.Guaranteed Pass
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following
client statements indicates understanding of the teaching?
ANSWER: "I’ll feed my baby every 2 hours."
A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should
explain to the client that the purpose of this medication is to prevent which of the following conditions?
ANSWER: Postpartum hemorrhage
A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the
nurse expect to palpate the fundus?
ANSWER: Slightly above the umbilicus
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation
and 100% cervical effacement. The nurse obtains the client’s blood pressure reading as 82/52 mm Hg. Which of the
following nursing interventions should the nurse perform?
ANSWER: Assist the client to turn onto her side
.A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is
documented as: –1. Which of the following interpretations of this finding should the nurse make?
Answer: The presenting part is 1 cm above the ischial spines.
A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should
recognize this finding as an indication of which of the following conditions?
Answer: Placenta previa
A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes
the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are
two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of
the following interpretations of these findings should the nurse make?
Answer: A nonreactive test
A nurse in a provider’s office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis.
The client asks why she is having an ultrasound prior to the
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, procedure. Which of the following is an appropriate response by the nurse? Answer: . "It assists in identifying the location
of the placenta and fetus."
A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client
asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the
nurse?
ANSWER: "It detects Rh-positive antibodies in the mother’s blood."
A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should
the nurse expect?
ANSWER: . Fundus firm, at the level of the umbilicus
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on
these findings, which of the following actions should the nurse take?
ANSWER: Assist the client to the bathroom to void
A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz.
(4252 g). The nurse should recognize that this client is at risk for which of the following postpartum
complications? ANSWER: Uterine atony
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad
within 10 min. Which of the following actions should the nurse take first?
ANSWER: Massage the client's fundus.
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and
bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following
complications?
ANSWER: Disseminated intravascular coagulation
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in
labor. Which of the following findings confirm to the nurse that the client is in labor?
ANSWER: Cervical dilation
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with
blood in a 30-min period. Which of the following is the priority nursing intervention at this time?
ANSWER: Palpate the client’s uterine fundus.
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