Answers | Latest Version | 2025/2026 |
Correct & Verified
A nurse is caring for a client in active labor who is experiencing late decelerations on the fetal
monitor. What is the nurse’s priority action?
✔✔Reposition the client to her left side to improve placental perfusion.
A nurse is assessing a client at 36 weeks gestation who reports a headache and blurred vision.
What condition should the nurse suspect?
✔✔Preeclampsia.
A client at 28 weeks gestation is receiving magnesium sulfate for preterm labor. What finding
should the nurse report immediately?
✔✔Respiratory rate of 10 breaths per minute.
A nurse is caring for a postpartum client who is breastfeeding. The client reports pain and
redness in one breast. What should the nurse suspect?
✔✔Mastitis.
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,A client is in the second stage of labor and reports a strong urge to push. What is the priority
nursing action?
✔✔Assess for full cervical dilation before allowing the client to push.
A nurse is assessing a newborn 1 hour after birth and notes a respiratory rate of 70 breaths/min
with nasal flaring. What is the appropriate nursing action?
✔✔Notify the provider of signs of respiratory distress.
A nurse is providing discharge teaching to a client with a cesarean birth. What instruction should
be included regarding activity?
✔✔Avoid lifting anything heavier than the newborn for at least 2 weeks.
A nurse is caring for a client with hyperemesis gravidarum. What laboratory value should the
nurse expect?
✔✔Elevated urine ketones.
A nurse is reviewing fundal height measurement for a client at 20 weeks gestation. Where should
the fundus be located?
✔✔At the level of the umbilicus.
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,A nurse is teaching a client about performing kick counts during the third trimester. What should
the nurse include?
✔✔Report fewer than 10 movements in 2 hours.
A client in her third trimester states she feels lightheaded when lying on her back. What is the
appropriate nursing response?
✔✔Encourage the client to lie on her left side to prevent supine hypotension.
A nurse is caring for a client who is 1 day postpartum. The uterus is firm and located 2
fingerbreadths above the umbilicus. What should the nurse do?
✔✔Encourage the client to void and reassess the fundus.
A nurse is caring for a newborn with a blood glucose level of 34 mg/dL. What is the first nursing
action?
✔✔Feed the newborn to increase glucose levels.
A nurse is assessing a newborn and notes meconium-stained amniotic fluid. What complication
should the nurse monitor for?
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, ✔✔Meconium aspiration syndrome.
A nurse is assessing a client at 12 weeks gestation. What is the expected fetal heart rate using
Doppler?
✔✔110 to 160 beats per minute.
A nurse is performing a nonstress test. What finding indicates a reactive result?
✔✔Two or more accelerations in fetal heart rate in 20 minutes.
A nurse is teaching a newly pregnant client about expected changes. Which skin change is
expected during pregnancy?
✔✔Linea nigra development on the abdomen.
A client at 38 weeks gestation reports a sudden gush of fluid from the vagina. What is the first
nursing action?
✔✔Check the fetal heart rate.
A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse
expect?
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