A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to
perform Leopold maneuvers. Which of the following images indicates the first step of
Leopold maneuvers?
A.
B.
C.
D. - ANSC.
Evidence-based practice indicates the nurse should perform this step first when
performing Leopold maneuvers. During this step, the nurse palpates the client's
abdomen with the palms to determine which fetal part is in the uterine fundus. This step
also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech)
of the fetus.
A nurse in a clinic is caring for a 16-year-old adolescent.
Which of the following conditions should the nurse identify as being consistent with the
adolescent's assessment findings?
For each finding, click to specify if the assessment findings are consistent with
trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one
disease process.
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual - ANSTrichomoniasis
B. Greenish discharge
Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis
causes thick, white, lumpy discharge.
D. Pain on urination
Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the
result of urine flowing over an irritated and inflamed vulva and surrounding skin.
E. Absence of condom use
Sexual activity without the use of a condom can result in th e transmission of STIs.
Candidiasis is a vaginal infection that is not sexually transmitted.
Gonorrhea
A. Abdominal pain
Gonorrhea can present with reports of acute or chronic lower abdominal pain.
B. Greenish discharge
Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis
causes thick, white, lumpy discharge.
D. Pain on urination
,Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the
result of urine flowing over an irritated and inflamed vulva and surrounding skin.
E. Absence of condom use
Sexual
A nurse in a clinic is caring for a 16-year-old adolescent.
Which of the following findings should the nurse report to the provider?
Select all that apply.
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
Nurses' Notes
1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on
0 to 10 pain scale and describes pain as constant and dull. Repor - ANSA. Abdominal
assessment
Abdominal tenderness with palpation is not an expected finding with an abdominal
assessment; therefore, the nurse should report this finding to the provider.
B. Vaginal discharge
Greenish vaginal discharge indicates that the adolescent has an infection, w hich is not
an expected finding; therefore, the nurse should report this finding to the provider.
D. Temperature
The client's temperature of 38.3° C (101° F) is above the expected reference range. An
elevated temperature could signal infection or inflammation; therefore, the nurse should
report this finding to the provider.
E. Dyspareunia
Dyspareunia is painful intercourse, which can be associated with STIs; therefore, the
nurse should report this finding to the provider.
F. Condom usage
Sexual activity without the use of condoms increases the risk of contracting STIs;
therefore, the nurse should report this finding to the provider.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients
should the nurse see first?
A. A client who is at 11 weeks of gestation and reports abdominal cramping
,B. A client who is at 15 weeks of gestation and reports tingling and numbness in right
hand
C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days
D. A client who is at 8 weeks of gestation and reports having three bloody noses in the
past week - ANSA. A client who is at 11 weeks of gestation and reports abdominal
cramping
When using the urgent vs nonurgent approach to client care, the nurse should
determine that the priority finding is a client who is at 11 weeks of gestation and reports
abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or
manifestations of spontaneous abortion. The nurse should request that the provider see
this client first.
A nurse in a provider's office is reviewing the medical record of a client who is in the first
trimester of pregnancy. Which of the following findings should the nurse identify as a
risk factor for the development of preeclampsia?
A. Singleton pregnancy
B. BMI of 20
C. Maternal age 32 years
D. Pregestational diabetes mellitus - ANSD. Pregestational diabetes mellitus
Pregestational diabetes mellitus increases a client's risk for the development of
preeclampsia. Other risk factors include preexisting hypertension, renal disease,
systemic lupus erythematosus, and rheumatoid arthritis.
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings
should the nurse report to the provider? (Click on the "Exhibit" button for additional
information about the client. Th ere are three tabs that contain separate categories of
data.)
Graphic Record
Blood pressure 130/78 mm Hg, Respiratory rate 20/min, Heart rate 90/min
Diagnostic Results
Hemoglobin 12 g/dL, Hematocrit 34 - ANSC. Fundal height measurement
A fundal height measurement of 30 cm should be reported to the provider. Fundal
height should be measured in centimeters and is the same as the number of gestational
weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse
should report this finding to the provider.
A nurse is admitting a client to the labor and delivery unit when the client states, "My
water just broke." Which of the following interventions is the nurse's priority?
, A. Perform Nitrazine testing.
B. Assess the fluid.
C. Check cervical dilation.
D. Begin FHR monitoring. - ANSD. Begin FHR monitoring.
The greatest risk to the client and her fetus following a rupture of membranes is
umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well -
being. Therefore, this is the priority action the nurse should take.
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For
which of the following complications should the nurse assess?
A. Abruptio placenta
B. Placenta previa
C. Preeclampsia
D. Maternal bradycardia - ANSA. Abruptio placenta
Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing
hyperglycemia. Which of the following findings should the nurse expect?
A. Reports increased urinary output
B. Diaphoresis
C. Reports blurred vision
D. Shallow respirations - ANSA. Reports increased urinary output
Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain,
constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other
manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and
acetone, and a blood glucose level greater than 200 mg/dL.
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma.
Which of the following manifestations should the nurse expect?
A. Lochia serosa vaginal drainage
B. Vaginal pressure
C. Intermittent vaginal pain
D. Yellow exudate vaginal drainage - ANSB. Vaginal pressure
The nurse should expect a client who has a vaginal hematoma to report pressure in the
vagina due to the blood that leaked into the tissues.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal
visit. Which of the following findings should the nurse report to the provider?
perform Leopold maneuvers. Which of the following images indicates the first step of
Leopold maneuvers?
A.
B.
C.
D. - ANSC.
Evidence-based practice indicates the nurse should perform this step first when
performing Leopold maneuvers. During this step, the nurse palpates the client's
abdomen with the palms to determine which fetal part is in the uterine fundus. This step
also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech)
of the fetus.
A nurse in a clinic is caring for a 16-year-old adolescent.
Which of the following conditions should the nurse identify as being consistent with the
adolescent's assessment findings?
For each finding, click to specify if the assessment findings are consistent with
trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one
disease process.
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual - ANSTrichomoniasis
B. Greenish discharge
Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis
causes thick, white, lumpy discharge.
D. Pain on urination
Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the
result of urine flowing over an irritated and inflamed vulva and surrounding skin.
E. Absence of condom use
Sexual activity without the use of a condom can result in th e transmission of STIs.
Candidiasis is a vaginal infection that is not sexually transmitted.
Gonorrhea
A. Abdominal pain
Gonorrhea can present with reports of acute or chronic lower abdominal pain.
B. Greenish discharge
Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis
causes thick, white, lumpy discharge.
D. Pain on urination
,Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the
result of urine flowing over an irritated and inflamed vulva and surrounding skin.
E. Absence of condom use
Sexual
A nurse in a clinic is caring for a 16-year-old adolescent.
Which of the following findings should the nurse report to the provider?
Select all that apply.
History and Physical
Adolescent is sexually active with two current partners.
IUD in place
Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
Nurses' Notes
1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on
0 to 10 pain scale and describes pain as constant and dull. Repor - ANSA. Abdominal
assessment
Abdominal tenderness with palpation is not an expected finding with an abdominal
assessment; therefore, the nurse should report this finding to the provider.
B. Vaginal discharge
Greenish vaginal discharge indicates that the adolescent has an infection, w hich is not
an expected finding; therefore, the nurse should report this finding to the provider.
D. Temperature
The client's temperature of 38.3° C (101° F) is above the expected reference range. An
elevated temperature could signal infection or inflammation; therefore, the nurse should
report this finding to the provider.
E. Dyspareunia
Dyspareunia is painful intercourse, which can be associated with STIs; therefore, the
nurse should report this finding to the provider.
F. Condom usage
Sexual activity without the use of condoms increases the risk of contracting STIs;
therefore, the nurse should report this finding to the provider.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients
should the nurse see first?
A. A client who is at 11 weeks of gestation and reports abdominal cramping
,B. A client who is at 15 weeks of gestation and reports tingling and numbness in right
hand
C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days
D. A client who is at 8 weeks of gestation and reports having three bloody noses in the
past week - ANSA. A client who is at 11 weeks of gestation and reports abdominal
cramping
When using the urgent vs nonurgent approach to client care, the nurse should
determine that the priority finding is a client who is at 11 weeks of gestation and reports
abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or
manifestations of spontaneous abortion. The nurse should request that the provider see
this client first.
A nurse in a provider's office is reviewing the medical record of a client who is in the first
trimester of pregnancy. Which of the following findings should the nurse identify as a
risk factor for the development of preeclampsia?
A. Singleton pregnancy
B. BMI of 20
C. Maternal age 32 years
D. Pregestational diabetes mellitus - ANSD. Pregestational diabetes mellitus
Pregestational diabetes mellitus increases a client's risk for the development of
preeclampsia. Other risk factors include preexisting hypertension, renal disease,
systemic lupus erythematosus, and rheumatoid arthritis.
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of
gestation. Upon reviewing the client's medical record, which of the following findings
should the nurse report to the provider? (Click on the "Exhibit" button for additional
information about the client. Th ere are three tabs that contain separate categories of
data.)
Graphic Record
Blood pressure 130/78 mm Hg, Respiratory rate 20/min, Heart rate 90/min
Diagnostic Results
Hemoglobin 12 g/dL, Hematocrit 34 - ANSC. Fundal height measurement
A fundal height measurement of 30 cm should be reported to the provider. Fundal
height should be measured in centimeters and is the same as the number of gestational
weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse
should report this finding to the provider.
A nurse is admitting a client to the labor and delivery unit when the client states, "My
water just broke." Which of the following interventions is the nurse's priority?
, A. Perform Nitrazine testing.
B. Assess the fluid.
C. Check cervical dilation.
D. Begin FHR monitoring. - ANSD. Begin FHR monitoring.
The greatest risk to the client and her fetus following a rupture of membranes is
umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well -
being. Therefore, this is the priority action the nurse should take.
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For
which of the following complications should the nurse assess?
A. Abruptio placenta
B. Placenta previa
C. Preeclampsia
D. Maternal bradycardia - ANSA. Abruptio placenta
Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing
hyperglycemia. Which of the following findings should the nurse expect?
A. Reports increased urinary output
B. Diaphoresis
C. Reports blurred vision
D. Shallow respirations - ANSA. Reports increased urinary output
Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain,
constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other
manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and
acetone, and a blood glucose level greater than 200 mg/dL.
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma.
Which of the following manifestations should the nurse expect?
A. Lochia serosa vaginal drainage
B. Vaginal pressure
C. Intermittent vaginal pain
D. Yellow exudate vaginal drainage - ANSB. Vaginal pressure
The nurse should expect a client who has a vaginal hematoma to report pressure in the
vagina due to the blood that leaked into the tissues.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal
visit. Which of the following findings should the nurse report to the provider?
