NURSING Med Surg 2 / SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE / Questions and Answers / Already Graded A

NURSING Med Surg 2 / SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is th e most appropriate for the child? Private room 2) The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor 3) The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? Assess the client's readiness to learn. 4) A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action? Monitor respiratory status. 5) The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used. 1) Place the client in a semi Fowler's position. 2) Turn on the suction device and set the regulator at 80 mm Hg. 3) Attach the suction tubing to the suction catheter. 4) Hyperoxygenate the client. 5) Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm. 6) Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth. 6) The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority? Remove the IV catheter. 7) A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used. 1) Close the roller clamp on the IV tubing. 2) Spike the IV bag and half-fill the drip chamber. 3) Open the roller clamp and fill the tubing. 4) Uncap the distal end of the tubing. 5) Attach the distal end of the tubing to the client. 8) The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 9) The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? The client with problems clearing the airway related to abdominal incision pain 10) The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? Prepare the child for a chest radiograph. 11) The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made? "Actual or life-threatening concerns are the priority." 12) A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used. 1) Check the client's blood glucose level. 2) Give the client ½ cup (118 mL) of fruit juice to drink. 3) Take the client's vital signs. 4) Retest the blood glucose level. 5) Give the client a small snack of carbohydrate and protein. 6) Document the client's complaints, actions taken, and outcome. 13) An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? A 45-year-old man with chest pain, shortness of breath, and diaphoresis 14) The nurse is assigned to care for 4 clients. Which client should the nurse assess first? A client who has a peripheral (index finger) oxygen saturation percentage of 85% 15) The nurse has received her client assignment for the day. Which client should the nurse care for first? A client with postoperative pain reported at 7 out of 10, with 10 being the worst 16) The nurse has received the client assignment for the day. Which client should the nurse care for first? The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination 17) The nurse is the first responder at the scene of a 6- car crash on a highway. Which victim should the nurse attend to first? A victim experiencing dyspnea 18) The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. A client with a Holter monitor A client receiving oral antibiotics A client experiencing sinus rhythm 19) The nurse has received her client assignment for the day. Which client should the nurse check first? A client who has just returned from surgery 20) The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? Victim with an apparent chest wall defect and asymmetrical chest wall movement 21) The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma 22) The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? The confused 12-year-old with bright red blood pulsing from an open fracture of the femur 23) The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. The client who 24 hours earlier gave birth to her second child by caesarean delivery The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation 24) The nurse has received her client assignment for the day. Which client should the nurse care for first? The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath 25) During morning report, the day nurse is given information on the assigned clients. Which client should the nurse assess first? The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon 26) The nurse determines that which client has the highest priority needs? The client who has an irregular apical pulse of 120 beats per minute 27) When planning care, which client should the nurse assess first? The client with a chest tube for a pneumothorax 28) The nurse assigned to 4 clients reviews client data at the beginning of the shift. To which information should the nurse give highest priority? Pulse oximetry reading 89% 29) A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 a.m. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? Arrange the actions in the order that they should be performed. All options must be used. 1) A client with diabetes mellitus who needs a fasting blood glucose level drawn 2) The first dressing change for a client requiring twice-daily dressing changes 3) A client being visited by the home health aide at 1030 4) A client requiring supervision of a dressing change 5) A client requiring an admission assessment to home health care 6) The second dressing change for a client requiring twice-daily dressing changes 30) The nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 1) Clamp the intravenous (IV) catheter. 2) Position the client in a left Trendelenburg's position. 3) Contact the health care provider (HCP). 4) Administer oxygen. 5) Take the client's vital signs. 6) Document the occurrence. 31) A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 1) Verify the health care provider's (HCP's) prescription for the blood transfusion. 2) Ensure that an informed consent has been signed. 3) Insert an 18- or 19-gauge intravenous catheter into the client. 4) Obtain the unit of blood from the blood bank. 5) Ask a licensed nurse to assist in confirming vital signs and blood compatibility and verifying client identity. 6) Hang the bag of blood. 32) The nurse is monitoring a client in labor who is receiving oxytocin and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 1) Stop the oxytocin infusion. 2) Reposition the client. 3) Administer oxygen by face mask at 8 to 10 L/min. 4) Perform a vaginal examination. 5) Check the client's blood pressure. 6) Administer medication as prescribed to reduce uterine activity. 33) After correctly completing the rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps should the nurse take to administer medication via a volume control container? Arrange the actions in the order that they should be performed. All options must be used. 1) Fill volume control container with desired amount of IV fluid by opening clamp between volume control container and main IV bag. 2) Close the clamp and check to be sure that clamp on air vent volume control container is open. 3) Clean injection port on top of volume control container with an antiseptic swab. 4) Remove needle cap and insert needleless syringe tip through the port, and then inject the medication. Label the volume control container with the name of the medication, dosage, total volume including diluents, and time of administration. 5) Regulate intravenous (IV) infusion rate to allow medication to infuse in the time recommended by institutional policies. 6) Dispose of the syringe in puncture-proof and leak-proof container. Discard supplies and perform hand hygiene. 34) The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? Bright red bleeding from a neck wound 35) The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? A victim experiencing airway obstruc 36) The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. A client experiencing sinus rhythm A client receiving oral anticoagulants A client with chronic atrial fibrillation 37) The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? A young woman who appears dazed and confused and is shivering 38) Which client should the emergency department triage nurse classify as emergent? A client with crushing substernal pain who is short of breath 39) The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? Refer to Figure. (Figure from McKinney et al. [2013], p. 310.) View Figure Normal 40) The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." "The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy." 41) The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client? "This is necessary to assist in identifying potential infections that may need to be treated." 42) A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client? "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." 43) The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding? Fundus is at the appropriate level. 44) The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? The client has a history of hypertension. 45) During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? "Diet and insulin needs change during pregnancy." 46) The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction? "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." 47) The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18- month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason? Reduce excessive maternal stress and fatigue. 48) The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? Whole-grain cereal 49) The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? Leafy green vegetables 50) A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply. The client is wearing knee-high nylon stockings. The client is wearing sweatpants with snug elastic ankle bands. 51) A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction? "I should do more exercises to strengthen my back muscles." 52) A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen." 53) The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? Drink 8 glasses of water per day. 54) A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response? "This test measures amniotic fluid volume and fetal activity." 55) The nurse is taking a nutritional history from a 16- year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem? "I want to gain only 10 pounds because I want to have a small, petite baby." 56) The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? Monitor for appropriate weight gain patterns. 57) The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? Dried fruits 58) The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item? Orange juice 59) A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? "I will need to prepare myself and my family for the loss of this pregnancy." 60) The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? History of syphilis 61) The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority? Monitoring the apical pulse 62) The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply. Use of fertility medications History of Chlamydia Use of an intrauterine device History of pelvic inflammatory disease (PID) 63) The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? The client's last baby weighed 10 pounds at birth. 64) The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment? Increased insulin 65) The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply. Vaginal bleeding Excessive nausea and vomiting Larger-than-normal uterus for gestational age Elevated levels of human chorionic gonadotropin (hCG) 66) The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid? Dried peas 67) A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements? Select all that apply. "This test can be used as a screening for spina bifida." "This test is a screening test, and I will need other testing if I have abnormal results." "This test can indicate if I may be at an increased risk for having a child with Down syndrome." 68) A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2018, and ended the menses on March 14, 2018. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits (mmddyy). Correct Answer: 69) The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement? "An increase in pulse rate occurs." 70) The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply. Viruses Nutrients Antibodies Medications 71) A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms? Eating dry crackers before arising 72) The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction? Restrict visitors who may have an active infection. 73) A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit? Monitor for fetal movement. 74) A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? Reduce external stimuli. 75) A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client? A private room 2 doors away from the nurses' station 76) A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure? "The procedure is performed using artificial insemination of sperm instilled through the vagina." 77) The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes? Select all that apply. Places the client at risk for dystocia Has an increased probability of cesarean section Has a flat shape that may impede fetal descent 78) The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply. Plan for weekly nonstress tests at 32 weeks. Obtain nutritional counseling with a dietitian. 79) The nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid? Spinach 80) The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain? Calcium gluconate injection 81) A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client? Pain, itching, and vaginal discharge 82) The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd). Correct Answer: 1116 83) The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness? Compression of the vena cava 84) A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? "I should wear underwear with a cotton panel liner." 85) The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response? "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." 86) A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and should tell the client that which change may persist after she gives birth? Striae gravidarum 87) A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement? "I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water." 88) A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction? "I should drink unpasteurized milk only." 89) A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension? "My vision for the past 2 days has been really fuzzy." 90) A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse? Respiratory rate of 10 breaths/minute 91) The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time? Select all that apply. The fetus is approximately 42 to 48 cm long. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1. 92) A client who has just been told that she is pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response? "Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine." 93) During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia? Maternal infection 94) The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply. Assess blood pressure. Check the urine for protein. Assess deep tendon reflexes. Teach the importance of keeping track of a daily weight. 95) During a woman's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What should be the nurse's next intervention? Document findings in the electronic health record. 96) The nurse is teaching a woman in her first trimester measures to alleviate nausea and vomiting. Which statement by the woman indicates that further teaching is required? "I will eat dry crackers for breakfast after I get up." 97) The nursing instructor asks a nursing student who is preparing to assist with the assessment of an 18 weeks' gestation gravida 2, para 1 (G2P1) pregnant woman to describe expectations related to the process of quickening. Which statements, if made by the student, indicate an understanding of this process? Select all that apply. "It is the fetal movement that is felt by the mother." "It is typically experienced by the multigravida client between 16 and 18 weeks' gestation." 98) The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation? "I don't like my face anymore. I always look like I have been crying." 99) The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority? Insufficient fluid volume 100) The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions? "The iron is best absorbed if taken on an empty stomach." 101) A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the woman? "You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed." 102) A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client? "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed." 103) A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply. The breast changes occur because of the secretion of estrogen and progesterone. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida. 104) The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action? Massaging the abdomen during contractions, using both hands in a circular motion 105) During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutritional measures to minimize this problem? "I will eat fresh fruits and vegetables for snacks and for dessert each day." 106) A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs? "I should avoid stressful situations." 107) The nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign? Bluish discoloration of cervix and vagina 108) A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse include in the teaching? Select all that apply. An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation. 109) A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider (HCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the HCP has documented the results as negative. How should the nurse interpret this finding? A normal test result 110) A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information? HIV antibodies are detected by the enzyme- linked immunosorbent assay (ELISA) test. 111) In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections? Establish a therapeutic relationship. 112) The clinic nurse is teaching a pregnant woman about the warning signs in pregnancy. Which, if identified as a warning sign by the woman, should indicate a need for further education? Presence of irregular, painless contractions 113) The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that it is 99.2°F. Based on this finding, which nursing action is most appropriate? Document the temperature. 114) A 39-week-gestation pregnant client calls the maternity unit, stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which is the best response made by the nurse? "Fetal movements do not decrease as a woman nears term; therefore, you should be seen by your health care provider for further evaluation." 115) A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 99°F. The nurse plans care based on which interpretation? The woman requires further evaluation for preterm labor. 116) The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client? "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated." 117) A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication? Abruptio placentae 118) The result of a biophysical profile (BPP) of a 28-year- old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action? Place the fetal heart monitor on the client in order to do a nonstress test (NST). 119) A client in week 35 of her pregnancy is placed on the fetal heart monitor for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes which conclusion regarding the NST? Refer to Figure. (From McKinney et al. [2013], p. 319.) View Figure The FHR is reactive, with a baseline of 130 beats/minute, moderate variability, and no decelerations. 120) The charge nurse on a labor and delivery unit has numerous admissions of laboring clients and must transfer 1 of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client is the most appropriate one to transfer? The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding 121) Which medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate? Phenytoin 122) The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply. Painless, bright red vaginal bleeding Location in the lower uterine segment 123) A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 18 weeks 124) The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply. Abdominal pain Firm uterus by palpation 125) A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider (HCP). The nurse should tell the woman to call the HCP if which occurs? Weight increases by more than 1 pound in a week. 126) A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? Apply heat to the affected area. 127) The nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur? She will feel some pressure when the vaginal probe is moved. 128) The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What should be the nurse's response? "Prolactin stimulates the secretion of milk, which is called lactogenesis." 129) The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates a need for further teaching? "I cannot exercise because of the negative effects on insulin production." 130) The nurse is caring for a client with a diagnosis of endometriosis. The client asks the nurse to describe this condition. How should the nurse respond? Select all that apply. "It is the presence of tissue outside the uterus that resembles the endometrium." "Major symptoms of endometriosis are pelvic pain, dysmenorrhea, and dyspareunia." 131) A client calls the health care provider's office to schedule an appointment because she has missed 2 menstrual cycles and has always been very regular. The client receives an appointment for the next day. The nurse should expect which findings to be present at this prenatal visit if the client is pregnant? Select all that apply. Chadwick's sign Positive pregnancy test 132) The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses should the nurse give the client about the role of estrogen? Select all that apply. It increases the blood flow to mucous membranes and causes them to swell and soften. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. 133) The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the sex of the fetus is determined by which weeks? 12 to 16 134) The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was and the client reports February 9, 2018. Using Nägele's rule, the nurse determines that what is the estimated date of delivery? Fill in the blank. Record your answer using 6 digits (mmddyy). Correct Answer: 135) A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which is the most appropriate nursing action? Assess for signs of venous thrombosis. 136) A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate? Notify the health care provider (HCP). 137) The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures? "It may be necessary to have a cesarean section for delivery." 138) A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate? "Breast-feeding is allowed after the baby has been vaccinated with immune globulin." 139) The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)? 32 cm 140) A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should the nurse implement? Instruct the client that these are common and may occur throughout the pregnancy. 141) The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of first trimester pregnancy signs. Which signs should the nurse anticipate as being present during this time frame? Select all that apply. Hegar's sign Goodell's sign Chadwick's sign 142) A nursing instructor asks a nursing student to describe the process of quickening. Which statements by the student indicate an understanding of this term? Select all that apply. "It is the fetal movement that is felt by the mother." "It is a process that occurs in the pregnant woman as early as 16 weeks but definitely by week 20." 143) A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make? Between 16 and 20 weeks 144) A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? Retesting rubella titer during pregnancy 145) A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply. "The exercises will help strengthen the pelvic floor in preparation for delivery." "The exercises will help strengthen the muscles that support the bladder and urethra." 146) The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching? "I should lie on my back to perform the procedure." 147) A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client? "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." 148) The nurse provides teaching on how to relieve discomfort to a client in her second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching? "When I get home I should lie on the floor, with my legs elevated on a couch, and turn my hips and knees at right angles." 149) A pregnant client calls the nurse at the health care provider's office and reports that she has noticed a thin, colorless vaginal drainage. Which information is most appropriate for the nurse to provide to the client? The vaginal discharge may be bothersome but is a normal occurrence. 150) The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result? Normal findings 151) A pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. Which activity should the nurse tell the client to perform when the cramps occur? Dorsiflex the foot while extending the knee. 152) The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching? "I should apply heat packs to the hemorrhoids to help them shrink." 153) The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food should the nurse instruct the client to eat to supplement the dietary source of calcium? Broccoli 154) The nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food should the nurse encourage the client to consume because it is highest in folic acid? Green leafy vegetables 155) A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. Which exercise should the nurse instruct the client to engage in? Swimming 156) A pregnant client reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. A sputum culture is obtained, and Mycobacterium tuberculosis is identified in the sputum. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis? Isoniazid plus rifampin will be required for a total of 9 months. 157) The nurse provides home care instructions to a pregnant client with a history of cardiac disease. Which statement made by the client indicates a need for further teaching? "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." 158) The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved? Complaints of daily headaches and fatigue 159) The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk? Presence of cats in the home 160) Which is the priority nursing action for the client with an ectopic pregnancy? Monitoring the pulse and blood pressure 161) The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data should alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? Select all that apply. The client's last baby weighed 10 lb at birth. The client has a history of gestational diabetes with her previous pregnancy. 162) The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that which may be required during the second half of pregnancy? Increased insulin 163) The nurse is providing instructions about taking iron supplements to a pregnant client. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which drink? Orange juice 164) The nurse is assisting the health care provider to perform Leopold's maneuvers on a pregnant client. Which action should the nurse perform before the procedure? Ask the client to urinate. 165) The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period? A 26-year-old client with a family history of thrombophlebitis 166) The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should determine that the client needs further teaching if the client believes that which is true about nutrition during pregnancy? Pregnancy greatly increases the risk of malnourishment for the mother. 167) The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time? The client's fear 168) The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. Petechiae Hematuria Prolonged clotting times Oozing from injection sites 169) The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? Forceps delivery 170) The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? Breathe rapidly. 171) The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 172) A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate? Every 15 minutes 173) The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? Palpating the maternal radial pulse while listening to the FHR 174) The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? A fetal heart rate of 90 beats/minute 175) The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? Continuous electronic fetal monitoring 176) The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? Placental separation 177) During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? Prevent dehydration and hypoxemia. 178) A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? Measure fundal height. 179) The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? Clear and maintain an open airway. 180) A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted? Painless vaginal bleeding 181) A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. Increase in fundal height Hard, boardlike abdomen Persistent abdominal pain 182) The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 183) An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal? Pale straw in color, with flecks of vernix 184) A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? Continue to monitor the client. 185) The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. Keep the room semi-dark. Initiate seizure precautions. Pad the side rails of the bed. Avoid environmental stimulation. 186) The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? Monitoring the mother's blood pressure 187) The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? Assess the fetal heart rate. 188) The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? Moderate variability present 189) The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? Click on the image to indicate your answer. (From Jarvis [2013], pp. 646–648.) Correct Answer Indication: 190) The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? Encourage an upright or side-lying maternal position. 191) The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client? Assess for signs and symptoms of labor. 192) The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? Butorphanol tartrate 193) The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? Complaints of severe abdominal pain 194) The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? Fear of losing control 195) A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? Postpartum infection 196) Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? Administer oxygen at 8 to 10 L/min via face mask. 197) A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action? Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 198) A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? Explain to the client why a cesarean delivery is necessary. 199) The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. Tachycardia Fetal hypoxia Metabolic academia Congenital anomalies 200) After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? Assess the vagina and cervix with a gloved hand. 201) On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations? Periodic, early decelerations that indicate fetal head compression 202) Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. Turn the woman to a lateral position. Increase the rate of the intravenous infusion. Administer oxygen by face mask at 10 L/minute. 203) The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 204) On March 10, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7 the previous year. The nurse plans care based on which interpretation? The client is possibly in preterm labor. 205) The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and should expect to note which prescribed treatment for this condition? Oxytocin infusion 206) A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider has prescribed an epidural block. Which nursing intervention should be implemented after the epidural block has been placed? Palpate the bladder at frequent intervals. 207) The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? Document the findings and continue to monitor fetal patterns. 208) The nurse is caring for a