and Answers Graded A+
Place procedure equipment at bedside - ANSWER The action the nurse should perform for a postpartum
client exhibiting symptoms of a spinal headache.
Inform the anesthesia care provider - ANSWER The first action the nurse should take when a client
scheduled for a repeat cesarean section drank coffee shortly before the procedure.
Massage the fundus every 4 hours - ANSWER The priority nursing action for a 30-year-old primigravida
who delivered a 9-pound infant vaginally after a 30-hour labor.
Use alternative form of birth control - ANSWER The information the nurse should provide to a client
breastfeeding and using the same diaphragm from before pregnancy.
Herpes simplex virus - ANSWER The condition indicated by several shallow small vesicles on the pubis
labia and perineum in a client at 37 weeks gestation.
Maternal blood pressure - ANSWER Most important information to provide when notifying the
healthcare provider of a client's condition after excessive uncontrolled vaginal bleeding.
Priority nursing intervention - ANSWER Ask the client if she has experienced any recent changes in
vaginal discharge for a 16-year-old pregnant client at 32 weeks gestation.
Zidovudine during labor - ANSWER This treatment helps prevent transmission of the virus to the fetus for
a client who is HIV positive.
Best method to obtain blood sample from newborn - ANSWER Use a lancet to puncture the outer lateral
aspect of the heel to obtain hemoglobin and hematocrit levels.
Magnesium sulfate intervention - ANSWER Stop the magnesium sulfate infusion immediately if deep
tendon reflexes are 1+, respiratory rate is 12 breaths/min, urinary output is 90 mL in 4 hours, and
magnesium sulfate levels is 9 mEq/L.
Most accurate determination of fetal position - ANSWER Ultrasound is the assessment method that
provides the most accurate determination of fetal position at 29 weeks gestation.
First action when umbilical cord is on perineum - ANSWER Place the client in trendelenburg position
when the client in labor states, 'I think my water just broke.'
, Normal finding postpartum - ANSWER Document the normal finding if the nurse is unable to palpate the
uterine fundus for a client who is 14 days postpartum.
Complication from amniocentesis - ANSWER Low back pain with pelvic cramping indicates the nurse that
the client is experiencing a complication from the amniocentesis.
Medication for newborn with gonorrhea - ANSWER Erythromycin ointment should be administered to a
newborn delivered vaginally by a client who is positive for gonorrhea.
Vital signs documentation - ANSWER Document the vital signs in the record for a primipara who
delivered vaginally with current vital signs of temp 100.4, HR 58 beats/min, respiratory rate 16
breaths/min, and BP 130/74 mmHg.
Nutrition class for pregnant adolescents - ANSWER Plan to include taking folic acid supplements daily,
increasing food intake by 300 to 400 calories per day, and taking iron and calcium supplements daily.
Action after placing newborn in isolette - ANSWER Place erythromycin ophthalmic ointment in both eyes
after drying a 36-week gestation newborn with several blankets.
Best intervention for breastfeeding - ANSWER Evaluate the infant's sucking reflex then give the infant to
the mother to assist a primipara who wishes to breastfeed her infant.
Best method to estimate gestational age - ANSWER Ultrasonography provides the best estimate of
gestational age for a pregnant client who smokes one pack of cigarettes per day.
Information for primigravida client - ANSWER Provide techniques to breastfeed for a primigravida client
in the 4th stage of labor after the delivery of a newborn male infant.
First action for pain in stitches - ANSWER Visualize the perineum and check the episiotomy for a client
who reports pain in her stitches after a mid-line episiotomy.
Action regarding radioactive iodine - ANSWER Explain to the client that the procedure will need to be
canceled until confirmation is obtained that the client is not pregnant.
First action after delivering in parking lot - ANSWER Massage the fundus and give an oxytocic agent for a
woman who delivered a term infant and the placenta in the hospital parking lot 10 minutes ago.
Breastfeeding instruction for mastitis - ANSWER Provide instructions regarding breastfeeding for a
woman who develops mastitis in her left breast after delivering her infant two weeks ago.
Client with peptic ulcer on misoprostol - ANSWER You may be at higher risk for having a spontaneous
miscarriage
Triple screen analysis preparation - ANSWER Prepare to draw blood for analysis
32 week gestation with abdominal tenderness - ANSWER Lactated ringers at 200 ml/hr using an 18 gauge
needle
Critical assessment finding after c-section - ANSWER Uterine atony
Therapeutic response to atropine injection - ANSWER Increase pulse and reduced oral secretions