Anurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
(© Administer prescribed analgesic medication
(© Encourage the clien to rest berween contractions.
© Vassage
the dlient's back.
() Tumthe clientonto her left side.
Anurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates
understanding of the teaching?
(@ "will decrease my daily fiber intake."
() "l make sure | reduce saltin my diet”
© 'l eat more protein at each meal."
(O "will consume more vitamin D-rich foods."
Anurse on the labor and delivery unit s caring for a patient who is having induction of labor with oxytocin administered through a secondary IV
line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform
decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should
the nurse take?
(O Decrease the rate of infusion of the maintenance IV solution,
@ Discontinue the infusion of the IV oxytocin,
(@ Increase the rate of infusion of the IV oxytocin.
(@ slowthe client's rate of breathing.
Anurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the
umbilicus, lochia rubra is modarate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings
should the nurse make?
8 8 4 5 0 8 08 8 s 8 s 8 0 s e e s 80 s 8 s s 0 S 880 S8 s 8048058 e0 e s
(O The clientis exhibiting early indications of mastiis.
‘ @ Additional interventions are not indicated at this time.
(© Application of a heating pad to the breasts is indicated.
() Theclient should be advised to remove her nursing bra.
,Anurse s caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her
fingers are tingling. Which of the following actions should the nurse take?
() Administer oxygen via nasal cannula.
@ Assist the client to breathe into a paper bag.
(O Havethe client tuck her chin to her chest.
(© Instruct the client to increase her respiratory rate to more than 42 breaths per min.
Anurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or
not." Which of the following should the nurse recognize as a sign of true labor?
() Rupture of the membranes
‘ @ Changes inthe cervix
() station of the presenting part
(@ Pattern of contractions.
Anurseis caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did
not have natural childbirth. Which of the following responses should the nurse make?
@ 'tsounds like you are feeling sad that things didn't g0 as planned.”
(©) "atleast you know you have a healthy baby."
(0) "Maybe next time you can have a vaginal delivery."
(© ™ou can resume sexual relations sooner than if you had delivered vaginally."
Anurse at a prenatal caring fora in her first trimester of pregnancy. The c s the nurse that she is upset because,
although she and her hushand planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in
her life. Which of the following is an appropriate response by the nurse?
"Ambivalent feelings are quite common for women early in pregnancy.”
() "Perhaps you should see a counselor to discuss these feelings further."
() "Have you spoken to your mother about these feelings?”
*Don't worry. You will be fine once the baby is born."
, Anurse s caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
(O Adiient whois experiencing fetal death at 32 weeks of gestation
@ Aclient whoiis experiencing preterm labor at 26 weeks of gestation
(O Aclient whois experiencing Braxton-Hicks contractions at 36 weeks of gestation
() Adlient who has a post-term pregnancy at 42 weeks of gestation
Ahome health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements
indicates understanding of the teaching?
@ "Il let my baby drain one breast at each feeding.”
@ 1l try drinking an herbal te to reduce the engorgement."
@ 11l apply cold compresses 20 minutes before each feeding.”
© i feed my baby every 2 hours."
Anurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following
findings indicates that the fetal lungs are mature?
(© Phosphatidylglycerol (PG) absent
() Biophysical
profile score of 8
‘ © Lecithin/sphingomyelin (LrS) ratio of 21
() Nonstress testis reactive
Anurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart
rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions
should the nurse take first?
D R R R I R R S I A S R N A AT SR R SR SRS A
@ Place the dient in the lateral position.
(© Increase the rate of maintenance IV infusion.
@ Elevate the client's legs.
(O Admirister oxygen using a nonrebreather mask.
(© Administer prescribed analgesic medication
(© Encourage the clien to rest berween contractions.
© Vassage
the dlient's back.
() Tumthe clientonto her left side.
Anurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates
understanding of the teaching?
(@ "will decrease my daily fiber intake."
() "l make sure | reduce saltin my diet”
© 'l eat more protein at each meal."
(O "will consume more vitamin D-rich foods."
Anurse on the labor and delivery unit s caring for a patient who is having induction of labor with oxytocin administered through a secondary IV
line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform
decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should
the nurse take?
(O Decrease the rate of infusion of the maintenance IV solution,
@ Discontinue the infusion of the IV oxytocin,
(@ Increase the rate of infusion of the IV oxytocin.
(@ slowthe client's rate of breathing.
Anurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the
umbilicus, lochia rubra is modarate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings
should the nurse make?
8 8 4 5 0 8 08 8 s 8 s 8 0 s e e s 80 s 8 s s 0 S 880 S8 s 8048058 e0 e s
(O The clientis exhibiting early indications of mastiis.
‘ @ Additional interventions are not indicated at this time.
(© Application of a heating pad to the breasts is indicated.
() Theclient should be advised to remove her nursing bra.
,Anurse s caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her
fingers are tingling. Which of the following actions should the nurse take?
() Administer oxygen via nasal cannula.
@ Assist the client to breathe into a paper bag.
(O Havethe client tuck her chin to her chest.
(© Instruct the client to increase her respiratory rate to more than 42 breaths per min.
Anurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or
not." Which of the following should the nurse recognize as a sign of true labor?
() Rupture of the membranes
‘ @ Changes inthe cervix
() station of the presenting part
(@ Pattern of contractions.
Anurseis caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did
not have natural childbirth. Which of the following responses should the nurse make?
@ 'tsounds like you are feeling sad that things didn't g0 as planned.”
(©) "atleast you know you have a healthy baby."
(0) "Maybe next time you can have a vaginal delivery."
(© ™ou can resume sexual relations sooner than if you had delivered vaginally."
Anurse at a prenatal caring fora in her first trimester of pregnancy. The c s the nurse that she is upset because,
although she and her hushand planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in
her life. Which of the following is an appropriate response by the nurse?
"Ambivalent feelings are quite common for women early in pregnancy.”
() "Perhaps you should see a counselor to discuss these feelings further."
() "Have you spoken to your mother about these feelings?”
*Don't worry. You will be fine once the baby is born."
, Anurse s caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
(O Adiient whois experiencing fetal death at 32 weeks of gestation
@ Aclient whoiis experiencing preterm labor at 26 weeks of gestation
(O Aclient whois experiencing Braxton-Hicks contractions at 36 weeks of gestation
() Adlient who has a post-term pregnancy at 42 weeks of gestation
Ahome health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements
indicates understanding of the teaching?
@ "Il let my baby drain one breast at each feeding.”
@ 1l try drinking an herbal te to reduce the engorgement."
@ 11l apply cold compresses 20 minutes before each feeding.”
© i feed my baby every 2 hours."
Anurse is caring for a client who is scheduled for a cesarean birth based upon the fetal lungs having reached maturity. Which of the following
findings indicates that the fetal lungs are mature?
(© Phosphatidylglycerol (PG) absent
() Biophysical
profile score of 8
‘ © Lecithin/sphingomyelin (LrS) ratio of 21
() Nonstress testis reactive
Anurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart
rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions
should the nurse take first?
D R R R I R R S I A S R N A AT SR R SR SRS A
@ Place the dient in the lateral position.
(© Increase the rate of maintenance IV infusion.
@ Elevate the client's legs.
(O Admirister oxygen using a nonrebreather mask.
