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,Terms in this set (100)
A nurse is contributing to the POC for a pt who has a) The nurse should instruct the pt to consume liquid & solid foods separately to
hyperemesis gravidarum. Which of the following prevent the stomach from overfilling.
interventions should the nurse recommend? b) The nurse should obtain specimens for a urinalysis & CBC, as well as
electrolytes, liver enzymes, & bilirubin levels. A uric acid level is a laboratory test
a) Encourage fluids w/ meals. essential for clients who have preeclampsia.
b) Obtain a specimen for uric acid level. c) The nurse should initiate a low-fat & high-protein diet.
c) Initiate a high-fat & low-protein diet. d) The nurse should monitor intake & output to evaluate the pt's hydration
d) Monitor intake & output. status & determine whether other interventions are necessary.
A nurse is reinforcing teaching about newborn home safety a) The space b/t the mattress & the sides of the crib should be < 2 finger widths, or
precautions w/ a group of guardians. Which of the < 2 cm (0.8 in), to prevent entrapment, which can lead to extremity fractures &
following instructions should the nurse include? suffocation.
b) The nurse should reinforce that crib slats should be > 5.71 cm (2.25 in)
a) "You should be able to place 3 fingers b/t the mattress & apart to prevent entrapment, which can lead to extremity fractures &
the sides of the crib." suffocation.
b) "You should ensure that the crib slats are no more than c) Attaching a pacifier to the newborn's clothing can increase the risk of suffocation.
2.25 in apart." d) Guardians should set water heaters at 49°C (120.2°F) or less.
c) "You should attach a pacifier to your baby's clothing."
d) "You should set your water heater at 130°F."
A nurse is reinforcing teaching about car seat safety w/ the a) The guardian should position the newborn's car seat rear-facing in the middle of
guardian of a newborn. Which of the following statements the back seat from birth for as long as possible until they meet the height and
by the guardian indicates an understanding of the weight restrictions set by the car seat's manufacturer.
teaching? b) The guardian should position the retainer clip at the level of the newborn's
axillae & not over the neck or abdomen.
a) "I will place the baby's car seat in a rear-facing position c) The guardian should place the shoulder harness straps in the slots at or below
until she is 1 yr old." the level of the newborn's shoulders.
b) "I will position the retainer clip at the level of the baby's d) The guardian should position the newborn in the car seat at a 45° angle to
armpits." prevent the newborn's head from falling forward, which can lead to airway
c) "I will place the shoulder harness straps in a slot 2 in obstruction & suffocation.
above the baby's shoulders."
d) "I will position the baby at a 60° angle in the car seat."
A nurse is collecting data from a pt who gave birth 18 hrs a) The fundus should be located at the level of the umbilicus during the first
ago. Which of the following findings should the nurse 24 hrs postpartum and decrease 1 cm each day after that. A fundus that is
identify as an indication of a postpartum complication? palpable at a higher than expected level could be an indication of uterine
atony, which can result in maternal hemorrhage.
a) Fundus is palpable at 2 cm above the umbilicus. b) The temperature is an expected finding in the first 24 hr postpartum d/t
b) Temperature is 38°C (100.4°F). dehydration.
c) Lochia increases after breastfeeding. c) Increased lochia after breastfeeding is an expected finding. Maternal oxytocin is
d) The perineal pad contains several small blood clots. released during breastfeeding, which causes uterine contractions. The contractions
decrease the risk of postpartum hemorrhage and expel lochia which has pooled in
the uterus.
d) Lochia containing small blood clots is an expected finding in the first 24 hrs
postpartum. Lochia that is bright red or contains large blood clots indicates
excessive bleeding.
A nurse in a clinic is collecting data from a pt who is at 12 a) Fetal heart tones are audible w/ an US stethoscope at the end of the first
weeks of gestation. Which of the following actions should trimester.
the nurse take? b) The nurse should obtain a blood sample for the MSAFP screen between 16-18
a) Use an ultrasound stethoscope to listen to fetal heart weeks of gestation.
tones. c) The nurse should collect a vaginal & anal specimen for GBS between 35-37
b) Obtain a blood sample for the maternal serum alpha- weeks of gestation.
fetoprotein (MSAFP) screen. d) The nurse should measure fundal height regularly b/t 18-30 weeks of gestation.
c) Collect a vaginal and an anal specimen for a group
B Streptococus (GBS).
d) Measure fundal height for gestational age.
, A nurse is reinforcing education about the prevention of a) The client should only transport their newborn between the nursery and their
newborn abduction w/ a pt who recently gave birth. Which room in a bassinet.
of the following statements should the nurse identify as an b) An alarm will sound if someone removes the newborn's safety device, or if
indication that the client understands the instructions? someone transports the newborn past an established facility parameter.
c) The client should always request ID from any healthcare personnel that is
a) "I can carry my baby back to the nursery in my arms." removing their newborn from the room. Only facility personnel w/ badges indicating
b) "An alarm will sound if someone removes my baby's that the individual works specifically in the maternal/newborn unit should transport
safety device." newborns. This is a safety precaution to prevent newborn abduction.
c) "The nurse is not required to show their ID when taking d) Leaving a newborn unattended while showering places the newborn at risk for
my baby back to the nursery." abduction.
d) "I can leave my baby in the bassinet while I take a
shower."
A nurse is planning to reinforce d/c teaching about formula a) The guardian should schedule the newborn's feedings every 3-4 hrs.
feeding w/ the guardian of a newborn. Which of the b) A newborn will typically drink 15-30 mL of formula per feeding during the first 24-
following instructions should the nurse plan to include? 48 hrs.
c) Formula contains enough water to meet a newborn's fluid needs. Offering water
a) Provide the newborn w/ 6-8 feedings during a 24-hr b/t feedings can lead to an inadequate caloric intake.
period. d) The nurse or guardian should burp the newborn a few times during the feeding to
b) Ensure that the newborn receives 45-60 mL of formula reduce spitting up. Burping the newborn several times throughout the feeding can
per feeding during the first 48 hrs. decrease episodes of regurgitation after the feeding.
c) Offer water to the newborn b/t feedings.
d) Delay burping the newborn until the feeding is complete.
A nurse is contributing to the POC for a pt who has a) The nurse should use an 18-gauge catheter to administer magnesium sulfate to
eclampsia. Which of the following interventions should the the client; however, there is another action the nurse should take first.
nurse plan to include as the priority immediately following a b) The nurse should insert an indwelling urinary catheter to monitor the pt's output;
seizure? however, there is another action the nurse should take first.
c) The first action the nurse should take when using the ABC approach to pt
a) Initiate an IV line w/ an 18-gauge needle. care is to administer oxygen via facemask at 10 L/min to increase
b) Insert an indwelling urinary catheter. oxygenation.
c) Administer oxygen via facemask at 10 L/min. d) The nurse should monitor the pt during magnesium sulfate therapy, which is used
d) Monitor the pt during magnesium sulfate therapy. to prevent further seizure activity; however, there is another action the nurse should
take first.
A nurse is reinforcing teaching about preventing UTIs w/ a a) The nurse should instruct a pt who has urinary incontinence to perform Kegel
pt who is at 25 weeks of gestation. Which of the following exercises to strengthen the muscles of the pelvic floor.
instructions should the nurse include? b) The nurse should instruct the pt to urinate & empty the bladder completely
before going to bed at night to prevent stasis of urine. A full bladder provides
a) "You should perform Kegel exercises 4x/day." an environment that fosters bacterial growth.
b) "You should empty your bladder before you go to bed at c) The nurse should instruct the pt to wipe from front to back after voiding to avoid
night." transferring fecal bacterial to the urethra.
c) "You should wipe from back to front after urinating." d) The nurse should instruct the pt to wear all cotton undergarments to avoid
d) "You should wear underwear made from nylon." trapping heat & moisture in the genital area.
A nurse is collecting data from a 28 yo pt who is requesting a) A Hx of mononucleosis is not a contraindication for oral contraceptive use.
an Rx for an oral contraceptive. Which of the following info Although infection is not a contraindication, the pt will need to know that there are
in the pt's Hx should the nurse identify as a some antibiotic & antiviral meds that can reduce the effectiveness of oral
contraindication for the use of oral contraceptives? contraceptives.
b) Frequent headaches w/ visual changes can indicate a cardiovascular
a) Hx of mononucleosis 1 yr ago condition, such as HTN. A cardiovascular disorder is a contraindication for
b) Frequent headaches w/ visual changes oral contraceptive use b/c the combination can increase the risks of
c) Reports of occasional heartburn in the evening cerebrovascular accident, myocardial infarction, & thromboembolism.
d) Irregular menstrual cycles w/ dysmenorrhea c) Occasional heartburn in the evening is not contraindication for oral contraceptive
use as long as it is not a manifestation of a more serious disorder. Gallbladder
disease and liver cirrhosis, for example, are contraindications for oral contraceptive
use, and both these disorders can cause indigestion.
d) Irregular menstrual cycles w/ dysmenorrhea are not a contraindication for using
oral contraceptives. In fact, non-contraceptive advantages of oral contraceptive use
include regulation of irregular cycles & relief of menstrual pain.
A nurse is collecting data from a pt who is at 38 weeks of a) Glycosuria is a potential complication of gestational DM & the nurse should
gestation. Which of the following findings should the nurse report this finding to the provider.
report to the provider? b) Leg cramps are an expected finding during the 3rd trimester of pregnancy d/t
poor peripheral circulation.
a) Glycosuria c) Insomnia is an expected finding during the 3rd trimester of pregnancy d/t the
b) Leg cramps physical discomforts of pregnancy.
c) Insomnia d) Leukorrhea is an expected finding throughout pregnancy d/t an increased
d) Leukorrhea amount of cervical mucus resulting from hormonal changes.
P
N
M
a
t
e
r
n
a
l/
N
e
w
b
o
r
n
A
&
B
Students
also
studied
,Terms in this set (100)
A nurse is contributing to the POC for a pt who has a) The nurse should instruct the pt to consume liquid & solid foods separately to
hyperemesis gravidarum. Which of the following prevent the stomach from overfilling.
interventions should the nurse recommend? b) The nurse should obtain specimens for a urinalysis & CBC, as well as
electrolytes, liver enzymes, & bilirubin levels. A uric acid level is a laboratory test
a) Encourage fluids w/ meals. essential for clients who have preeclampsia.
b) Obtain a specimen for uric acid level. c) The nurse should initiate a low-fat & high-protein diet.
c) Initiate a high-fat & low-protein diet. d) The nurse should monitor intake & output to evaluate the pt's hydration
d) Monitor intake & output. status & determine whether other interventions are necessary.
A nurse is reinforcing teaching about newborn home safety a) The space b/t the mattress & the sides of the crib should be < 2 finger widths, or
precautions w/ a group of guardians. Which of the < 2 cm (0.8 in), to prevent entrapment, which can lead to extremity fractures &
following instructions should the nurse include? suffocation.
b) The nurse should reinforce that crib slats should be > 5.71 cm (2.25 in)
a) "You should be able to place 3 fingers b/t the mattress & apart to prevent entrapment, which can lead to extremity fractures &
the sides of the crib." suffocation.
b) "You should ensure that the crib slats are no more than c) Attaching a pacifier to the newborn's clothing can increase the risk of suffocation.
2.25 in apart." d) Guardians should set water heaters at 49°C (120.2°F) or less.
c) "You should attach a pacifier to your baby's clothing."
d) "You should set your water heater at 130°F."
A nurse is reinforcing teaching about car seat safety w/ the a) The guardian should position the newborn's car seat rear-facing in the middle of
guardian of a newborn. Which of the following statements the back seat from birth for as long as possible until they meet the height and
by the guardian indicates an understanding of the weight restrictions set by the car seat's manufacturer.
teaching? b) The guardian should position the retainer clip at the level of the newborn's
axillae & not over the neck or abdomen.
a) "I will place the baby's car seat in a rear-facing position c) The guardian should place the shoulder harness straps in the slots at or below
until she is 1 yr old." the level of the newborn's shoulders.
b) "I will position the retainer clip at the level of the baby's d) The guardian should position the newborn in the car seat at a 45° angle to
armpits." prevent the newborn's head from falling forward, which can lead to airway
c) "I will place the shoulder harness straps in a slot 2 in obstruction & suffocation.
above the baby's shoulders."
d) "I will position the baby at a 60° angle in the car seat."
A nurse is collecting data from a pt who gave birth 18 hrs a) The fundus should be located at the level of the umbilicus during the first
ago. Which of the following findings should the nurse 24 hrs postpartum and decrease 1 cm each day after that. A fundus that is
identify as an indication of a postpartum complication? palpable at a higher than expected level could be an indication of uterine
atony, which can result in maternal hemorrhage.
a) Fundus is palpable at 2 cm above the umbilicus. b) The temperature is an expected finding in the first 24 hr postpartum d/t
b) Temperature is 38°C (100.4°F). dehydration.
c) Lochia increases after breastfeeding. c) Increased lochia after breastfeeding is an expected finding. Maternal oxytocin is
d) The perineal pad contains several small blood clots. released during breastfeeding, which causes uterine contractions. The contractions
decrease the risk of postpartum hemorrhage and expel lochia which has pooled in
the uterus.
d) Lochia containing small blood clots is an expected finding in the first 24 hrs
postpartum. Lochia that is bright red or contains large blood clots indicates
excessive bleeding.
A nurse in a clinic is collecting data from a pt who is at 12 a) Fetal heart tones are audible w/ an US stethoscope at the end of the first
weeks of gestation. Which of the following actions should trimester.
the nurse take? b) The nurse should obtain a blood sample for the MSAFP screen between 16-18
a) Use an ultrasound stethoscope to listen to fetal heart weeks of gestation.
tones. c) The nurse should collect a vaginal & anal specimen for GBS between 35-37
b) Obtain a blood sample for the maternal serum alpha- weeks of gestation.
fetoprotein (MSAFP) screen. d) The nurse should measure fundal height regularly b/t 18-30 weeks of gestation.
c) Collect a vaginal and an anal specimen for a group
B Streptococus (GBS).
d) Measure fundal height for gestational age.
, A nurse is reinforcing education about the prevention of a) The client should only transport their newborn between the nursery and their
newborn abduction w/ a pt who recently gave birth. Which room in a bassinet.
of the following statements should the nurse identify as an b) An alarm will sound if someone removes the newborn's safety device, or if
indication that the client understands the instructions? someone transports the newborn past an established facility parameter.
c) The client should always request ID from any healthcare personnel that is
a) "I can carry my baby back to the nursery in my arms." removing their newborn from the room. Only facility personnel w/ badges indicating
b) "An alarm will sound if someone removes my baby's that the individual works specifically in the maternal/newborn unit should transport
safety device." newborns. This is a safety precaution to prevent newborn abduction.
c) "The nurse is not required to show their ID when taking d) Leaving a newborn unattended while showering places the newborn at risk for
my baby back to the nursery." abduction.
d) "I can leave my baby in the bassinet while I take a
shower."
A nurse is planning to reinforce d/c teaching about formula a) The guardian should schedule the newborn's feedings every 3-4 hrs.
feeding w/ the guardian of a newborn. Which of the b) A newborn will typically drink 15-30 mL of formula per feeding during the first 24-
following instructions should the nurse plan to include? 48 hrs.
c) Formula contains enough water to meet a newborn's fluid needs. Offering water
a) Provide the newborn w/ 6-8 feedings during a 24-hr b/t feedings can lead to an inadequate caloric intake.
period. d) The nurse or guardian should burp the newborn a few times during the feeding to
b) Ensure that the newborn receives 45-60 mL of formula reduce spitting up. Burping the newborn several times throughout the feeding can
per feeding during the first 48 hrs. decrease episodes of regurgitation after the feeding.
c) Offer water to the newborn b/t feedings.
d) Delay burping the newborn until the feeding is complete.
A nurse is contributing to the POC for a pt who has a) The nurse should use an 18-gauge catheter to administer magnesium sulfate to
eclampsia. Which of the following interventions should the the client; however, there is another action the nurse should take first.
nurse plan to include as the priority immediately following a b) The nurse should insert an indwelling urinary catheter to monitor the pt's output;
seizure? however, there is another action the nurse should take first.
c) The first action the nurse should take when using the ABC approach to pt
a) Initiate an IV line w/ an 18-gauge needle. care is to administer oxygen via facemask at 10 L/min to increase
b) Insert an indwelling urinary catheter. oxygenation.
c) Administer oxygen via facemask at 10 L/min. d) The nurse should monitor the pt during magnesium sulfate therapy, which is used
d) Monitor the pt during magnesium sulfate therapy. to prevent further seizure activity; however, there is another action the nurse should
take first.
A nurse is reinforcing teaching about preventing UTIs w/ a a) The nurse should instruct a pt who has urinary incontinence to perform Kegel
pt who is at 25 weeks of gestation. Which of the following exercises to strengthen the muscles of the pelvic floor.
instructions should the nurse include? b) The nurse should instruct the pt to urinate & empty the bladder completely
before going to bed at night to prevent stasis of urine. A full bladder provides
a) "You should perform Kegel exercises 4x/day." an environment that fosters bacterial growth.
b) "You should empty your bladder before you go to bed at c) The nurse should instruct the pt to wipe from front to back after voiding to avoid
night." transferring fecal bacterial to the urethra.
c) "You should wipe from back to front after urinating." d) The nurse should instruct the pt to wear all cotton undergarments to avoid
d) "You should wear underwear made from nylon." trapping heat & moisture in the genital area.
A nurse is collecting data from a 28 yo pt who is requesting a) A Hx of mononucleosis is not a contraindication for oral contraceptive use.
an Rx for an oral contraceptive. Which of the following info Although infection is not a contraindication, the pt will need to know that there are
in the pt's Hx should the nurse identify as a some antibiotic & antiviral meds that can reduce the effectiveness of oral
contraindication for the use of oral contraceptives? contraceptives.
b) Frequent headaches w/ visual changes can indicate a cardiovascular
a) Hx of mononucleosis 1 yr ago condition, such as HTN. A cardiovascular disorder is a contraindication for
b) Frequent headaches w/ visual changes oral contraceptive use b/c the combination can increase the risks of
c) Reports of occasional heartburn in the evening cerebrovascular accident, myocardial infarction, & thromboembolism.
d) Irregular menstrual cycles w/ dysmenorrhea c) Occasional heartburn in the evening is not contraindication for oral contraceptive
use as long as it is not a manifestation of a more serious disorder. Gallbladder
disease and liver cirrhosis, for example, are contraindications for oral contraceptive
use, and both these disorders can cause indigestion.
d) Irregular menstrual cycles w/ dysmenorrhea are not a contraindication for using
oral contraceptives. In fact, non-contraceptive advantages of oral contraceptive use
include regulation of irregular cycles & relief of menstrual pain.
A nurse is collecting data from a pt who is at 38 weeks of a) Glycosuria is a potential complication of gestational DM & the nurse should
gestation. Which of the following findings should the nurse report this finding to the provider.
report to the provider? b) Leg cramps are an expected finding during the 3rd trimester of pregnancy d/t
poor peripheral circulation.
a) Glycosuria c) Insomnia is an expected finding during the 3rd trimester of pregnancy d/t the
b) Leg cramps physical discomforts of pregnancy.
c) Insomnia d) Leukorrhea is an expected finding throughout pregnancy d/t an increased
d) Leukorrhea amount of cervical mucus resulting from hormonal changes.
