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Pt has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? |
BUN 25 mg/dL |
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Family planning for a pt. with a new prescription for a diaphragm. Which of the following statements should be included? |
"You should leave the diaphragm in place for at least 6 hrs after intercourse." |
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Reviewing the medical records of a pt. who is postpartum and has preeclampsia. Which lab results should be reported to the MD? |
Platelets 50,000/mm3 |
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A nurse is teaching a pt. about Rho(D) immune globulin. Which statement by the pt. indicates understanding? |
"I will need this medication if I have an amniocentesis" |
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A nurse is assessing a pt. who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? |
Swelling of the face |
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Teaching a pt. who is pregnant about managing N/V. Which of the following instructions should the nurse include in the teaching? |
"Eat high-carbohydrate foods." |
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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? |
Remove all clothing from the newborn except the diaper. |
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Caring for a pt. and her partner who have experienced a fetal death. Which action should be taken? |
Take photos of the newborn to give to the parents. |
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Pt is 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Appropriate action to take? |
Have the client change positions. |
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Assessing a pt. who gave birth vaginally 12 hrs ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? |
Assist the client to empty her bladder. |
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A nurse is performing a routine assessment on a pt. who is at 18 weeks of gestation. Which of the following findings should be expected? |
FHR 152/min |
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A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? |
Dry the newborn |
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A nurse is teaching a new mother about steps the nurses will take to promote the security and safety of the newborn. Which of the following statements should the nurse make? |
"Staff members who take care of your baby will be wearing a photo identification badge." |
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A nurse is assesing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? |
Vomiting |
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A nurse is reviewing the lab report of a pt. who is 24 hrs postpartum following a vaginal delivery. Which of the following lab results should the nurse identify as an indicator of a postpartum infection? |
Erythrocyte sedimentation rate (ESR) 26 mm/hr |
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A nurse in an antepartal 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 findings should the nurse report to the provider? |
Fundal height measurement |
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A nurse is caring for a pt. following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? |
Leakage of fluid from the vagina. |
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A nurse is caring for a pt. who is in active labor and has had no cervical change in the last 4 hrs. Which of the following statements should the nurse make? |
"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." |
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A nurse is providing discharge teaching to a pt. who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching? |
"You should get a 2-hr oral glucose tolerance test in 6-12 weeks." |
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A nurse is caring for a pt. 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? |
A reduction in respiratory distress in the newborn. |
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A nurse is teaching a pt. who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the pt. indicates an understanding? |
"I should take 600 micrograms of folic acid each day." |
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A nurse is teaching a pt. who is in preterm labor about terbutaline. Which of the following statements by the pt. indicates an understanding of the teaching? |
"I will have blood tests because my potassium might decrease." |
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A nurse is creating a plan of care for a pt. who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? |
Protect the client’s head and feet from cold air. |
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A nurse on a postpartum unit is caring for a pt. who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? |
Massage the client’s fundus |
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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 locate a pocket of fluid. |
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A nurse is demonstrating to a pt. how to bathe her 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 |
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A nurse is assessing a newborn 12 hrs after birth. Which of the following manifestations should the nurse report to the MD? |
Jaundice |
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A nurse is reviewing the medical record of a pt. who is one day postpartum. The pt. had a vaginal birth with a 4th-degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions? |
Bisacodyl rectal suppository daily as needed for constipation. |
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A nurse is calculating a pt’s expected date of birth using Naegele’s rule. The pt. tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the pt’s expected date of birth? |
September 3rd |
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A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain. |
Chin quivering |
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A nurse in a prenatal clinic is caring for a pt. who reports that her menstrual period is 2 weeks late. The pt. appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make. |
"You can miss your period for several other reasons. Describe your typical menstrual cycle" |
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A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (select all) |
Flaccid uterus Excessive vaginal bleeding |
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A nurse on the postpartum unit is caring for a pt. following a cesarean birth. Which of the following assessments is the nurse’s priority.? |
Amount of lochia |
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A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior? |
Lays the newborn across her lap and gently sways. |
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A nurse in a prenatal clinic is assessing a group of pts. Which of the following pts. should the nurse request the provider see first? |
A client who is at 11 weeks of gestation and reports abdominal cramping. |
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A nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10 mcg/mL. How may mL should the nurse administer? (nearest 10th) |
0.5 mL |
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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 |
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A nurse is caring for a pt. who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? |
Perform Leopold maneuvers |
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A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (select all) |
A heart rate of 154/min Respiratory rate 58/min Weight 2.6 kg (5 lbs 12 oz) |
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A pt. who is at 34 weeks of gestation asks the nurse how she will know when she is in labor and should go to the hospital. Which of the following responses should the nurse make? |
"You will notice blood-tinged discharge from your vagina." |
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A nurse is teaching a client who is at 35 weeks of gestation about clinical manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? |
Headache that is unrelieved by analgesia |
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A nurse in the antepartum clinic is assessing a pt’s adaption to pregnancy. The pt. states that she is, "happy one minute and crying the next." The nurse should interpret the pt’s statement as indication of which of the following? |
Emotional lability |
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A nurse is caring for a pt who is in labor and whose fetus is in the right occiput posterior position. The pt. is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? |
Apply sacral counterpressure. |
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A nurse is assessing a pt who is in labor and notes early decelerations on the fetal monitor. Which of the following findings should the nurse identify as a possible cause of the early decelerations? |
Fetal head compression |
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A staff nurse on an obstetric unit is caring for a pt. who is scheduled for an induced abortion. The staff nurse informs the nurse manager that she has a moral issue withe the pt’s decision. Which of the following actions should the nurse manager take? |
Reassign the client to another staff nurse |
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A nurse is planning care for a pt who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? |
Temperature |
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A nurse is teaching a pt. who is at 8 weeks of gestation about exercise. Which of the following instructions should the nurse include in the teaching? |
"You should exercise for 30 mins each day." |
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A nurse is caring for a pt. becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? |
Determine respiratory function. |
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A nurse is caring for a pt who is pregnant and is at the end of her 1st trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT) ? |
Just above the symphysis pubis |
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A charge nurse on a L&D unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the 1st step of Leopold maneuvers. |
The nurse palpates the pt’s abdomen with her palms to determine which fetal part is in the uterine fundus. |
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A nurse is planning discharge for a pt. who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for the lactation suppression? |
Apply cabbage leaves to the breasts. |
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A nurse is caring for a pt. who is at 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 |
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A nurse is caring for a pt who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the pt having a seizure. After turning the pt’s head to one side, which of the following actions should the nurse take next? |
Administer O2 via a nonrebreather mask |
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A nurse is planning care for a pt. who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? |
Instruct the client to press the provided button each time fetal movement is detected. |
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A nurse is providing teaching about comfort measures to a pt. who is breastfeeding and is experiencing engorgement. Which of the following nonpharmacological measures should the nurse include in the teaching? |
"You should use cold compresses after each feeding." |
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A nurse is caring for a prenatal pt who has parvovirus B19 (5th disease). Which of the following actions should the nurse take? |
Schedule an ultrasound examination. |
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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? |
"Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen." |
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A nurse on an antepartum unit is caring for 4 pts. Which of the following pts. should the nurse identify as the priority? |
A client who is at 34 weeks of gestation and reports epigastric pain. |
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A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching? |
"You can share your room with your baby for the next few weeks." |
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A nurse is caring for a postpartum pt who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? |
Maintain the client on best rest. |
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