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Which client finding should the nurse document as a positive sign of pregnancy?
Last menstrual cycle occurred 2 months ago.
A urine sample with a positive pregnancy test.
Presence of Braxton Hicks contractions.
Fetal heart tones (FHT) heard with a doppler. - ANSWER Fetal heart tones (FHT) heard
with a doppler.
The nurse is caring for a client in active labor and observes V shape decelerations in the fetal
heart rate occurring with the peak of each contraction. What action should the nurse
implement?
Notify the healthcare provider of fetal status.
Give oxygen at 10 L per nasal cannula.
Place the client in a side-lying position.
Increase the flow rate of intravenous fluids. - ANSWER Place the client in a side-lying
position.
While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp
that cross the suture lines. How should the nurse document this finding?
Molding.
Hemangioma.
Cephalohematoma.
Caput succedaneum. - ANSWER Caput succedaneum.
1
,The mother of a neonate asks the nurse why it is so important to keep the infant warm.
What information should the nurse provide?
The kidneys and renal function are not fully developed.
Warmth promotes sleep so the infant will grow quickly.
A large body surface area favors heat loss to the environment.
The thick layer of subcutaneous fat is inadequate for insulation. - ANSWER A large
body surface area favors heat loss to the environment.
A gravid client develops maternal hypotension following regional anesthesia. What
intervention(s) should the nurse implement? (Select all that apply.)
Select all that apply
Administer oxygen.
Increase IV fluids.
Perform a vaginal examination.
Assist client to a sitting position.
Place the client in a lateral position.
Monitor fetal status. - ANSWER Administer oxygen.
Increase IV fluids.
Place the client in a lateral position.
Monitor fetal status.
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her
husband thinks she is imagining things. What information should the nurse provide?
Many women imagine what their baby is like by interpreting fetal movements.
The fetus in utero is capable of hearing and does respond to the mother's voice.
The healthcare provider should address her concerns about her baby's hearing function.
The interaction between the mother's voice and the fetus's response ensures bonding. -
ANSWER The fetus in utero is capable of hearing and does respond to the mother's
voice.
2
,When assessing a newborn infant's heart rate, which technique is most important for the
nurse to use?
Quiet the infant before counting the heart rate.
Listen at the apex of the heart.
Count the heart rate for at least one full minute.
Palpate the umbilical cord. - ANSWER Count the heart rate for at least one full minute.
A client is experiencing "back" labor and complains of intense pain in the lower lumbar-
sacral area. What action should the nurse implement?
Perform effleurage on the abdomen.
Encourage pant-blow breathing techniques.
Apply counter pressure against the sacrum.
Assist the client in guided imagery. - ANSWER Apply counter pressure against the
sacrum.
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter
should the nurse assess first for signs of internal hemorrhage?
Vaginal bleeding.
Complaints of abdominal pain.
Changes in fetal heart rate patterns.
Alteration in maternal blood pressure. - ANSWER Changes in fetal heart rate patterns.
Which procedure evaluates the effect of fetal movement on fetal heart activity?
Sonography.
Contraction test.
Biophysical profile.
Non-stress test (NST). - ANSWER Non-stress test (NST).
3
, A female client who wants to delivery at home asks the nurse to explain the role of a nurse-
midwife in providing obstetric care. What information should the nurse provide?
Birth in the home setting is the preference for a using a midwife for delivery.
The pregnancy should progress normally and be considered low risk.
Natural child birth without analgesia is used to manage pain during labor.
An obstetrician should also follow the client during pregnancy. - ANSWER The
pregnancy should progress normally and be considered low risk.
Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks
gestation?
Pica.
Pyrosis.
Ptyalism.
Decreased peristalsis. - ANSWER Pica.
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother
tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best
for the nurse to make?
Inform the mother that the injection was prescribed by the healthcare provider.
Explore the mother's concerns about the infant receiving an injection of vitamin K.
Explain that vitamin K is required by state law and compliance is mandatory.
Remind the mother that all babies receive this shot and it is relatively painless. -
ANSWER Explore the mother's concerns about the infant receiving an injection of
vitamin K
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at
32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters
the right ventricle, what is the priority nursing assessment?
Assess fetal response to the procedure.
Note any complaint of sudden chest pain.
4
Which client finding should the nurse document as a positive sign of pregnancy?
Last menstrual cycle occurred 2 months ago.
A urine sample with a positive pregnancy test.
Presence of Braxton Hicks contractions.
Fetal heart tones (FHT) heard with a doppler. - ANSWER Fetal heart tones (FHT) heard
with a doppler.
The nurse is caring for a client in active labor and observes V shape decelerations in the fetal
heart rate occurring with the peak of each contraction. What action should the nurse
implement?
Notify the healthcare provider of fetal status.
Give oxygen at 10 L per nasal cannula.
Place the client in a side-lying position.
Increase the flow rate of intravenous fluids. - ANSWER Place the client in a side-lying
position.
While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp
that cross the suture lines. How should the nurse document this finding?
Molding.
Hemangioma.
Cephalohematoma.
Caput succedaneum. - ANSWER Caput succedaneum.
1
,The mother of a neonate asks the nurse why it is so important to keep the infant warm.
What information should the nurse provide?
The kidneys and renal function are not fully developed.
Warmth promotes sleep so the infant will grow quickly.
A large body surface area favors heat loss to the environment.
The thick layer of subcutaneous fat is inadequate for insulation. - ANSWER A large
body surface area favors heat loss to the environment.
A gravid client develops maternal hypotension following regional anesthesia. What
intervention(s) should the nurse implement? (Select all that apply.)
Select all that apply
Administer oxygen.
Increase IV fluids.
Perform a vaginal examination.
Assist client to a sitting position.
Place the client in a lateral position.
Monitor fetal status. - ANSWER Administer oxygen.
Increase IV fluids.
Place the client in a lateral position.
Monitor fetal status.
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her
husband thinks she is imagining things. What information should the nurse provide?
Many women imagine what their baby is like by interpreting fetal movements.
The fetus in utero is capable of hearing and does respond to the mother's voice.
The healthcare provider should address her concerns about her baby's hearing function.
The interaction between the mother's voice and the fetus's response ensures bonding. -
ANSWER The fetus in utero is capable of hearing and does respond to the mother's
voice.
2
,When assessing a newborn infant's heart rate, which technique is most important for the
nurse to use?
Quiet the infant before counting the heart rate.
Listen at the apex of the heart.
Count the heart rate for at least one full minute.
Palpate the umbilical cord. - ANSWER Count the heart rate for at least one full minute.
A client is experiencing "back" labor and complains of intense pain in the lower lumbar-
sacral area. What action should the nurse implement?
Perform effleurage on the abdomen.
Encourage pant-blow breathing techniques.
Apply counter pressure against the sacrum.
Assist the client in guided imagery. - ANSWER Apply counter pressure against the
sacrum.
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter
should the nurse assess first for signs of internal hemorrhage?
Vaginal bleeding.
Complaints of abdominal pain.
Changes in fetal heart rate patterns.
Alteration in maternal blood pressure. - ANSWER Changes in fetal heart rate patterns.
Which procedure evaluates the effect of fetal movement on fetal heart activity?
Sonography.
Contraction test.
Biophysical profile.
Non-stress test (NST). - ANSWER Non-stress test (NST).
3
, A female client who wants to delivery at home asks the nurse to explain the role of a nurse-
midwife in providing obstetric care. What information should the nurse provide?
Birth in the home setting is the preference for a using a midwife for delivery.
The pregnancy should progress normally and be considered low risk.
Natural child birth without analgesia is used to manage pain during labor.
An obstetrician should also follow the client during pregnancy. - ANSWER The
pregnancy should progress normally and be considered low risk.
Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks
gestation?
Pica.
Pyrosis.
Ptyalism.
Decreased peristalsis. - ANSWER Pica.
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother
tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best
for the nurse to make?
Inform the mother that the injection was prescribed by the healthcare provider.
Explore the mother's concerns about the infant receiving an injection of vitamin K.
Explain that vitamin K is required by state law and compliance is mandatory.
Remind the mother that all babies receive this shot and it is relatively painless. -
ANSWER Explore the mother's concerns about the infant receiving an injection of
vitamin K
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at
32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters
the right ventricle, what is the priority nursing assessment?
Assess fetal response to the procedure.
Note any complaint of sudden chest pain.
4
