exit h (2) Q&A GRADE A
A nurse is trying to determine whether a pregnant woman's membranes have ruptured.
What findings support the conclusion that they have ruptured? Select all that apply.
Nitrazine paper turns blue on contact with the fluid. - (correct answer)Microscopic
examination of the fluid reveals kerning.
The nurse manager receives report on the following laboring clients. Which client should
the nurse see first? - (correct answer)G6 P5 with intact membranes at 5 cm of dilation
The nurse is providing care to a multiparous client in active labor. The client is
requesting something for the pain. What is the nurse's next action? - (correct
answer)Examining the client's cervix for dilation and effacement
A client at 10 weeks' gestation complains of frequent urination. Before explaining this
phenomenon to the client in language that she will understand, the nurse remembers
that: - (correct answer)Softening and compressibility of the lower uterine segment
results in uterine anteflexion.
Organize the steps in infant cardiopulmonary resuscitation (CPR) in the correct
sequence. - (correct answer)Note the infant's color and tap or gently shake the
shoulders.
Position the infant supine on a firm, flat surface.
Open the airway with the head tilt-chin lift method and listen for exhalation.
Initiate rescue breathing at a rate of 40 to 60 breaths/min.
Check the pulse at the brachial artery.
Initiate chest compressions in a 30:2 ratio
A client is admitted to the birthing unit in active labor. Cervical dilation has progressed
from 2 to 3 cm over the previous 8 hours. The health care provider determines that the
client has hypotonic dystocia, and an infusion of oxytocin (Pitocin) is prescribed to
augment her contractions. What is the most important nursing action at this time? -
(correct answer)Monitoring the duration and intensity of the contractions
,After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking."
How should the nurse respond? - (correct answer)I'll get you some warm blankets to
help make the chill go away."
Nursing assessment of a client in labor reveals that she is entering the transition phase
of the first stage of labor. Which clinical manifestations support this conclusion? -
(correct answer)Increased bloody show, irritability, and shaking
Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left
leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which
anticoagulant does the nurse expect to administer? - (correct answer)Continuous
infusion of heparin
How should a nurse direct care for a client in the transition phase of the first stage of
labor? - (correct answer)Helping the client maintain control
A primipara is admitted to the birthing room in active labor. The fetus's head is engaged
and the cervix is dilated 9 cm when there is a gush of fluid from the vagina. Place the
nursing actions in order of priority. - (correct answer)1.
Monitor the fetal heart rate for signs of compromise.
Test the fluid's pH with Nitrazine paper.
Perform a vaginal examination to ascertain the progression of labor.
Notify the practitioner
At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the
postpartum unit. What is the nurse's priority when planning morning care for this client?
- (correct answer)Planning nursing care activities that provide time for the client to rest
and sleep
Which of the following variables are scored on a biophysical profile? Select all that
apply. - (correct answer)Fetal tone
, Fetal movement
Amniotic fluid index
Fetal breathing movements
During labor a client who is receiving epidural anesthesia has an episode of severe
nausea, and her skin becomes pale and clammy. What is the immediate nursing action?
- (correct answer)Elevating the legs
A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is
very important during pregnancy and that she is taking a prescribed supplement. She
asks the nurse what foods contain folic acid (folate) so she may add them to her diet in
its natural form. Which foods should the nurse recommend? Select all that apply. -
(correct answer)Black and pinto beans
Enriched bread and pasta
A nurse is caring for a primigravida during labor. What does the nurse note that
indicates that birth is about to take place? - (correct answer)The perineum has begun to
bulge with each contraction.
What actions are part of nursing care during the fourth stage of labor for the client with a
fourth-degree laceration? Select all that apply. - (correct answer)Pain management with
oral analgesics
Assessment of the site every 15 minutes
Application of an ice pack for 20-minute intervals
After a client has been in labor for 6 hours at home, she is admitted to the birthing room.
The client is dilated 5 cm and at −1 station. In the next hour her contractions gradually
become irregular and are more uncomfortable. Which possibility should the nurse
consider first? - (correct answer)The client has a full bladder
A 24-year-old client who has been told that she is pregnant is at her first prenatal visit.
She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding
A nurse is trying to determine whether a pregnant woman's membranes have ruptured.
What findings support the conclusion that they have ruptured? Select all that apply.
Nitrazine paper turns blue on contact with the fluid. - (correct answer)Microscopic
examination of the fluid reveals kerning.
The nurse manager receives report on the following laboring clients. Which client should
the nurse see first? - (correct answer)G6 P5 with intact membranes at 5 cm of dilation
The nurse is providing care to a multiparous client in active labor. The client is
requesting something for the pain. What is the nurse's next action? - (correct
answer)Examining the client's cervix for dilation and effacement
A client at 10 weeks' gestation complains of frequent urination. Before explaining this
phenomenon to the client in language that she will understand, the nurse remembers
that: - (correct answer)Softening and compressibility of the lower uterine segment
results in uterine anteflexion.
Organize the steps in infant cardiopulmonary resuscitation (CPR) in the correct
sequence. - (correct answer)Note the infant's color and tap or gently shake the
shoulders.
Position the infant supine on a firm, flat surface.
Open the airway with the head tilt-chin lift method and listen for exhalation.
Initiate rescue breathing at a rate of 40 to 60 breaths/min.
Check the pulse at the brachial artery.
Initiate chest compressions in a 30:2 ratio
A client is admitted to the birthing unit in active labor. Cervical dilation has progressed
from 2 to 3 cm over the previous 8 hours. The health care provider determines that the
client has hypotonic dystocia, and an infusion of oxytocin (Pitocin) is prescribed to
augment her contractions. What is the most important nursing action at this time? -
(correct answer)Monitoring the duration and intensity of the contractions
,After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking."
How should the nurse respond? - (correct answer)I'll get you some warm blankets to
help make the chill go away."
Nursing assessment of a client in labor reveals that she is entering the transition phase
of the first stage of labor. Which clinical manifestations support this conclusion? -
(correct answer)Increased bloody show, irritability, and shaking
Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left
leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which
anticoagulant does the nurse expect to administer? - (correct answer)Continuous
infusion of heparin
How should a nurse direct care for a client in the transition phase of the first stage of
labor? - (correct answer)Helping the client maintain control
A primipara is admitted to the birthing room in active labor. The fetus's head is engaged
and the cervix is dilated 9 cm when there is a gush of fluid from the vagina. Place the
nursing actions in order of priority. - (correct answer)1.
Monitor the fetal heart rate for signs of compromise.
Test the fluid's pH with Nitrazine paper.
Perform a vaginal examination to ascertain the progression of labor.
Notify the practitioner
At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the
postpartum unit. What is the nurse's priority when planning morning care for this client?
- (correct answer)Planning nursing care activities that provide time for the client to rest
and sleep
Which of the following variables are scored on a biophysical profile? Select all that
apply. - (correct answer)Fetal tone
, Fetal movement
Amniotic fluid index
Fetal breathing movements
During labor a client who is receiving epidural anesthesia has an episode of severe
nausea, and her skin becomes pale and clammy. What is the immediate nursing action?
- (correct answer)Elevating the legs
A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is
very important during pregnancy and that she is taking a prescribed supplement. She
asks the nurse what foods contain folic acid (folate) so she may add them to her diet in
its natural form. Which foods should the nurse recommend? Select all that apply. -
(correct answer)Black and pinto beans
Enriched bread and pasta
A nurse is caring for a primigravida during labor. What does the nurse note that
indicates that birth is about to take place? - (correct answer)The perineum has begun to
bulge with each contraction.
What actions are part of nursing care during the fourth stage of labor for the client with a
fourth-degree laceration? Select all that apply. - (correct answer)Pain management with
oral analgesics
Assessment of the site every 15 minutes
Application of an ice pack for 20-minute intervals
After a client has been in labor for 6 hours at home, she is admitted to the birthing room.
The client is dilated 5 cm and at −1 station. In the next hour her contractions gradually
become irregular and are more uncomfortable. Which possibility should the nurse
consider first? - (correct answer)The client has a full bladder
A 24-year-old client who has been told that she is pregnant is at her first prenatal visit.
She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding
