicus 15. The postpartum client is being treated for a UTI. Determine the flow rate for the following IV being administered by the infusion pump, Ampicilin 1.5g in 50 ml, 0.9% NS over 30 minutes A. 75 ml/hr B. 133.3 ml/hr C. 150 ml/hr D. 100 ml/hr 16. A 15 year old female experiences a miscarriage at 12 weeks gestation. When she is informed about the miscarriage she begins to cry stating that she was upset about her pregnancy at first and now she is being punished for not her wanting her baby. Which of the following statements would be most therapeutic? A. “You are still young, you probably were not ready for a baby right now” B. “This must be so hard for you. I am here if you want to talk” C. “At least this happened early in your pregnancy before you felt your baby move” D. “There is a good reason why this happened, God knows best.” 17. A woman gave birth to twin girls, one of whom was stillborn. Which of the following nursing actions would be most helpful initially in supporting the woman as she copes with her loss? A. Remind her that she should be happy that one daughter survived and is healthy B. Have the client take pictures of the both babies C. Encourage the woman to hold the deceased twin in her arms to say good-bye D. Offer the opportunity for counseling to help her with her grief E. Inquire about the woman’s desire to hold the deceased twin 18. The nurse is reviewing a female client’s health care history prior to the planned cesarean section. The nurse notes that the Hematocrit is 30. Based on the observation, what action or change in the plan of care should be taken by the nurse, if any? A. Preoperative medications may need to be changed. B. No specific action is needed. C. The nurse may need to notify the surgeon of this low value. D. Preoperative vital signs will need to be taken with a greater frequency. 19. Infertility is defined as inability to conceive after months of unprotected intercourse with the same partner. A. 6 B. 12 C. 18 D. 24 20. A married woman presents to the clinic with complaints of grayish vaginal discharge with a “fishy”odor. Which of the following statements demonstrates that your teaching regarding bacterial vaginosis (BV) has been understood? Select all that apply. A. “I should avoid alcohol consumption during treatment with Flagyl” B. “It is not necessary to treat my partner.” C. “I should take scented bubble bath to get rid of the odor” D. “BV is a sexually transmitted disease” 21. The nurse is caring for a pregnant client who complains of new onset of aching, pulling, and stiffness to her lower back. Her pain sore is 5 out of 10 on the pain of the following is an appropriate working nursing diagnosis? A. Risk for dinse syndrome related to severe pain. B. Impaired physical inability related to numbness and weakness of the legs. C. Disturbed energy related to chronic pain as evidence by the pain of 5 out 10. D. Alteration in comfort, pain related to increase in the normal lumbosacral curvatureas evidence by numbness. 22. The nurse in the prenatal clinic assesses a 26 year old client at 13 weeks gestation. Which presumptive signs of pregnancy should the nurse anticipate? A. Hegar’s sign and quickening B. Ballouement and positive pregnancy test C. Chadwick’s sign and uterine shuffle D. Excessive fatigue and urinary frequency 23. The nurse in the prenatal clinic was planning care for a pregnant 15 year old client. The nurse knows that this adolescence is at greatest risk for which maternal complication? A. Postpartum hemorrhag e B. Hypoglycemia C. Cesarean birth D. Pre-eclampsia 24. The antepartum client tells the nurse her last period was May 18. The nurse uses Nagele’s rule to compute the client’s expected date of birth and tells the client that the correct date of birth will be: A. February 11 B. February 18 C. February 25 D. February 28 25. The nurse evaluation of a pregnant woman’s knowledge about urinary tract infection. The nurse recognizes that the patient understands the teaching when the patient states: Select all that apply A. “I will drink one quart of fluid weekly” B. “I have stopped using bubble baths and oils” C. “I have started wearing under panty with cotton crotch” D. “I try not to drink fluids after 5PM 26. On sterile speculum examination, the obstetrical care provider finds that the cervix is open with no products of conception seen outside the cervix. The anticipated plan of care for the patient would be based on the knowledge that this is which type of spontaneous abortion? A. Incomplete B. Inevitable C. Threatened D. Septic 27. After a patient gives birth, the nurse expects the patient’s oestrogen and progesterone levels will: A. Drop significantly B. Gradually return to normal C. Increase slightly D. Remain the same 28. Complications of circumcision include which of the following? Select all that apply A. Bradycardia. B. Urethral sternosis. C. Infection. D. Hypertonia. 29. The nurse who performs a vaginal examination to assess a woman’s progress in labor should: A. Perform an examination every two hours during the active phase of labor B. Perform the examination more frequently if vaginal bleeding is present C. Wear two clean gloves for each examination D. Discuss findings with the examination with the patient E. The nurse is not able to perform the vaginal exam . 35) The nurse is aware that at 12 weeks: a) Vernix is thick and severs as the body of the baby b) The baby can hear sounds outside of the womb c) Sex organs are visible via ultrasounds d) The baby is able to move. 36) Which of the following questions should be asked of a woman during a health assessment? (Select all that apply). a) Has anyone ever forced you to have sex? b) Are you sexually active? c) Are you ever afraid to go home? d) Does anyone you know ever hit you? e) Have you ever breastfed a child? 37) A patient is 38 weeks gestation is receiving Pitocin augmentation. The Pitocin is currently at 4mU/min. The patient has an external monitor and is in active labor. The nurse assesses the fetal heart rate (FHR) strips below. Which of the following should the nurse do first? Strip shows fetal bradycardia with late decelerations with contractions closely together and irregular. a) Prepare to administer terbutaline 0.25 mg subq times 1 dose b) Increase the Pitocin by 2mU/min c) Administer oxygen by nasal cannula at 2 litters d) Stop the Pitocin e) Check the patient, do a vaginal examination. 38) A woman has been diagnosed with pelvic inflammatory disease. Which of the following organism is the most likely causative agent? a) Herpes Virus b) Candida albicans c) Neisseria gonorrhea d) Trponema pallidum 39) During the development of the fetus the nurse is aware that the pregnant client should not be exposed to which of the following? (Select all that apply). a) Exercise b) MMR c) Tetanus Vaccine d) Tetracycline 40) The ability of the fetus to live outside the uterine environment is known as: a) Viability b) Lightening c) Quickening d) Adaptation 41) Ordered 20 unite/1ml of Pitocin in 500 cc of lactated Ringers. Start at 2 mu/minute. The rate on the pump should be set at: a) 2ml/hr b) 3ml/hr c) 4ml/hr d) 6ml/hr e) 12ml/hr 42) Fetal bradycardia is commonly associated with: a) Intra-amniotic infection b) Hypovolemia c) Maternal hypotension d) A and B e) B and C 43) Concerning factors in how the fetus moves through the birth canal, nurses should be aware that: a) The fetal attitude describes the angle at which the fetus exits the uterus b) Of the two primary fetal lies, the horizontal is where the long axis of the fetus is parallel with the long of the mother c) The normal attitude of the fetus is termed presentation d) The transverse lie is preferred for vaginal birth 44) A patient is 40 weeks gestation in active labor. The nurse observes the following strip of a patient with external fetal monitoring. The nurse interprets the strip as which of the following? a) Fetal tachycardia with effective contractions b) Variable decelerations with contractions every 2-5 minutes c) Early decelerations with contractions d) Fetal bradycardia with ineffective contractions every 2-3 minutes. e) Variable decelerations with mild to moderate contractions. 45) Adverse effects associated with epidural opioids may include which of the following? (Select all that apply) a) Infection b) Pruritus c) Tachycardia d) Delayed respiratory depression. 46) Review the following and identify the presentation, position and lie a) ROT, Longitudinal lie b) LOT, Transverse lie c) ROA, Longitudinal lie d) LOA, Transverse lie e) LOT, Longitudinal lie 47) The pregnant patient demonstrates understanding of the nurse’s instruction if she states that a positive sign of pregnancy is: a) Elevated HCG levels b) Palpation of the fetus c) Quickening of the fetus d) Ultrasound scanning of the fetus 48) Which of the following statement is false? a) It is important to maintain a healthy diet while you are pregnant b) Herbal preparations are natural and will not harm the developing fetus c) It is beneficial to continue your routine exercise d) During the first trimester an ultrasonography can be used to confirm pregnancy. 49) A patient is 38 weeks gestation is receiving Pitocin augmentation. The Pitocin is currently at 8mU/min and is on maintenance Lactated Ringers at 125ml/hr. the patient has an external fetal monitor and is in active labor. The nurse’s priority nursing action is to: (Select all that apply). a) Turn the patient to the lateral position b) Prepare for immediate cesarean delivery c) Increase rate of maintenance fluids d) Administer oxygen by face mask 10 litters e) Decrease the Pitocin 50) During a prenatal visit the nurse teaches the low-risk pregnant woman she should plan to return for her next prenatal appointment in: a) 1 week b) 2 weeks c) 3 weeks d) 4 weeks e) 5 weeks 51) Which of the following is the appropriate interpretation of the maneuvers by the fetus during the birthing process, also known as the cardinal movement, by the nurse? a) The seven critical movements must progress in a more or less orderly sequence. b) Asynclitism is sometimes achieved by means of leopold maneuver. c) The effect of forces determining the decent are modified by the shape of the woman’s pelvis and the size of the fetal head. d) At birth the baby is said to achieve “Restitution” that is the return of the C shape of the womb. 52) A woman who is 37 weeks comes for her routine prenatal visit with her husband. The husband complains that his wife is acting differently last week. She has begun to clean the house every day. How should the nurse respond? a) That is interesting. Have you noticed this behavior before? b) We are not sure why this happens, but it may be related to hormonal changes of pregnancy that is called nesting. It is normal c) There is nothing wrong, just enjoy the clean house d) The physical stress of pregnancy is hard. Your wife can speak to our social worker today. 53) The nurse is performing a pelvic exam on a laboring client and discovers a loop of cord in the vagina. What is the initial nursing action? a) Call the physician or nurse midwife b) Administer oxygen at 5l per minutes c) Place the client on side lying position d) Leave gloved finger in the vagina 54) The nurse is aware that an evaluation for preterm labor might be necessary if a pregnant patient who is at 28 weeks gestation reports: a) “ I feel quickening in the morning” b) “I fell like my baby is balling up frequently” c) “I have a slight mucousy discharge after intercourse” d) “I have a burning sensation when I defecate” e) “I have cramps in my legs after being on my feet at work” 55) Nursing care management of a client who is 33 weeks gestation in an acute facility with a diagnosis of preterm labor should include which of the following? a) Serial fetal heart rate tracing and centrally acting muscle relaxants b) Oral hydration, strict bed rest, and prostanglandin synthesizers c) Bed rest, sexual abstinence, and weekly uterine activity monitoring d) Tocolytic medication and weekly uterine activity monitoring. e) Hydration, bed rest, and daily uterine activity monitoring 56) In evaluating the effectiveness of Pitocin induction, the nurse would expect: a) Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart. b) The intensity of contraction to be at least 110 to 130 mm hg c) Labor to progress at least 2 centimeters per dilation. d) That at least 30 mU/min of oxytocin will be needed to achieve cervical dilation. 57) A primigravida has just delivered a health infant girl. The nurse is about to administer erythromycin ointment in the infant’s eyes when the mother asks, “what is that medication for” The nurse responds: a) It is an eye ointment to help your baby see better b) It is to protect your baby from contracting ophthalmic ulcerations c) It is given prophylactically to prevent eye infection d) It will protect your baby’s eyes drom drying out over the next few days 58) During the assessment of a client with a concealed abruptio placenta the nurse is aware that a possible complication is: a) Urinary tract infection and hemorrhage b) Uterine irritation and marked variability c) Vaginal hematomas and non-reassuring fetal heart rate d) Bleeding uterine contractions and fetal distress. e) Retained placental fragment and hyperstimulation. 59) The nurse is aware that a contraindication for conducting a contraction stress test is; a) Intrauterine growth restriction b) Diabetes mellitus c) Marginal abruptio placenta d) Pregnancy at 42 weeks gestation. 60) Which of the following is a highest priority for a client who is 4 hours with postpartum hemorrhage? a) Knowledge deficit related to lack of information about signs of postpartum hemorrhage b) Fatigue related to anemia from postpartum bleeding. c) Fluid volume deficit related to blood loss secondary to uterine atony d) Activity intolerance related to enforced bed rest to control postpartum bleeding. 61) A nurse reviewing a 24-hours-postpartum client. The admission hematocrit was 41%, and the current is 30%. What should be the initial nursing action in response to this report? a) Notify the lab for another blood drawn to verify accuracy of the report b) Report the lab values to the physician or midwife c) Administer 2 unites of typed and crossed matched blood d) Increase intravenous infusion rate 62) The Nurse has received new medication and treatment for a pregnant client who is 33 weeks pregnant. The client has a history of asthma. The client has been admitted for the treatment of asthma exacerbation. Which of the following medication ordered would be most concerning and warrant the nurse to call the physician? (Select all that apply) a) Terbutalin 0.25 mi CONTINUED......................DOWNLOAD FOR BEST REVISION TO BEST SCORES
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