A clinic nurse is reviewing dietary instructions with a client who is 20 weeks gestation
and taking iron supplements. WHich of the following statements by the client indicated
an understanding of the instructions?
1. "I should take my iron with a cup of coffee"
2. "I should double my dose if i forget and miss a day"
3. "I should increase my fluid intake while i am taking iron"
4. "I should limit the fiber in my diet because i am taking iron" - ANS3. "I should increase
my fluid intake while i am taking iron"
A nurse in a clinic is assisting with the plan of care for a client who is 36 weeks
gestation. Which of the following actions should the nurse include in the plan of care?
1. Obtain a culture for group B streptococcus B-hemolytic
2. Collect a blood sample or maternal serum alpha-fetoprotein
3. Administer Rh0(D) immune globulin
4. Perform a 1-hr glucose tolerance test - ANS1. Obtain a culture for group B
streptococcus B-hemolytic
- screen in clients who are 35-37 weeks of gestation
A nurse in a clinic is caring for a client who tests positive for gonorrhea. Which of the
following findings should the nurse expect during data collection?
1. Chronic pelvic pain
2. Blood in the urine
3. Painless labial lesions
4. Perineal itching - ANS1. Chronic pelvic pain
A nurse in a prenatal clinic is reinforcing nutritional teaching with a client who is at 10
weeks gestation. Which of the following statements by the client indicated an
understanding of the instruction?
1. "I eat a 6-ounce can of white tuna every other day"
2. "I make sure that I get 1,000 milligrams of calcium per day"
3. "I am consuming 300 Micrograms of folate each day"
4. "I limit my caffeine intake to three cups of coffee each day" - ANS2. "I make sure that
I get 1,000 milligrams of calcium per day"
- to support fetal bone and tooth development
A nurse in an antepartum clinic is collecting data from a client hwo is at 12 weeks of
gestation. Which of the following findings should the nurse report to the provider?
1. Hematocrit of 35%
2. Weight increase of 3 kg (6.6 lb) in one month
3. Urine dipstick negative for ketones
4. Fetal heart auscultated just above the symphysis pubis - ANS2. Weight increase of 3
kg (6.6 lb) in one month
- a client with normal pregnancy should gain weight 2.2-4.4.lb during first trimester
,A nurse in an antepartum clinic is reinforcing teaching with a client who is 32 weeks of
gestation and is scheduled for a nonstress test. Which of the following information
should the nurse include in the teaching?
1. "You will be lying on you r back during the test"
2. "You will be given IV oxytocin to stimulate contractions during the test"
3. "You will be asked to press a button when you feel your baby move during the test"
4. "You will need to drink at least 32 ounces of fluid to fill your bladder before the test" -
ANS3. "You will be asked to press a button when you feel your baby move du ring the
test"
A nurse is an antepartum clinic is collecting data from a client who is 28 weeks
gestation. Which of the following findings should the nurse identify as an indication of a
potential complication?
1. Fetal heart rate 120/min
2. Dysuria
3. Leukorrhea
4. Fasting blood glucose 80 mg/dL - ANS2. Dysuria
-unexpected finding that can indicate a UTI
A nurse is assisting with collecting data from a newborn who is 4hr old. Which of the
following findings is the priority for the nurse to report to the provider?
1. Generalized petechiae
2. Cephalhematoma
3. Heart rate 170/min
4. Temp 97.6F - ANS1. Generalized petechiae
A nurse is assisting with discharge teaching about pain management to a client who
had a c-section birth and is experiencing gas pain. Which of the following instructions
should the nurse include int he teaching?
1. Drink fluids through a straw
2. Rock in a rocking chair
3. Lie supine when in bed
4. Consume whole milk with meals - ANS2. Rock in a rocking chair
A nurse is assisting with the admission of a client who has pertussis and is 28 weeks
gestation. Which of the following types of transmission -based isolation precautions
should the nurse initiate for the client?
1. Airborne
2. Contrast
3. Droplet
4. Protective environment - ANS3. Droplet
A nurse is assisting with the admission of a client whose labor is being induced. The
client reports using heroin 6 hrs ago. For which of the following manifestations of
abstinence should the nurse monitor the client?
1. Constipation
,2, Insomnia
3. Flaccid muscles
4. Euphoria - ANS2. Insomnia
A nurse is assisting with the care of a client who is in active labor and noted late
deceleration in the fetal heart rate. Which of the following actions should the nurse take
first?
1. Palpate the client's uterus to check for tachysystole
2. Place the client in a side-lying position
3. Administer oxygen at 10 L/min via nonrebreather face mask
4. Increase the rate of the clients IV fluids - ANS2. Place the client in a side-lying
position
A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is
receiving phototherapy. Which of the following findings should the nurse identify as a
potential complication of phototherapy?
1. Loose stools
2. Decreased urinary output
3. Axillary temp of 98.6 F
4. Skin rash - ANS2. Decreased urinary output
-phototherapy can lead to dehydration
A nurse is assisting with the care of a postpartum client and their newborn. The nurse
observes that the newborn appears to be choking on formula. Which of the following
actions should the nurse take? (select all that apply)
1. Reposition the newborn
2. Suction the newborns mouth with a bulb syringe
3. Apply oxygen via nasal cannula
4. Perform chest percussions
5. Auscultate breath sounds - ANS1. Reposition the newborn
2. Suction the newborns mouth with a bulb syringe
5. Auscultate breath sounds
A nurse is assisting with the data collection of a newborn who is 1 hr old. Which of the
following manifestations should indicate to the nurse that the newborn is experiencing
difficulty transitioning to extrauterine life?
1. Retractions
2. Acrocyanosis
3. Respirations 40/min
4. Temp 98F - ANS1. Retractions
A nurse is asssiting with the care of a client who is in active stage of labor. FOr which of
the following findings should the nurse notify the provider?
1. Spontaneous rupture of membranes
2. prolapsed umbilical cord
3. Pink to blood mucus discharge
, 4. Contraction duration of 60 seconds - ANS2. prolapsed umbilical cord
A nurse is caring for a client who is 1 hr postpartum and has a 3rd-degree perineal
laceration. Which of the following actions should the nurse perform? (Select all that
apply)
1. Apply an ice pack to the client's perineum
2. Have the client sit on a pillow
3. Place which hazel pads on the client's perineum
4. Prepare the sitz bath water to 107.6 F
5. Encourage the client to use a squeeze bottle to cleanse the perineum with each void
- ANS1. Apply an ice pack to the client's perineum
3. Place which hazel pads on the client's perineum
5. Encourage the client to use a squeeze bottle to cleanse the perineum with each void
A nurse is caring for a client who is 16 weeks of gestation and is at risk for developing
hyperemesis gravidarum. Which of the following conditions places the client at an
increased risk of developing this condition?
1. Placenta previa
2. Hypertension
3. Iron deficiency anemia
4. Diabetes mellitus - ANS4. Diabetes mellitus
A nurse is caring for a postpartum client who has an episiotomy. Which of the following
actions should the nurse take?
1. Apply an anesthetic spray to the client's perineal area as needed for pain
2. Place a donut pillow under the clients when sitting in a chair
3. Apply a moist heat pack to the client's perineal area for 20 min every hour for the first
24 hours
4. Assist the client with changing the perineal pad every 8 hr to expedite healing -
ANS1. Apply an anesthetic spray to the client's perineal area as needed for pain
A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the
following findings indicates that the client is at risk for dehydration?
1. Hematuria
2. Sodium 140 mEq/L
3. Potassium 3.5 mEq/L
4. Ketonuria - ANS4. Ketonuria
A nurse is collecting data from a client who is 36 weeks gestation. Which of the
following manifestations should the nurse report to the provider as potentially a
complication of pregnancy?
1. Insomnia
2. Breast tenderness
3. Frequent headaches
4. Leg cramps - ANS3. Frequent headaches
and taking iron supplements. WHich of the following statements by the client indicated
an understanding of the instructions?
1. "I should take my iron with a cup of coffee"
2. "I should double my dose if i forget and miss a day"
3. "I should increase my fluid intake while i am taking iron"
4. "I should limit the fiber in my diet because i am taking iron" - ANS3. "I should increase
my fluid intake while i am taking iron"
A nurse in a clinic is assisting with the plan of care for a client who is 36 weeks
gestation. Which of the following actions should the nurse include in the plan of care?
1. Obtain a culture for group B streptococcus B-hemolytic
2. Collect a blood sample or maternal serum alpha-fetoprotein
3. Administer Rh0(D) immune globulin
4. Perform a 1-hr glucose tolerance test - ANS1. Obtain a culture for group B
streptococcus B-hemolytic
- screen in clients who are 35-37 weeks of gestation
A nurse in a clinic is caring for a client who tests positive for gonorrhea. Which of the
following findings should the nurse expect during data collection?
1. Chronic pelvic pain
2. Blood in the urine
3. Painless labial lesions
4. Perineal itching - ANS1. Chronic pelvic pain
A nurse in a prenatal clinic is reinforcing nutritional teaching with a client who is at 10
weeks gestation. Which of the following statements by the client indicated an
understanding of the instruction?
1. "I eat a 6-ounce can of white tuna every other day"
2. "I make sure that I get 1,000 milligrams of calcium per day"
3. "I am consuming 300 Micrograms of folate each day"
4. "I limit my caffeine intake to three cups of coffee each day" - ANS2. "I make sure that
I get 1,000 milligrams of calcium per day"
- to support fetal bone and tooth development
A nurse in an antepartum clinic is collecting data from a client hwo is at 12 weeks of
gestation. Which of the following findings should the nurse report to the provider?
1. Hematocrit of 35%
2. Weight increase of 3 kg (6.6 lb) in one month
3. Urine dipstick negative for ketones
4. Fetal heart auscultated just above the symphysis pubis - ANS2. Weight increase of 3
kg (6.6 lb) in one month
- a client with normal pregnancy should gain weight 2.2-4.4.lb during first trimester
,A nurse in an antepartum clinic is reinforcing teaching with a client who is 32 weeks of
gestation and is scheduled for a nonstress test. Which of the following information
should the nurse include in the teaching?
1. "You will be lying on you r back during the test"
2. "You will be given IV oxytocin to stimulate contractions during the test"
3. "You will be asked to press a button when you feel your baby move during the test"
4. "You will need to drink at least 32 ounces of fluid to fill your bladder before the test" -
ANS3. "You will be asked to press a button when you feel your baby move du ring the
test"
A nurse is an antepartum clinic is collecting data from a client who is 28 weeks
gestation. Which of the following findings should the nurse identify as an indication of a
potential complication?
1. Fetal heart rate 120/min
2. Dysuria
3. Leukorrhea
4. Fasting blood glucose 80 mg/dL - ANS2. Dysuria
-unexpected finding that can indicate a UTI
A nurse is assisting with collecting data from a newborn who is 4hr old. Which of the
following findings is the priority for the nurse to report to the provider?
1. Generalized petechiae
2. Cephalhematoma
3. Heart rate 170/min
4. Temp 97.6F - ANS1. Generalized petechiae
A nurse is assisting with discharge teaching about pain management to a client who
had a c-section birth and is experiencing gas pain. Which of the following instructions
should the nurse include int he teaching?
1. Drink fluids through a straw
2. Rock in a rocking chair
3. Lie supine when in bed
4. Consume whole milk with meals - ANS2. Rock in a rocking chair
A nurse is assisting with the admission of a client who has pertussis and is 28 weeks
gestation. Which of the following types of transmission -based isolation precautions
should the nurse initiate for the client?
1. Airborne
2. Contrast
3. Droplet
4. Protective environment - ANS3. Droplet
A nurse is assisting with the admission of a client whose labor is being induced. The
client reports using heroin 6 hrs ago. For which of the following manifestations of
abstinence should the nurse monitor the client?
1. Constipation
,2, Insomnia
3. Flaccid muscles
4. Euphoria - ANS2. Insomnia
A nurse is assisting with the care of a client who is in active labor and noted late
deceleration in the fetal heart rate. Which of the following actions should the nurse take
first?
1. Palpate the client's uterus to check for tachysystole
2. Place the client in a side-lying position
3. Administer oxygen at 10 L/min via nonrebreather face mask
4. Increase the rate of the clients IV fluids - ANS2. Place the client in a side-lying
position
A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is
receiving phototherapy. Which of the following findings should the nurse identify as a
potential complication of phototherapy?
1. Loose stools
2. Decreased urinary output
3. Axillary temp of 98.6 F
4. Skin rash - ANS2. Decreased urinary output
-phototherapy can lead to dehydration
A nurse is assisting with the care of a postpartum client and their newborn. The nurse
observes that the newborn appears to be choking on formula. Which of the following
actions should the nurse take? (select all that apply)
1. Reposition the newborn
2. Suction the newborns mouth with a bulb syringe
3. Apply oxygen via nasal cannula
4. Perform chest percussions
5. Auscultate breath sounds - ANS1. Reposition the newborn
2. Suction the newborns mouth with a bulb syringe
5. Auscultate breath sounds
A nurse is assisting with the data collection of a newborn who is 1 hr old. Which of the
following manifestations should indicate to the nurse that the newborn is experiencing
difficulty transitioning to extrauterine life?
1. Retractions
2. Acrocyanosis
3. Respirations 40/min
4. Temp 98F - ANS1. Retractions
A nurse is asssiting with the care of a client who is in active stage of labor. FOr which of
the following findings should the nurse notify the provider?
1. Spontaneous rupture of membranes
2. prolapsed umbilical cord
3. Pink to blood mucus discharge
, 4. Contraction duration of 60 seconds - ANS2. prolapsed umbilical cord
A nurse is caring for a client who is 1 hr postpartum and has a 3rd-degree perineal
laceration. Which of the following actions should the nurse perform? (Select all that
apply)
1. Apply an ice pack to the client's perineum
2. Have the client sit on a pillow
3. Place which hazel pads on the client's perineum
4. Prepare the sitz bath water to 107.6 F
5. Encourage the client to use a squeeze bottle to cleanse the perineum with each void
- ANS1. Apply an ice pack to the client's perineum
3. Place which hazel pads on the client's perineum
5. Encourage the client to use a squeeze bottle to cleanse the perineum with each void
A nurse is caring for a client who is 16 weeks of gestation and is at risk for developing
hyperemesis gravidarum. Which of the following conditions places the client at an
increased risk of developing this condition?
1. Placenta previa
2. Hypertension
3. Iron deficiency anemia
4. Diabetes mellitus - ANS4. Diabetes mellitus
A nurse is caring for a postpartum client who has an episiotomy. Which of the following
actions should the nurse take?
1. Apply an anesthetic spray to the client's perineal area as needed for pain
2. Place a donut pillow under the clients when sitting in a chair
3. Apply a moist heat pack to the client's perineal area for 20 min every hour for the first
24 hours
4. Assist the client with changing the perineal pad every 8 hr to expedite healing -
ANS1. Apply an anesthetic spray to the client's perineal area as needed for pain
A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the
following findings indicates that the client is at risk for dehydration?
1. Hematuria
2. Sodium 140 mEq/L
3. Potassium 3.5 mEq/L
4. Ketonuria - ANS4. Ketonuria
A nurse is collecting data from a client who is 36 weeks gestation. Which of the
following manifestations should the nurse report to the provider as potentially a
complication of pregnancy?
1. Insomnia
2. Breast tenderness
3. Frequent headaches
4. Leg cramps - ANS3. Frequent headaches
