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Question 1
A newborns head circumference is 12 inches (30.5 cm) and his chest measurement is
13 inches(33 centimeters). The nurse notes that this infant has no molding, and it was
a bridge presentation delivered by cesarean section. What action should the nurse
take
based on this data?
A. No action needs to be taken, it is normal for an infant born by caesarean section to
have
a smallhead circumference.
B. Notify the pediatrician immediately. These signs support the possibility of
hydrocephalus.
C. Call these findings to the attention of the pediatrician. The head/chest ratio is
abnormal.
D. Record the findings on the chart. They are within normal limits.
Correct Answer
C. Call these findings to the attention of the pediatrician. The head/chest ratio is
abnormal.
Question 2
A client at 30 weeks gestation reports that she has not felt the baby move in the last
24 hours. Concerned she arrives in a panic at the obstetric clinic where she is
immediately sent to the hospital. which assessment warrants immediate intervention
by the nurse?
A. Fetal Heart rate 60 beats per minute
B. Ruptured amniotic membrane
C. onset of uterine contractions
D. leaking amniotic fluid.
Correct Answer
A. Fetal Heart rate 60 beats per minute
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,Question 3
At 12 hours after the birth of a healthy infant the mother complains of feeling
constant vaginal pressure. The nurse determines the fundus is firm and at midline
with moderate rubra lochia. which action should nurse take?
A Check the suprapubic area for distention.
B. Inform the client to take a warm sitz bath
C. Inspect clients perineal and rectal areas
D. Apply a fresh pad and check in 1 hour.
Correct Answer
C. Inspect clients perineal and rectal areas
Question 4
The health care provider prescribes 10 units per liters of oxytocin via IV drip to
augment a client's labor because she's experiencing a prolonged active phase.
Which finding would cause the nurse to immediately discontinue the oxytocin?
A Contraction duration of 100 seconds.
B. For contractions in 10 minutes.
C. Uterus is soft.
D. early deceleration of fetal heart rate.
Correct Answer
A. Contraction duration of 100 seconds.
Question 5
The nurse is caring for a multiparous client who is 8 centimeters dilated 100% effaced
and the fetal head is at 0 station. The clients is shivering and states extreme
discomfort with the urge to bear down. which intervention should the nurse
implement?
A Administer IV pain medication
B. Perform a vaginal exam
C. Reposition to side lying
D. Encourage pushing with each contraction
Correct Answer
D. Encourage pushing with each contraction
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,Question 6
A newborn assessment reveals spina bifida occulta. Which maternity factors
should nurse identify as having the greatest impact on the development of this
newborn complication.
A Short interval pregnancy
B. Folic acid deficiency
C. Preeclampsia
D. Tobacco use
Correct Answer
B. Folic acid deficiency
Question 7
The nurse is preparing to administer phytonadione to a newborn. Which statement
makes
made bythe parents indicates understanding why the nurse is administering this
medication.
A Improve insufficient dietary intake.
B. Stimulates the immune system
C. Help an immature liver.
D. Prevent hemorrhagic disorders.
Correct Answer
D. Prevent hemorrhagic disorders.
Question 8
What should be the primary focus of nursing care in the transitional phase of Labor
for a client who anticipates an unmedicated delivery?
A Assessing the strength of uterine contractions
B. Re-evaluate the need for medication
C. Remind her to push 3 times with each contraction.
D. Assessing her to maintain control.
Correct Answer
A. Assessing the strength of uterine contractions
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, Question 9
In The Ballard Gestational Age Assessment Tool, the nurse determines that a 15-
month-old infant as a gestational age of 42 weeks. Based on this finding which
intervention is most important for the nurse to implement.
A Provide blow by oxygen
B. Provide a capillary blood glucose
C. draw arterial blood gases
D. Apply a pulse oximeter to the foot.
Correct Answer
B. Provide a capillary blood glucose
Question 10
A woman who is 38 weeks gestation is receiving magnesium sulfate for severe
preeclampsia. which assessment finding warrants immediate intervention by the
nurse?
A. Dizziness while standing
B. Sinus tachycardia
C. Lower Back pain
D. Absent Patellar reflexes.
Correct Answer
D. Absent Patellar reflexes.
Question 11
A client who is 24 weeks gestation arrives to the clinic reporting swollen hands. On
examination the nurse notes the clients as had a rapid weight gain over six weeks.
which action should a nurse implements next?
A Review previous blood pressures in the chart.
B. Obtain the clients blood pressure.
C. Observe and time the client's contractions. Examined the client for pedal edema.
D. examine the client for pedal edema
Correct Answer
B. Obtain the clients blood pressure.
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