A patient with preeclampsia is on seizure precautions and recieving a maintenance dose of 2g of magnesium sulfate per hour the nurse observes that the patient is lethargic and has respirations of 6 breaths per minute what should the nurse do
stop the magnesium and prepare to administer calcium gluconate
A 22 year old multigravida mother is 15 weeks pregnant she has three children at home one male delivered at 37 weeks gestation and twins delivered at 36 weeks gestation she also has 2 abortions what would be her G-gravidity and P-parity
G-5 P-2
A 30 year old nulligravid female made an appointment to see the doctor about her health she wants to concieve and have a baby she wants to see the doctor before doing so all of the following can be included in a preconception teaching except
ideal time for conception and delivery
An emergency cesearen section has just been ordered because of category III FHR tracing the anesthesia provider asks the nurse to give the patient a bolus of lactated ringers solution before and during surgery what is the rationale for this action
to protect the patient in case she has excessive bleeding after delivery
A 34 year old first time mother is diagnosed with gestational diabetes mellitus at 20 weeks gestation the patient is in the doctors office and complains of tiredness dry mouth and drowsiness what nursing interventions would be appropriate at this time
check the glucose level and give the patient insulin as per MD order
An ectopic pregnancy can be devastating to the life of the female. Obstetric nurses must be aware of the possible sides of ectopic pregnancies. Identify the correct sites of ectopic pregnancy (SATA)
Ampular
isthmic
frimbral
A 16 year old primipara (first pregnancy) presents to the labor unit at term. The mother has not had any prenatal care. The nurse obtains orders for a complete prenatal panel,which includes a blood type and screen and a Coombs test. The test indicates that the patient has AB negative blood and a negative Coombs test result. What should the nurse
do
Wait until after delivery to determine whether the newborns blood type warrants Rho(D)IG administration to the patient.
A 25 years old mother is 20 weeks pregnant. The doctor orders a sonogram because he suspects the baby may have spina bifida. What of the following information is correct?(Select all that apply)
The Baby may need surgery to fix this condition
Deficiency of folic acid can lead to this condition
The condition is incomplete closure of the spine
A 44 year multigravida mother is in the 3rd stage of labor. The nurse is teaching a new nurse about the stages of labor. The nurse knows that the new nurse is CORRECT if she states which of the following:
The 3rd stage of labor ends after the placenta is delivered
A 25 year old mother delivered a baby boy at 39 weeks gestation. The nurse practitioner is assessing the maturation age of the baby. Which of the following characteristics may be least likely observed in a baby of the above gestation age?
Relaxed upper extremities
While newborns may need some degree of resuscitation in the extra uterine environment, the preterm neonate may require even more extensive assistance. Which of the following is the nurse aware of when caring for the preterm neonate? (Select all that apply)
Abnormal Respiratory Functions
Hyperbilirubnemia
Hypoglycemia
The doctor orders Iron 325 mg for a 24 year old patient at 20 weeks gestation. The nurse correctly gives the patient 1 tablet BID. How many mg of the patient gets in 24 hours?
650
A woman will be taking oral contraceptives using a 28 day pack. The nurse should advise this woman to protect against pregnancy by:
Taking one pill at the same time everyday
The physician has explained to the patient that her baby needs to be delivered by an emergency cesarean delivery. The patient is crying because she wanted to deliver her baby“naturally”. What is the most appropriate nursing action?
Tell the support person that this is a normal feeling and that the patient will get over it during the postpartum period.
A 23 year old female is diagnosed with chronic hypertension. The patient wants to know about chronic hypertension. Which of the following is the correct information about chronic hypertension?
Chronic Hypertension is identified before 20- weeks of gestation and blood pressure elevated beyond postpartum week
What considerations may affect a family’s decision on whether to circumcise their male newborn
family beliefs regarding hygiene, religious beliefs tradition, culture, and social norms
A 45 year old patient who is G1P0 has arrived for amniocentesis. She is extremely anxious about the procedure and the potential effects on her fetus, and she admits that she is afraid of needles. The practitioner describes a procedure and explains potential complications to her. Oral and written informed consent arc we confirmed. During the procedure what is the best thing for the nurse to do?
Provide support as needed to the patient and her support person.
The nurse is reviewing the external fetal monitor tracing of a patient who is undergoing an oxytocin stimulated contraction stress test. The nurse notes that the patient has had six uterine contractions within 10 minutes, each lasting about 90 seconds. The HR is 100 bpm and lady celebrations are associated with the last for uterine contractions. Which of the following interventions should the nurse do?
The nurse should perform intrauterine resuscitative measure to TB
A baby born at 36 weeks gestation phototherapy for hyperbilirubinemia. The mother wants to know what will happen to the baby while receiving this treatment. Which of the following information about the treatment of hyperbilirubinemia is incorrect?
The baby will be wrapped in a blanket to keep her warm
All babies need to be monitored after delivery. Which of the following babies need to be monitored for glucose extrauterine? (Select all that apply)
The neonate delivered at 34 weeks gestation with birth weight 2560 g.
The neonate delivered at 37 weeks with birth weight 2359 g.
The neonate to be delivered at 39 weeks gestation and shivering.
A laboring woman who is a gravida 2 , para 1 is being cared for in the family birth unit.Her cervix is currently 5cm and 100% effaced. The fetus is -2 station and cephalic in the left occiput anterior position. The patient calls the nurse to the room and reports a large gush of fluid with her most recent contraction. The nurse assesses that the patient memebrane are ruptured and that the amniotic fluid is green and watery. What is the most important nursing intervention at this time?
Assess the FHR to check for any change in the baseline of any abnormal patterns
A 24- year old female G2P1is in labor and delivery unit with ectopic pregnancy. The nurse knows numerous factors may increase the risk for ectopic pregnancy. What are some factors that may increase the risk for ectopic pregnancy?(select all that apply)
Failed tubal ligation
scaring of the fallopian tube
infection such as chlamydia
The nurse has received a report about a woman in labor. The woman's last vaginal examination was 10cm. 80% and -3. The nurse's interpretation of this assessment is that
The cervix is 10cm dilated , its 80%, and the presenting part is 3cm above the ischial spine.
A 20 year old mother is 32 weeks pregnant. She is diagnosed with Gestational hypertension. The nurse placed her on the external fetal monitor. After 10 minutes the fetal heartbeat remains at 140 beats per min without any changes. The nurse may use vibroacoustic stimulation.
to elicit acceleration in the fetal heart rate.
A 40 year old woman who is gravida 3, para 2, has received an epidural anesthetic for pain management during labor. Her cervix is 8cm dilated and 100% effaced. She rates her pain 8 on a scale of 0 to 10. She is able to talk through her contractions without grimacing and is dozing between contractions. She ask the nurse. “Why isn't my epidural working? I didn’t feel anything with my other babies.” What is the most likely reason for the patient question?
Previous birth experience may affect patient perception and expectation of the current labor process.
A multigravida female had a cesarean section yesterday. The doctor order percocet (acetaminophen and codeine) 2 tablets to be given every 4 hours as needed for pain scale of (numeric pain 0 to 10) numeric 6-10. What is the maximum number of tablets patients received in a 24 hour period?
12
The result of the lab drawn for Group B streptococcus (GBS) for women in a labor is positive. The woman wants to know about this infection. What information about GBS is correct?
Antibiotic will be administered before vagiinal delivery to prevent the neonate from getting infection
Subinvolution is the failure of the uterus to reduce to its normal size and condition after pregnancy. Which of the following can be used to treat such a diagnosis?
Dilation and Curettage to remove possible placenta retention
A nurse notices that a newborn who is 30 hours old has not yet passed a Meconium stool.what should the nurse do
Assess the newborns feeding patterns
A 29-year-old patient is 20 weeks pregnant. The patient states “my mother has a history of diabetic Mellitus For many years” the nurse knows that family history may be a risk factor for gestational diabetes mellitus. the patient was sent for a one hour oral glucose challenge test (GCT) the result is 123 MG/DL. What is the next appropriate action of the nurse?
Inform the patient that the result indicates normal glucose level
A 26-year-old female is 15 weeks pregnant for the first time. the doctor orders a sonogram to monitor the baby. the sonogram shows trisomy 18 (Edward syndrome) the mother wants to know about trisomy 18. which information about trisomy 18 is correct?
It is chromosomal condition that causes mental retardation in the baby
The nurse is teaching a group of pregnant mothers about the cycles of violence. during which phase of the cycle of violence does the batterer or becomes sorrowful and ask for forgiveness?
Honeymoon
The prenatal nurse is giving discharge instructions to a woman status post suction curettage secondary to a HYdatidiform mole (molar pregnancy) which information about hydatidiform is correct?
The major risk to a patient after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that her body produces during pregnancy. if she were to get pregnant, it would make the diagnosis of this cancer more difficult
A nurse who is training a new nurse on the labor and delivery unit explains a different rules for magnesium sulfate in labor and delivery. what should the nurse tell the new nurse?
Magnesium sulfate can be used to treat preeclampsia, eclampsia and Preterm labor and to provide fetal neuroprotection
Substance abuse in pregnancy can adversely affect the neonate. A 25 year-old mother reports history and current drug use in pregnancy. After interviewing the mother, the nurse provides teaching about the effect of substance abuse to the mother. What information should be included in the teaching. (Select all that apply)
Explain to the mother the importance of abstaining from drug usage.
Provide telephone number and address of facilities the mother can receive treatment.
Clearly explain the effect of substance abuse on the neonate.
Provide written material about substance abuse
Infants can acquire infection, before, during, and after birth. There are vertical and horizontal transmission of infection. Which of the following interventions may prevent horizontal transmission of infection?
All staff and visitors must wash their hands before and after caring for the newborn
A 44-year-old woman states that she is currently 32 weeks gestation. She also states she has a 10 years old at home who was delivered at 33 weeks of gestation. She also had an abortion at 19 weeks. What is her gravidity and parity using the GTPAL system?
4-1-1-1-2
A woman is in the clinic for prenatal care. The nurse knows that abuse of intimate partners increases with pregnancy. What are some interview questions the nurse can use when screening for abuse? (select all that apply)
Have you been slapped, kit or physically harmed by anyone?
Has anyone forced you to have sexual activities within this year?
Have you been emotionally or sexually abused by your partner or anyone?
When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may:
Harm the infant
A patient has delivered a baby boy. The nurse assessed the patient’s fundus and found that it was boggy and 2 centimeters above the umbilicus. The Sanitary pad is saturated with bright red blood in 10 minutes. What is the next action of the Nurse?
Call the doctor now to examine the patient
The nurse is monitoring a 25-year-old mother in labor. The nurse noted the above fetal heart rate tracing. What is the priority action of the nurse?
Bradycardia so the nurse repositions the patient to her left side and administer oxygen
A 30-year-old female is 34 weeks pregnant. The nurse smells a strong offensive odor coming from the woman. The nurse teaches the woman about personal hygiene and self- care. What intervention is important regarding personal care?
The patient can to take sitz bath every other day to relax the muscle
A woman arrives for evaluation of her symptoms, which included a missed period, adnexal fullness, tenderness, and dark red vaginal bleeding. On examination the nurse notices an echo motif blueness around the woman’s umbilicus and and recognizes this assessment finding as
Cullen’s sign associated with a ruptured ectopic pregnancy
A postpartum woman wants more information about breast-feeding. She delivered her baby 2 days ago and is ready to be discharged home. She wants to know how she can be sure she is effectively breast-feeding. The following are correct information about breast-feeding except:
The mother should co-sleep with babies to facilitate breast-feeding
Following a labor induction, a mother with gestational diabetes delivers a term newborn. One minute after birth, the heart rate is 120 bpm, respiratory effort is adequate with a good cry, reflects irritability shows a good cry response to stimulation, some flexion of the extremities is noted, and the newborn has bluish extremities (acrocyanosis). Based on these findings, what is the 1-minute Apgar score?
8
A 24-year-old is 30 weeks pregnant and is admitted to the prenatal unit of the hospital. The doctor orders ampicillin 2 g to be given every six hours. The medication is available to grams in 100 ML in normal sailing. How many grams will she receive in a 24 hour period?
8mg
After delivery a patient developed a temperature 100.5°F. Infection suspected so the doctor orders ampicillin 2 g every eight hours. The medication is available to grams in 100 ML normal saline. How many ML of medication must the nurse use in a 24 hour period?
300
A patient is 15 weeks pregnant. She needs normal sailing to start at 12:00 midnight. The doctor orders 1000 ML normal Saline to run in 10 hours. The nurse uses a drop factor of 30 gtt/minute. How many gtt/minute would she receive? Round after the nearest whole number
50 gtt/min
A patient has just been admitted for induction of labor after being diagnosed with a fetal demise in the office at 36 weeks' gestation. The nurse is talking with the patient’s family. What is an appropriate comment to say to the patient and family?
How are you dealing with all of this
The nurse is reviewing the External Fetal Monitor tracing of a patient who is undergoing an oxytocin-stimulated Contraction Stress Test. The nurse notes that the patient has had six uterine contractions within 10 minutes, each lasting about 90 seconds. The FHR is 100 beats per minute, and late decelerations are associated with the last four uterine contractions.Which of the following intervention should the nurse do?
The nurse should perform intrauterine resuscitative measure
A 16 year old primipara presents to the labor unit at term. The mother has nit had any prenatal care. The nurse obtains/orders a complete prenatal panel, which includes a blood type and screen and a coombs test. The test indicate that the patient has AB negative blood and a negative coombs test result. What should the nurse do?
Wait until after delivery to determine whether the newborn's blood type warrants Rho(D) IG administration to the patient.
After delivery a patient developed a temperature 100.5°F. Infection suspected so the doctor orders ampicillin 2 g every eight hours. The medication is available to grams in 100 ML normal saline. How many ML of medication must the nurse use in a 24 hour period?
300
follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which are facilitating behaviors? (Select all that apply)
The parents speak to the baby when changing the diapers
The parents examine the baby's feet and fingers,
The parents burp the baby after feeding
The result of Group B Streptococcus (GBS) for a patient in labor is positive. The patient wants to know about this test result. What information about GBS is correct?
Antibiotic will be administered before vaginal delivery to prevent the neonate from getting infection
A woman is undergoing a Pitocin contraction stress test (CST) She is having contractions that occur every 5 minutes for 10 minutes. The fetal heart rate (FHR) has a baseline ofapproximately 150 beats/min with no decelerations. The interpretation of this test is said to be:
Negative
A patient includes on her plan that she desires non-pharmacological pain management as ways to control her pain. Some non-pharmacological interventions for pain relief may include which of the following. (Select all that applies)
Water therapy
Music Therapy
Imagery
A client 36 weeks gestation is presented to the emergency room and reported severe abdominal pain and vaginal bleeding like a period. The nurse assesses the client and finds the following board like abdomen and moderate vagina bleeding HR 98, BP 162/ 98, RR 24, O2 Sat 99% on room air, fetal heart rate 180 with minimal late decelerations noted with every contraction. Which is the priority nursing action?
Turn the patient and start oxygen by facemask STAT
A 24 years old female G2 P1 is in the labor and delivery unit with ectopic pregnancy. The nurse knows numerous factors may increase the risk for ectopic pregnancy. What are some factors that may increase the risk for ectopic pregnancy? (Select all that apply)
Pelvic inflammatory disease
Scarring of the fallopian tube
failed tubligation
A 21-year-old woman is in labor. The doctor orders a sonogram to see the position of the baby. The sonogram shows that both feet and hands flexed, the presenting part is the buttocks. The nurse knows that the baby is breach. Which of the following would the nurse document?
Frank breach
A 33 years old female diagnosed with chronic hypertension. The patient wants to know about chronic hypertension. Which of the following is the correct information about chronic hypertension in a pregnant patient?
Chronic hypertension is identified before 20 weeks of gestation and blood pressure elevated beyond postpartum week
A patient has delivered a baby boy. The nurse assessed the patient’s fundus and found that it was boggy and centimeters above the umbilicus. The sanitary pad is saturated with bright red blood in 10 minutes. What is the next action of the nurse?
Call the doctor now to examine the patient
When the nurse last assessed a postpartum patient 4 hours ago, her fundus was 1 cm below the umbilicus, midline, and firm. The patient’s bleeding was light. The nurse now notices that the fundus is 1 cm above the umbilicus, at midline and firm, the patient’s bleeding is currently moderate. What should be the nurse’s next action?
bladder distension
A 24-year-old first time mother delivered a healthy baby girl After the delivery of the 37 weeks old neonate the nurse provides ways to prevent heat loss. Which of the following interventions will prevent heat loss from conduction?
Place a dry towel on the scale before weighing the neonate
A 24-year-old first time mother delivered a healthy baby girl. After the delivery of the 37 weeks old neonate, the nurse provides ways to prevent heat loss. Which of the following intervention will prevent heat loss from evaporation?
Prompt drying after bathing the baby
Mrs. Johnson is 40 weeks pregnant. She is in the labor and delivery unit with fluid leakage and is 8 cm dilated. The nurse placed Mrs. Johnson on the electronic fetal monitor. The nurse explains to the doctor that fetal tracing is Category 1. Which of the following information is INCORRECT about Category1 fetal heart tracing?
There is the presence of tachycardia in a Category I fetal heart rate tracing
Mrs. Johnson is 40 weeks pregnant. She is in the labor and delivery unit with fluid leakage and is 8cm dilated. The nurse placed Mrs. Johnson on the electronic fetal monitor. The nurse explains to the doctor that fetal tracing is Category 1. Which of the following information is INCORRECT about Category 1 fetal heart tracing?
The presence of one late deceleration is acceptable in a Category 1 fetal heart rate tracing
The nurse is preparing a multipara at term for a vaginal birth. The patient has an epidural and currently has an indwelling bladder catheter. What action regarding the indwelling bladder catheter should the nurse perform while the patient is in labor?
Remove the indwelling bladder catheter immediately before birth
Subinvolution is the failure of the uterus to reduce to it’s normal size and condition after pregnancy. Which of the following can be used to treat such as a diagnosis?
Methylergonovine maleate to promote uterine tone
A postpartum woman wants more information about breastfeeding. She delivered her baby 2 days ago and is ready to be discharged home. She wants to know how she can be sure she is effectively breastfeeding. The following are correct information about breastfeeding except.
The mother should co-sleep with babies to facilitate breastfeeding
A 15 years primigravida mother at 25 week gestation is admitted for Sickle Cell anemia Crisis. All the following are critical intervention for this patient EXCEPT:
Avoidance of food that has folic acid
A patient with preeclampsia is on seizure precautions and receiving a maintenance does of 2 g of magnesium sulfate per hour. The nurse observes that the patient is lethargic and has respirations of 16 breaths per minute. What should the nurse do first?
Assess DTRs and document vital signs
The nurse is assessing the newborn bay reflexes. The nurse touches the corner of the infant mouth with a nipple. The infant turns towards the stimulus and open his mouth Which of the following reflexes has been assessed?
Rooting reflex
The newborn baby is crying with pink color, flexing both legs and arms; and heart rate 120 at one minute of birth. What is the next best action of the nurse?
She performs reassessment in 5 minutes
A 25 years old mother is 20 weeks pregnant. The doctor orders a sonogram because he suspects the baby may have spina bifida. Which of the following information is correct about this condition?(Select all that applies)
Deficiency of folic acid can lead to this condition
The condition is incomplete closure of the spine
The baby may need surgery to fix this condition
The nurse has received report about a woman in labor. The woman’s last vaginal examination was 10 cm, 80%, and - 3. The nurse interpretation of this assessment is that.
The cervix is 10 cm dilated it is affected 80% and the precenting part is 3 cm above the ischial spines
A 26-year-old female is 15 weeks pregnant for the first time. The doctor orders a sonogram to monitor the baby. The sonogram show Trisomy 18 (Edwards Syndrome). The mother wants to know about Trisomy 18. Which information about Trisomy 18 is correct?
It is chromosomal condition that cause mental retardation in the body.
A 34-year-old first time mother is diagnosed with Gestational Diabetes Mellitus at 20 weeks gestation. The patient is in the doctor’s office and complains of tiredness, dry mouth and drowsiness.What nursing intervention/s would be appropriate at this time?
Check the glucose level and report findings to the provider
Substances abuse in pregnancy can adversely affect the neonate. A 25-year-old mother reports history and current drug use in pregnancy. After interview the mother the nurse provides teaching about the effect of substances abuse to the mother. What information should be included in the teaching. (Select all that apply
Clearly explain the effect of substance abuse on the neonate
Provide written material about substance abuse
Explain to the mother the importance of abstaining from drug usage
Provide telephone number and address of facilities the mother can receive treatment
A laboring woman who is a gravida 2, para 1, is being for in the family birth unit. Her cervix is currently 5 cm dilated and 100% effaced. The fetus is at -2 station and cephalic in a left occiput anterior position. The patient calls the nurse to the room and reports a large gush of fluid with her most recent contraction. The nurse confirms ruptures membranes and noted that the amniotic fluid is green and watery. What is the most important nursing intervention at this time?
Assess the FHR to check for any change in baseline or any abnormal patterns.
A 45-year-old patient who is G1 P0 has arrived for amniocentesis. She is extremely anxious about the procedure and the potential effects on her fetus, and she admits that she is afraid of needles. The practitioner describes the procedure and explains potential complications to her. Oral and written informed consents are reconfirmed, During the procedure, what is the best thing for the nurse to do?
Provide support as needed to the patient and her support person
A women will be taking oral contraceptives using a 28 day pack. The nurse should advise this woman to protect against pregnancy by
take one pill as soon as possible then continue with the next dose if combined oral pill is missed once
On of the first symptoms of puerperal infection to assess for in the postpartum woman is:
Temperature of (100 4 F) or higher on successive days starting 24 hours after birth
A 20-year-old primigravida mother is 10 weeks pregnant. She arrives at the Obstetric clinic for her first appointment. All of the following should be included in parental teaching EXCEPT:
Promotion of exercise such as running, soccer, and basketball
A multigravida female states her last menstrual period (LMP) began on October 6, 2017. Using her (LMP) what is her estimated date of delivery (EDD)?
July 13, 2018
A primigravida at 40 week’s gestation is admitted for induction of labor. The patient has been diagnosed with GDM and is receiving insulin injections at home. Besides anticipating for a vaginal delivery, what should the nurse do?
Notify the parental team and be prepared for cesarean delivery
A 36-year-old female states that she might be 15 weeks pregnant. The nurse knows that there are the presumptive, probable and positive signs of pregnancy. Which of the following is the probable sign of pregnancy?
the midwife reported blush discoloration of the cervix
A 23 y.o. mother plans to exclusively formula feed her baby. On discharge the mother wants to know what she can add to the baby’s formula to enhance her baby nutritional intake. Which additional item can be added to the formula?
Nothing
A patient is post cerclage placement for incompetent cervix. What should the nurse include in patient teaching?
Report any cramping or vaginal bleeding
A patient admits to smoking “crack” cocaine prior to being admitted to the labor and delivery unit in active labor. Which assessments are critical for the nurse to initiate?
Uterine contractions, fetal heart rate
A 29-year old mother is 39 weeks pregnant. She reports to the nurse that she drank alcohol during her pregnancy. The nurse knows that alcoholism can cause which of the following in the baby:
microcephaly
The labor of a pregnant woman with preeclampsia is going to be induced. Before initiating the oxytocin infusion, the nurse reviews the women’s lates laboratory test findings. Which of the following labs may indicate preeclampsia is worsening?
The patient complained of blurred vision /elevated liver enzymes
A 29 year old patient is 20 weeks pregnant. The patients states “My mother has a history of diabeticmellitus for many years”. The nurse knows that family history may be a risk factor for GestationalDiabetes Mellitus. The patient was sent for one-hour oral glucose challenge test (GCT). The result test is123 mg/dl. What is the next inappropriate action of the nurse?
Informs the patient that the result indicates normal glucose level / document the result and inform the pt that the result is normal
25-year-old mother delivered a baby at 39 weeks gestation. The nurse practitioner is assessing maturation age of the baby. Which of the following characteristics may be least likely observed in a baby of the above gestation age?
Permeable skin / relaxed lower extremities
the nurse discharged Ms. Davis home after vaginal delivery of a baby boy. The mother checked the baby’s temperature and reported 38 degree Celsius. How will the nurse record this temperature in Fahrenheit?
100.4
While newborns may need some degree of resuscitation in the extra uterine environment, the preterm neonate may require even more extensive assistance. Which of the following is the nurse aware of when caring for the preterm neonate? (Select all that applies)
Hypoglycemia
Hyperbilirubinemia
Abnormal Respiratory Functions
A 44-year multigravida mother is in the 3rd stage of labor. The nurse is teaching a new nurse about the stages of labor. The nurse knows that the new nurse is CORRECT if she states which of the following
The 3rd stage of labor ends after the placenta is delivered
A 30 year old mother is concerned about her baby. She is 40 weeks pregnant and is in labor. The nurse notice that the fetal heart tracing shows late deceleration identify the INCORRECT information about late declaration?
The type of fetal tracing is due to head compression so intervention is not needed.
A mulipara who is gravida 3, para 2, presents to the labor and delivery triage area at term reporting contractions sand ruptured membranes. A pool of clear fluid is noted on the underpad, and during the sterile vaginal exam the nurse notes a pulsing loop of cord in the vagina. What actions should the nurse perform next?
Maintain her sterile gloved hand in the vagina and call for assistance.
A nurse is interviewing a pregnant patient during a prenatal visit. Which patient statement might suggest a need to evaluate further for preeclampsia?
My work shoes don’t fit me any more
The labor nurse is admitting a patient in active labor with a history of genital herpes. On assessment, the patient reports a recent outbreak, and the nurse verifies lesions on the perineum. What is the nurse’s next action?
Ask the patient when she last had anything to eat or drink.
A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following?
Shortness of Breath (SOB)
A maternity nurse is caring for a postpartum patient. The nurse is assessing for maternal adaptation and mother infant bonding. Which of the following behaviors by the patient indicates the need for the nurse to intervene? SATA
Demonstrates apathy when the infant cries.
Views the infant’s behavior as uncooperative during diaper changing
A nurse is caring for a preterm newborn with respiratory distress syndrome. which of the following should the nurse monitor to evaluate the newborn’s condition following administration of synthetic surfactant
Oxygen saturation
A nurse is caring for a patient diagnosed with ruptured ectopic pregnancy. Which of the following finding is seen with this condition?
Report of severe shoulder pain
A nurse is teaching a 16 year old about contraception. What statement by the client indicate need for further teaching? SATA
If I take my birth control pill every other day at 4pm, it is guaranteed to work
I cannot get pregnant if my partner pulls out
Using spermicide during intercourse will guarantee that I will not get pregnant or sexually transmitted infections
A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? (SATA)
Place used bottles in the dishwater
Check the nipple for appropriate flow of formula
Use tap water to dilute concentrated formula
Which intervention is the priority for the patient diagnosed with an intact tubal pregnancy?
Administration of methotrexate
A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (SATA)
Precipitous delivery
Inversion of the uterus
Retained placental fragments
A nurse is administering magnesium sulfate IV to a client who has severe pre-eclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (SATA)
Respirations less than 12/min
Urinary output less than 30mL/hr
Decreased level of consciousness
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?
Palpate the fundus of the uterus
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly hired nurses. Which of the following statements by a nurse indicates understanding of the teaching?
They are administered in an oral form.
A nurse in the postpartum unit is planning care for a patient who has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care?
Measure leg circumference
A pregnant patient presents to labor and delivery with a positive Group B Streptococcus (GBS) result. The woman wants to know about this infection. What information about GBS is correct
Antibiotic will be administered during labor before vaginal delivery to prevent the neonate from getting infection
A maternity nurse is reviewing ways to prevent a TORCH infection during pregnancy with a group of new nurses. Which of the following statement made by a nurse indicates understanding of the teaching?
a woman should avoid eating undercooked meat during pregnancy
A nurse caring for a pregnant patient that is undergoing a non stress test. The patient asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make?
It awakens a sleepy fetus
A nurse in a prenatal clinic is teaching a pregnant patient about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching?
You should empty your bladder prior to the procedure”
A patient who is 8 weeks pregnant tells the nurse that she is not happy about the pregnancy. Which of the following responses should the nurse take:
“It is normal to have these feelings during the first few month of pregnancy
A nurse is providing discharge instructions for a patient. At 4 weeks postpartum, the patient should contact her provider for which of the following findings?
“sore nipples with cracks and fissures”
A nurse is caring for a patient in labor. Her vaginal exam 2 hrs ago revealed cervix 3 cm,dilated, 100% effaced, -2 station with membranes intact. The patient suddenly states “Mywater broke.” The monitor reveals a FHR of 80 to 85 b/min, and the nurse performs a vaginalexam noticing clear fluid and a pulsating loop of umbilical cord in the patient’s vagina. Which of the following priority action should the nurse perform
Administer oxygen at 10L/min via a face mask
a nurse is completing a newborn assessment. Which of the following data indicate the newborn is adapting to extrauterine life (SATA)
apnea for 10 second periods
Obligatory nose breathing
A maternity nurse is caring for a pregnant patient who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing
Hyperglycemia
meconium aspiration
A labor and delivery nurse is planning care for a newly admitted patient who reports that she is in labor and has had vaginal bleeding for 2 weeks. Which of the following should the nurse include in her plan of care?
Defer vaginal examination
A patient with preeclampsia is being treated with bed rest and intravenous magnesium sulfate. The drug classification of this medication is a
Anticonvulsant
The priority nursing intervention when admitting a pregnant patient who has experienced a bleeding episode in late pregnancy is to?
assess fetal heart rate and maternal vital signs
a maternity nurse is caring for a patient who is in active labor and reports sever back pain.During assessment the fetus is noted to be in the occipital posterior position. Which of thefollowing maternal positions should the nurse suggest to the client to facilitate normal labor process
Hands and knees
A nurse is reviewing the health record of a pregnant patient. the provider indicated that the patient exhibits probably signs of pregnancy. Which of the following findings should the nurse expect?
goodell’s sign
ballotment
chadwick’s sign
During ambulation to the bathroom,, a one day postpartum section patient experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, at the midline and at the level of the umbilicus. How should the nurse interpret this data?
a normal postural discharge of lochia
A nurse in the labor and delivery unit is caring for patient in labor. The fetal heart rate is recorded 140 b/min. Contractions are occurring every 8 mins lasting 30 to 40 seconds. Vaginal exam revealed cervix 2 cm dilated, 50% effaced and -2 station. Which of the following stages and phases of labor is the patient experiencing?
first stage, active phase
A nurse is caring for a patient in labor who is receiving oxytocin for induction of labor with an intrauterine pressure catheter placed to monitor uterine contractions. For which of the following uterine contraction patterns should the nurse discontinue the infusion of oxytocin?
duration of 90 to 120 secs
A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish marking across the newborn’s lower back. The nurse should include and document which of the following information in the teaching?
“this is frequently seen in newborn who have dark skin
a nurse is caring for a neonate born at 38 weeks gestation, weighs 3200 g and in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following?
appropriate for gestational age
A nurse is caring for a pregnant patient with suspected hyperemesis gravidarum and is reviewing the laboratory reports. Which of the following findings is a manifestation of this condition?
Urine ketones present
A nurse is teaching a newly license nurse about neonate abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching?
The newborn will have a continuous high-pitched cry
A nurse is caring for a newborn immediately following birth. Which of the following is the highest priority action by the nurse at this time?
drying the skin of the newborn to prevent cooling of the body
A nurse is taking a newborn to a mother following circumcision. Which of the following actions should the nurse take for security purposes?
Match the mother’s identification band with the newborn’s band
A client who is 38 weeks gestation comes to the clinic for routine examination. the nurse is preparing discharge teaching for this client. What is the priority teaching for this client in 38 weeks gestation?
Maternal nutrition
A nurse is reviewing postpartum nutrition needs with a group of new mothers who are breastfeeding their newborn. Which of the following statements by one of the mothers indicates an understanding of the teaching?
I will continue my calcium supplements because I don’t like milk.”
a nurse is caring for a patient in second stage of labor. The patient’s significant order ask the nurse to explain how he will know when crowning occurs . Which of the following responses should the nurse make?
The vaginal area will bulge as the baby’s head appears.”
Which assessment in a patient diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication
Drowsiness
A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications is risk factor for this condition?
placenta previa
a nurse in a prenatal clinic is caring for four pregnant patients.. which of the following patient’s weight gain should the nurse report to the provider?
3.6 kg (8lb) weight gain and is in her first trimester
A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following?
Hemorrhage is the primary concern.
A nurse is reviewing car seat safety with the parents of a newborn. Which of the following statement if made by the patent indicates further teaching is required regarding car seats safety?
I will place the infant in the front seat forward-facing
a patient with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate
Worsening disease and impending convulsion
a nurse is teaching a patient who is breastfeeding and has mastitis. Which of the following responses should the nurse make?
Completely empty each breast at each feeding or use a pump
a nurse report is conducting a home visit for a client who is 1 week postpartum and breastfeeding. The client reports breast engorgement. Which of the following recommendations should the nurse make?
Apply cold compress between feedings
a nurse is teaching a group of new parents about proper technique for bottle feeding. which of the following instruction should the nurse provide?
Keep the nipple full of formula throughout the feeding
which instructions should the nurse include when teaching a pregnant patient with Class 2 heart disease?
Inform her of the need to limit fluid intake
A nurse is admitting a client who is in labor and has hiv. which of the following intervention should the nurse identify as contraindicated for this client
Forceps delivery
Internal fetal monitoring
Episiotomy
a nurse is caring for a patient who has postpartum psychosis. which of the following actions is the nurse’s priority?
ask the patient if she has thought of harming herself or her infant
a nurse is caring for a 1 hr postpartum patient following vaginal birth and experiencing uncontrollable shaking. the nurse should understand that shaking is due to which of following factors
change in body fluid
metabolic efforts of labor
a nurse is assessing a postpartum patient who is exhibiting tearfulness, insomnia, lack of appetite and a feeling of letdown. which of the following conditions are associated with these clinical findings ?
Postpartum blues
a nurse is completing a newborn assessment and observes small white nodules on the roof the newborn’s mouth. this finding is a characteristic of which of the following conditions
Epstein pearls
which intrapartum assessment should be avoided when caring for a patient with HELLP syndrome?
Abdominal palpations
a nurse in a clinic is caring for a post operative patient following a salpingectomy due to an ectopic pregnancy. which statement. by the client requires clarification?
it is good to know that I won’t have a tubal pregnancy in the future”
a nursing is caring for a patient who is in the first stage of labor and is encouraging the patient to void every 2 hours. which of the following statement justifies the nurse’s intervention
“A distended bladder reduces pelvic space needed for birth”
a nurse is reviwing contraindications for circumsion with a student nurse. which of the following conditions are contraindicated for this procedure?
Epispadias
family history of hemophilia
hypospadias
a nurse is reviewing care of the umbilical chord with the parent of a newborn. which of the following instruction should the nurse include in her teaching?
Keep the diaper folded below the cord
a maternity nurse is performing a fundal assessment for a patient who is 2 days postpartum and observes the perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small cloths. which of the following findings
should the nurse document?
A moderate lochia rubra
the nursing is caring a postpartum client who is bleeding excessively . the nurse is about to weight the pad she just removed from the client. the pad weighs 275 grams. what is the blood loss in milliliters?
255 ml
which routine nursing assessment is contraindicated for a patient admitted with suspected placenta previa?
Determining cervical dilation and effacement
a nurse is caring for a laboring patient who is using patterned breathing during labor. the patient reports numbness and tingling of the fingers. what priority intervention will the nurse perform first place?
an oxygen mask over the client’s nose and mouth
A cesearean section client who was diagnoses gestational hypertension in the labor is transferred to the postpartum unit post delivery. upon revewing the orders by the postpartum nurse, which prescription should the nurse clarify?
Ibuprofen
A nurse is assessing the reflexes of a newborn in checking for the moro reflex, the nurse should perform which of the following?
Hold the newborn in a semi-sitting position, then allow the head and trunck to fall backwards
a maternity nurse caring for a patient in labor who is experiencing incomplete uterine relaxation. between hypertonic contractions. the nurse should identify that this contraction pattern increases the risk for which of the following complications?
Reduced fetal oxygen supply
a nurse is caring a patient who is preterm labor and is scheduled to undergo an amniocentesis. the nurse should evaluate which of the following tests to assess fetal lung maturity?
Lecithin/spingomyelin (L/S) ration
A nursing is caring for an infant with hyperbilirubinemia and is receiving phototherapy. which of the following is a priority finding in the newborn?
Sunken fontanels
The nurse teaches a pregnant woman about the presumptive, probably and positive sings of pregnancy. The client demonstrates understanding of the nurse’s instructions if she states that a probable sign of pregnancy is which event?
A positive pregnancy test
The nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates understanding of the nurses instructions if she states that a positive sign of pregnancy is:
Fetal movement palpated by the nurse-midwife.
To minimize the incidence of mastitis and engorgement in breast-feeding patients, what nursing discharge instruction is best to give?
Using proper breastfeeding positioning techniques
The nurse is performing Leopold’s maneuver to determine fetal position in utero. What is the fetal position and presentation
Left sacrum anterior (LSA), frank breech
hich fetal heart rate (FHR) finding would indicate immediate reporting by the nurse during labor?
Prolonged decelerations
The nurse is caring for a 4-hour old 32-week gestation infant. Which assessment finding would require further evaluation?
Abdominal periodic breathing
A nurse is caring for a patient in the active phase of labor. The patient’s amniotic sac spontaneously ruptures. Suddenly the patient reports dyspnea, appears restless and cyanotic and becomes hypotensive and tachycardic. What should be the nurse’s immediate intervention?
Administer oxygen 10 liters via mask
A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to:
Perform fundal massage
The nurse has received a report about a patient in labor. The patient’s last vaginal examination was recorded as 6 cm, 40% and -1. Which should be the nurse’s interpretation of this assessment?
Cervix is 6 cm dilated, effaced 40%, and the presenting part is 1 cm above the ischial spines
A pregnant patient presents in labor at term, having no prenatal care. After birth, the infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant is also microcephalic. The patient should be questioned about use of which substance during pregnancy?
Alcohol
The nurse observes a teenage parent who seems to ignore the newborn. Which strategy would be most effective to facilitate attachment?
Place the baby in the patient’s arms and show how to breastfeed
The nurse is caring for a preterm infant and notes abdominal distention, temperature instability and bloody stools. What is the priority nursing intervention?
Keep baby NPO
A patient who wants to start trying to get pregnant in 3 months has come to the clinic for preconception counseling. Which is the best advice to give to the client
Make sure you include adequate folic acid in your diet
A nurse is reviewing the medical records of a postpartum client who has preeclampsia. Which of the following lab results should the nurse report to the doctor?
Platelets count of 50,000/mm3
The nurse is providing care for the antepartum woman should teach which information about contraction stress test (CST)
Is considered negative if no late decelerations are observed with the contractions
The nurse is assessing a new mother’s breastfeeding technique and notes the baby’s lips are making a smacking noise. What instruction should the nurse give the patient?
Unlatch and relatch the baby in the proper position
The nurse is preparing to discharge a patient who experienced a miscarriage at 10-weeks gestation. Which statement by the patient indicates further instruction is needed
I should expect to experience heavy bleeding for at least the next week
Which of the following life threatening complications can occur in a client receiving a tocolytic
agent?
Pulmonary edema
A patient admits to smoking “crack” cocaine prior to being admitted to the labor and delivery unit in active labor. Which assessments are critical for the nurse to initiate?
Uterine contractions, fetal heart rate
A nurse is working with an Orthodox Jewish patient who has just given birth to a stillborn infant. Which nursing intervention would be the best?
Ask the family if there is any special rituals that they would like to follow at this time
The nurse is caring for a patient receiving oxytocin in active labor and notes the fetal monitor strip below. After discontinuing oxytocin, what should the be the next nursing action?
Change the patient position
The nurse is providing genetic counseling for an expectant couple who has a child with trisonomy 18. What would be the nurse’s best action?
Discuss testing including amniocentesis to determine whether the fetus is affected.
A patient at 37 weeks gestation has been advised that she is positive group B streptococcus. Which is the best nursing statement to the patient?
The care provider will prescribe intravenous antibiotics for you. A visiting nurse will administer them to you in your home
When teaching a pregnant patient regarding personal hygiene, the maternity nurse should include which instructions
Tub bathing is permitted even in late pregnancy unless membranes have ruptured.
A 30-year old gravida, G3 P1101, states that she had a premature baby boy born 8 years ago died shortly after delivery from an infection secondary to spina bifida. The patient tells the nurse that she is planning to have another baby next year. Which intervention is most important for this patient?
Nutrition counseling
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?
Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide
A new parent has been diagnosed with postpartum psychosis. Which is essential and must be included in the family teaching for this patient?
Parent should never be left alone with her infant
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:
Abdominal distention, temperature instability, and grossly bloody stools
When assessing a patient diagnosed with an ectopic pregnancy, the nurse notes a positive Cullen’s sign. What should be the nurse’s first action.
Obtain vital signs
he nurse is reviewing the prenatal history of a patient in the first trimester of pregnancy. Which patient statement would indicate that additional teaching is needed?
I have 3 cats at home that need care
The nurse is assisting the provider in preparing to perform Leopold’s maneuver on a pregnant patient. After the nurse instructs the patient about the procedure and washes hands, what should be the next nursing action?
Ask the patient to urinate
During a patient’s physical examination, the nurse notes that the lower uterine segment is soft on palpation. Which is the best documentation for the finding?
Hegar’s sign
A patient is post cerclage placement for incompetent cervix. What should the nurse include in patient teaching?
Report any cramping or vaginal bleeding
A nurse in labor room is performing pericare on a patient in labor and she notes the presence of the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?
Place the client in Trendelenburg or knee chest position