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On the first postpartum day, the nurse examines the breasts of the new mother.
Which condition is the nurse most likely to.
A. Slightly firm with immediate let down response
B. Filing and secreting colostrum
C. Soft, with no change from before delivery
D. Firm, larger very tender to touch - ANSWER ✓ B. Filling and secreting
colostrum
The nurse who is working at a prenatal clinic notes a woman that is at 18 weeks of
gestation has two elevated maternal alpha feto-protein (MSAFP) values. What
action should the nurse implement?
A. Instruct the client to increase intake of folic acid supplements
B. Request a consultation with genetic counselor
C. Schedule a sonogram in the radiology department
D. Send the client to the laboratory for repeat MSAFP - ANSWER ✓ C. schedule a
sonogram in the radiology department
Following a minor vehicle collision , a client 36 weeks gestation is brought to the
emergency center. She is lying supine on a backboard , is awake , denies any
complaints. Her blood pressure is 80/50 mm Hg and heart rate is 130 beats per
min. What action should the nurse implement first?
A. Turn the board sideways to displace the uterus lateral
B. Palpate the abdomen for contractions
C. Infuse 1,000 normal saline using a large bore IV
D. Obtain blood sample for a complete blood count - ANSWER ✓ A. Turn the
board sideways to displace the uterus lateral
, When assessing a pregnant woman who is 39 weeks gestation who is admitted to
labor and delivery, which finding is most important to report the health care
provider?
A. + 1 proteinuria
B. 130/70 blood pressure
C. 102 oral temperature
D. +1 pedal edema - ANSWER ✓ C. 102 oral temperature
During a routine prenatal vital a client 32 weeks gestation complains of urinary
frequency has increased during the day as well at night. The nurse determines the
client is having irregular uterine contractions. What should the nurse implement ?
A. Ask the client if she had sexual intercourse yesterday
B. Determine if she has change in vaginal discharge
C. Collect urine sample from dipstick analysis
D. Obtain a midstream urine specimen for culture - ANSWER ✓ D. Obtain a
midstream urine specimen for culture
The nurse teaching a preconception preparation class is discussing ways to
improve dietary folic acid intake. Which evening snack contains the most folic
acid?
A. Fresh strawberries
B. Roasted peanuts in shell
C. Unflavored yogurt
D. Vanilla milkshake with protein supplement - ANSWER ✓ B. roasted peanut in
shell
A 38 week primigravida is admitted to labor and delivery after a non-reactive
result on a non-stress test (NST) .The nurse begins contraction stress test (CST)
with an oxytocin ( Pitocin ) infusion. Which finding is most important for the nurse
to report to the health care provider ?
A. Spontaneous rupture of membrane
B. Fetal heart rate accelerations with fetal movement
C. Absence of uterine contractions within 20 mins
D. A pattern of late fetal decelerations - ANSWER ✓ D. A pattern of late fetal
decelerations
, A primigravida is 36 weeks gestation, is Rh negative is experienced abdominal
trauma in a motor vehicle collision. Which assessment finding is most important
for the nurse to report to the healthcare provider?
A. Positive fetal hemoglobin test
B. Fetal heart rate is 162 beats / min
C. Trace of protein in urine
D. Mild contractions every 10 mins - ANSWER ✓ A. Positive fetal hemoglobin
test
The nurse is caring for an newborn who is 18 inches long, weighs 4 pounds , 14
ounces, has a head circumference of 13 inches and chest circumference is of 10
inches. Based on these physical findings , assessment for which condition has the
highest priority?
A. Hyperthermia
B. Hyperbillirubinemia
C. Polycythemia
D. Hypoglycemia - ANSWER ✓ D. Hypoglycemia
A school nurse is preparing a seminar to address the concerns of pregnant
adolescent. What information is most important for the nurse to include in this
program?
A. Nutritional requirements during pregnancy
B. Pain management options for labor
C. Comparison of infant feeding method
D. Symptoms to report to the healthcare provider - ANSWER ✓ A. Nutritional
requirements during pregnancy
A postpartal client who is bottle feeding develops engorgement . What is the best
recommendation for nurse to provide this client ?
A. Avoid stimulation to breast and wear a tight bra
B. Express small amount of breast milk in your hand
C. Take a prescribed analgesic and express the breast to air
D. Place warm packs on both sides of breast - ANSWER ✓ A. Avoid stimulation
to breast and wear tight bra
The nurse is assessing a patient who is 36 hours post delivery. Which finding
should the nurse report to the healthcare provider?
A. White blood cell count 19,000
B. Oral temperature of 100.6