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1. A multiparous client has been in labor for 8 hours when her membranes rupture.
Which action should the nurse implement first?
Prepare the client for imminent birth. Assess
the fetal heart rate and pattern. Document the
characteristics of the fluid.
Notify the client's primary healthcare provider.: Assess the fetal heart rate and pattern.
2. A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has
broken. While inspecting the client's perineum, the nurse notes the umbili- cal cord
protruding from the vagina. Which action should the nurse implement first?
Administer 10 L of oxygen via face mask. Give the
healthcare provider a status report. Place the
client in the knee-chest position.
Wrap the cord with gauze soaked in saline.: Place the client in the knee-chest position.
3. The nurse observes a new mother avoiding eye contact with her newborn. Which
action should the nurse take?
Ask the mother why she won't look at the infant. Observe
the mother for other bonding behaviors. Examine the
newborn's eyes for the ability to focus.
Recognize this as a common reaction in new mothers.: Observe the mother for other
bonding behaviors.
4. A client states, "During the three months I've been pregnant, it seems like I have had
,to go to the bathroom every five minutes." Which explanation should the nurse provide
to this client?
The client may have a bladder or kidney infection. Bladder
capacity increases during pregnancy.
During pregnancy, a woman is especially sensitive to body functions.
The growing uterus is putting pressure on the bladder.: The growing uterus is putting
pressure on the bladder.
5. Which nursing action should be implemented when intermittently gav- age-
feeding a preterm infant?
Allow the formula to flow by gravity.
,Avoid letting the infant suck on the tube. Insert
feeding tube through nares.
Apply steady pressure to the syringe.: Allow the formula to flow by gravity.
6. A client in her second trimester of pregnancy asks if it is safe for her to have a drink
with dinner. How should the nurse respond to the client?
During the second trimester beer can be consumed without harm to the fetus. Wine can
be consumed several times a week after the first trimester.
Only one drink with the evening meal is not harmful to the fetus.
Abstinence is strongly recommended throughout the pregnancy.: Abstinence is strongly
recommended throughout the pregnancy.
7. The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
Avoid alcohol because it is excreted in breast milk. Avoid
spicy foods to prevent infant colic.
Increase caloric intake by approximately 500 calories/day.
Double prenatal milk intake to improve Vitamin D transfer to the: Avoid alcohol because i
is excreted in breast milk.
8. A preterm infant with an apnea monitor experiences an episode of apnea. Which
action should the nurse implement first?
Ventilate with an Ambu bag.
Perform nasal and airway suctioning.
Administer supplemental oxygen.
Gently rub the infant's feet or back to stimulate respirations and place in the radiant
warmer.: Gently rub the infant's feet or back to stimulate respirations and place in the
radiant warmer.
9. A client delivers twins, one is stillborn and the other is recovering in an intensive
care nursery. As the nurse provides assistance to the bathroom, the client, softly crying,
states, "I wish my baby could have lived." Which response is best for the nurse to
provide?
, "Don't be sad. You'll need to be strong to care for your healthy baby." "Do you want
to go to the nursery and see your baby?"
"I am sorry for your loss. Do you want to talk about it?"
"It is always sad to lose a baby. Would you like me to call your minister?": "I am sorry for
your loss. Do you want to talk about it?"