A nurse is assessing a late preterm newborn. Which of the following
manifestations is an indication of hypoglycemia?
Respiratory distress
A nurse in a provider's office is reviewing the medical record of a client who is in
the first trimester of pregnancy. Which of the following should the nurse identify
as a risk factor for the development of preeclampsia
Pregestational Diabetes Mellitus
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following
findings should the nurse report to the provider?
Fundal Height Measurement
A nurse is assessing a newborn who is 16 hr old. Which of the following findings
should the nurse report to the provider?
Substernal Retractions
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy.
The nurse enters the room and observes the client having a seizure. After turning
the client head to the side, which of the following actions should the nurse take
immediately after the seizure?
Administer oxygen via a nonrebreather mask
A nurse is developing a plan of care for a newborn who is to undergo
phototherapy for hyperbillirubinemia. Which of the following actions should the
nurse include in the plan?
Remove all clothing form the newborn except the diaper
A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and
has just had an amniocentesis. Which of the following interventions is the nurse's
priority following the procedure?
Monitor the FHR
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of
gestation. Which of the following findings should the nurse report to the
provider?
Reports of decreased fetal movement
A nurse is admitting a client to the labor and delivery unit when the client states,
"My water just broke". Which of the following interventions is the nurse's
priority?
,Begin FHR monitoring
A nurse is caring for a client who is at 36 weeks of gestation and has a positive
contraction stress test. The nurse should plan to prepare the client for which of
the following diagnostic test?
Biophysicial profile
A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is
in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in
water (D5W). The nurse should set the IV infusion pump to administer how many
mL/hr?
50 ml/hr
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV
fluid replacement. Which of the following findings should the nurse report to the
provider?
BUN 25 mg/dL
A nurse is providing teaching about nonpharmological pain management to a
client who is breastfeeding and has engorgement. The nurse should recommend
the application of which of the following items?
Cold cabbage leaves
A nurse is assessing a client who is 1 day postpartum and has a vaginal
hematoma. Which of the following manifestations should the nurse expect?
Vaginal pressure
A nurse is assessing a newborn who was born at 26 weeks of gestation using the
New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil
A nurse is providing teaching for a client who have birth 2 hr ago about the
facility policy for newborn safety. Which of the following client statements
indicates an understanding of the teaching?
the person who comes to take my baby's pictures will be wearing a photo identification
badge
A nurse is assessing a client who is at 36 weeks of gestation. Which of the
following findings should the nurse report to the provider?
Report of visual disturbances
A nurse is providing teaching to a client about the physiological changes that
occur during pregnancy. The client is at 10 weeks of gestation and has a BMI
within the expected reference range. Which of the following client statements
indicates an understanding of the teaching?
"I will likely need to use alternative positions for sexual intercourse".
, A nurse is caring for a client who is anemic at 32 weeks of gestation and is in
preterm labor. The provider prescribed bethamethasone 12 mg IM. Which of the
following outcomes should the nurse expect?
A reduction in respiratory distress in the newborn
A nurse is caring for a client who is experiencing preeclampsia and has a new
prescription for IV magnesium sulfate. Which of the following medications should
the nurse anticipate administering if the client develops magnesium toxicity?
Calcium Gluconate
A nurse is caring for a client who is at 30 weeks of gestation and has a
prescription for magnesium sulfate IV to treat preterm labor. The nurse should
notify the provider of which of the following adverse effects?
Respiratory rate 10/min
A nurse is caring for a client who is to receive oxytocin to augment her labor.
Which of the following findings contraindicates the infusion of the oxytocin
infusion and should be reported to the provider?
Late Decelerations
A nurse is teaching a client who is at 37 weeks of gestation and has a
prescription for a non-stress test. Which of the following instructions should the
nurse include?
"You should press the handheld button when you feel your baby move."
A nurse is assessing a newborn who was delivered vaginally and experienced a
tight nuchal cord. Which of the following findings should the nurse expect?
Petechiae over the head
A nurse is transporting a newborn back to the parent's room following a
procedure. Which of the following actions should the nurse take?
Verify that the parent's identification band matches the newborn's identification band
A nurse is creating a plan of care who is postpartum and adheres to traditional
Hispanic cultural beliefs. Which of the following cultural practices should the
nurse include in the plan of care?
Protects the client's head and feet from cold air
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse
how to perform Leopoid maneuvers. Which of the following images indicates the
first step of Leopoid maneuvers?
Picture of nurse palpating top of belly; where bottom is
A nurse is developing a plan of care for a client who has preeclampsia and is
receiving magnesium sulfate via a continuous IV infusion. Which of the following
interventions should the nurse include in the plan?
Monitor the FHR continously
A nurse is assessing a client who is at 38 weeks of gestation during a weekly
prenatal visit. Which of the following findings should the nurse report to the
provider?
Weight gain of 2.2 kg (4.8 lb)
A nurse is caring for a client who is at 36 weeks of gestation and has a
prescription for an amniocentesis. For which of the following reasons should the
nurse prepare the client for an ultrasound?
To locate the pocket of fluid