The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which
assessment findings would alert the nurse to the possibility of this syndrome?
A. Tachypnea and retractions
B. Acrocyanosis and grunting
C. Hypotension and bradycardia
D. Presence of a barrel chest and acrocyanosis -
Ans A
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is
being breast-fed. The nurse should provide which most appropriate instruction to the mother?
A. Feed the newborn less frequently.
B. Continue to breast-feed every 2 to 4 hours.
C. Switch to bottle-feeding the infant for 2 weeks.
D. Stop breast-feeding and switch to bottle-feeding Permanently. -
Ans B
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes
mellitus. Which statement made by the client indicates a need for further teaching?
A. "I should stay on the diabetic diet."
B. "I should perform glucose monitoring at home."
, C. "I should avoid exercise because of the negative effects on insulin production."
D. "I should be aware of any infections and report signs of infection immediately to my health care
provider." -
Ans C
A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been
experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client
regarding management of care. Which statement made by the client indicates a need for further
instruction?
A. "I will watch for the evidence of the passage of tissue."
B. "I will maintain strict bed rest throughout the remainder of the pregnancy."
C. "I will count the number of perineal pads used on a daily basis and note the amount and color of
blood on the pad."
D. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the
last evidence of bleeding." -
Ans B
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is
beginning the second stage of labor?
A. The contractions are regular.
B. The membranes have ruptured.
C. The cervix is dilated completely.
D. The client begins to expel clear vaginal fluid. -
Ans C
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse
is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most
appropriate nursing action?
A. Administer oxygen via face mask.
B. Place the mother in a supine position.
C. Increase the rate of the oxytocin (Pitocin) intravenous infusion.
D. Document the findings and continue to monitor the fetal patterns. -