OB HESI Pediatric Assessment Performance 97% Questions and Answers + Rationales Latest 2025/26.

OB HESI Pediatric Assessment Performance 97% Questions and Answers + Rationales Latest 2025/26. HESI Pediatric Assessment Performance A vaginally delivered infant of an HIV-positive mother is admitted to the newborn nursery. Which intervention should the nurse perform first? Bathe the infant with antimicrobial soap. Measure the head and chest circumference. Obtain the infant's footprints. Administer vitamin K. A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? Supplementary iron is more efficiently utilized during pregnancy. It is difficult to consume 18 mg of additional iron by diet alone. Iron absorption is decreased in the GI tract during pregnancy. Iron is needed to prevent megaloblastic anemia in the last trimester. When assessing a client who is at 12 weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? At 16 weeks gestation. At 20 weeks gestation. At 24 weeks gestation. At 30 weeks gestation. A newborn, whose mother is HIV positive, is scheduled for a follow-up assessment. The nurse knows the most likely presenting symptom for a pediatric client with AIDS is which sign? Shortness of breath. Joint pain. A persistent cold. Organomegaly. After each feeding, a 3-day-old newborn is spitting up large amounts of a non-dairy-based formula. The pediatric healthcare provider changes the neonate's formula to a soy protein isolate-based infant formula. What information should the nurse provide to the mother about the newly prescribed formula? The new formula is a coconut milk formula used with babies with impaired fat absorption. The new formula is prescribed for infants with malabsorption syndromes. The new formula is a casein protein source that is low in phenylalanine. The prescribed formula is well tolerated by lactose-intolerant infants. The nurse should explain to a 30-year-old primigravida client that alpha-fetoprotein testing is recommended for which purpose? Detect cardiovascular disorders. Screen for neural tube defects. Monitor the placental functioning. Assess for maternal pre-eclampsia. A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? Length of labor and method of delivery. Infant's condition at birth and treatment received. Feeding method chosen by the parents. History of drugs given to the mother during labor. A 4-week-old premature infant has been receiving epoetin alfa for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? Slowly increasing urinary output over the last week. Respiratory rate changes from 40 to 60 breaths/minute. Changes in apical heart rate from 180 to 140 beats/minute. Change in indirect bilirubin from 12 mg/dL to 8 mg/dL. When assisting a client to relieve postpartum uterine contractions, which nursing intervention would be most helpful for the nurse to take? Lying client prone with a pillow on the abdomen. Asking the client to express milk via a breast pump. Massaging the client's abdomen. Giving oxytocic medications. When evaluating a laboring client's progress, which finding would be an indicator to the RN to encourage the client to begin pushing? There is only an anterior or posterior lip of the cervix left. The client describes the need to have a bowel movement. The cervix is completely dilated. The cervix is completely effaced. The nurse observes a new mother who is rooming in and caring for her newborn infant. Which observation indicates the need for further teaching? Cuddles the baby close to her. Rocks and soothes the infant in her arms. Places the infant prone in the bassinet. Wraps the baby in a warm blanket after bathing. In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines that the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.) A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which response is best for the nurse provide? "Weigh the baby daily, and if she is gaining weight, she is eating enough." "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." "Offer the baby an extra bottle of milk after her feeding, and see if she is still hungry." "If you're concerned, you might consider bottle feeding so that you can monitor her intake." When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) Select all that apply Mood swings. Panic attacks. Tearfulness. Decreased need for sleep. Disinterest in the infant. A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is the most effective to prevent nipple soreness? Wear a cotton bra. Increase nursing time gradually. Correctly place the infant on the breast. Manually express a small amount of milk before nursing. A multigravida client at 41 weeks gestation presents in the labor and delivery unit after a nonstress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? Biophysical profile (BPP). Ultrasound for fetal anomalies. Maternal serum alpha-fetoprotein (AF) screening. Percutaneous umbilical blood sampling (PUBS). A client at 32 weeks gestation comes to the prenatal clinic with reports of pedal edema, dyspnea, fatigue, and a moist cough. Which question is the most important for the nurse to ask this client? "Which symptom did you experience first?" "Are you eating large amounts of salty foods?" "Have you visited a foreign country recently?" "Do you have a history of rheumatic fever?" A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. Which action should the nurse implement? Notify the healthcare provider. Move the newborn to an isolation nursery. Document the finding in the infant's record. Obtain a culture of the vesicles. The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks gestation. Which type of emotional response should the nurse anticipate? Grief related to her perceptions about the loss of this child. Relief of ambivalent feelings experienced with this pregnancy. Shock because she may not have realized that she was pregnant. Guilt because she had not followed her healthcare provider's instructions. The total bilirubin level of a 36-hour breastfeeding newborn is 14 mg/dL. Based on this finding, which intervention should the nurse implement? Provide phototherapy for 30 minutes every 8 hours. Feed the newborn sterile water hourly. Encourage the mother to breastfeed frequently. Assess the newborn's blood glucose level. A client is admitted with the diagnosis of total placenta previa. Which finding is the most important for the nurse to report to the healthcare provider immediately? Heart rate of 100 beats/minute. Variable fetal heart rate. The onset of uterine contractions. Burning on urination. A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which is the most important drug the nurse should have available for signs of potential toxicity? Oxytocin. Calcium gluconate. Terbutaline. Naloxone. A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. Which action should the nurse take first? Notify the pediatrician immediately. Suction the infant's nares, then the oral cavity. Check the infant's oxygen saturation rate. Position the infant on the right side. A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? Refer the client to a social worker to arrange for home care. Recommend perinatal care from an obstetrician, not a nurse-midwife. Teach the client why keeping prenatal care appointments is important. Advise the client that neonatal intensive care may be needed. A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusions. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity? Deep tendon reflexes 2+. Blood pressure 140/90 mmHg. Respiratory rate 18 breaths/minute. Urine output 90 mL/4 hours. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. Which answer accurately reflects the nurse's understanding of the variation of an accumulation of blood between the periosteum and skull that does not cross the suture line? A cephalhematoma, caused by forceps trauma and may last up to 8 weeks. A subarachnoid hematoma, which requires immediate drainage to prevent further complications. Molding, caused by pressure during labor and will disappear within 2 to 3 days. A subdural hematoma which can result in lifelong damage. Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respiration and the nurse assesses an apical heart rate of 80 beats/minute and respiration of 20 breaths/minute. Which action should the nurse perform next? Initiate positive pressure ventilation. Intervene after the one-minute Apgar is assessed. Initiate CPR on the infant. Assess the infant's blood glucose level. The nurse is assessing a 3-day-old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? Yellowish tinge to the skin. Babinski reflex is present bilaterally. Pink papular rash on the face. Moro reflex was noted after a loud noise. The nurse on the postpartum unit receives reports for 4 clients during the change of shift. Which client should the nurse assess for risk of postpartum hemorrhage (PPH)? A primigravida who had a spontaneous birth of preterm twins. A multigravida who delivered an 8-pound 2-ounce infant after an 8 hour labor. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. A primiparous client who had an emergency cesarean birth due to fetal distress. A pregnant client with mitral stenosis Class III is prescribed complete bed rest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." "We want your baby to be healthy, and this is the only way we can make sure that will happen." "I know you're upset. Would you like to talk about some things you could do while in bed?" "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties." The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? Begin as soon as your baby is born to establish a four-hour feeding schedule. Resting helps with milk production. Ask that your baby be fed at night in the nursery. Feed your baby every 2 to 3 hours or on demand, whichever comes first. Do not allow your baby to nurse any longer than the prescribed number of minutes. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? Administer oxygen by face mask. Notify the healthcare provider of the client's symptoms. Have the client breathe into her cupped hands. Check the client's blood pressure and fetal heart rate. The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply Litmus paper. Fetal scalp electrode. A sterile glove. An amnihook. Sterile vaginal speculum. Lubricant. When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? Milia are red marks made by forceps and will disappear within 7 to 10 days. Meconium is the first stool and is usually yellow-gold in color. Vernix is a white, cheesy substance, predominantly located in the skin folds. Pseudostrabismus found in newborns is treated by minor surgery. The nurse caring for a laboring client encourages her to void at least every 2 hours, and record each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection. A woman who gave birth 48 hours ago is bottle-feeding her infant. During the assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. Which action should the nurse take? Apply cold compresses to both breasts for comfort. Instruct the client to run warm water on her breasts. Wear a loose-fitting bra to prevent nipple irritation. Express small amounts of milk to relieve pressure. A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? Cervical dilation of 5 cm with 90% effacement. White blood cell count of 12,000/mm3. Hemoglobin of 12 mg/dl and hematocrit of 38%. A platelet count of 67,000/mm3. A female client with insulin-dependent diabetes (type 1 diabetes mellitus) arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? "Your current dose of Insulin should be maintained throughout your pregnancy." "Maintain blood sugar levels in a constant range within normal limits during pregnancy." "The course and outcome of your pregnancy is not an achievable goal with diabetes." "Expect an increase in insulin dosages by 5 units/week during the first trimester." A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? Patellar reflex 4+. Blood pressure 158/80 mmHg. Four-hour urine output 240 mL. Respiration 12 breaths/minute. A client who had a miscarriage 6 months ago becomes pregnant. Which instruction is the most important for the nurse to provide this client? Elevate lower legs while resting. Increase caloric intake by 200 to 300 calories per day. Increase water intake to 8 full glasses per day. Take prescribed multivitamins and mineral supplements. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is given a dose of terbutaline sulfate 0.25 mg subcutaneously. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. Maternal and fetal heart rates. Hourly urinary output. Deep tendon reflexes. A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2022. Based on Naegele’s rule, what is the estimated date of delivery? April 25, 2023. May 9, 2023. May 29, 2023. June 2, 2023. During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Place the first action on top and the last action on the bottom.) 1. 2. 3. 4. A full-term infant is transferred to the nursery from labor and delivery. Which information is the most important for the nurse to receive when planning immediate care for the newborn? The length of labor and method of delivery. The infant's condition at birth and treatment received. The feeding method chosen by the parents. The history of drugs given to the mother during labor. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 mmHg to 90/60 mmHg. Which action will the nurse take? Notify the healthcare provider or anesthesiologist immediately. Continue to assess the blood pressure every 5 minutes. Place the woman in a lateral position. Turn off the continuous epidural. A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? Exercise regimen of both partners includes running four miles each morning. History of having sexual intercourse 2 to 3 times per week. The woman's menstrual period occurs every 35 days. They use lubricants with each sexual encounter to decrease friction. A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? Males inherit the disorder with a greater frequency than females. Each pregnancy carries a 50% chance of inheriting the disorder. The disorders can occur in 25% of pregnancies. All children will be carriers of the disorder. A 40-week gestation primigravida client is being induced with an oxytocin secondary infusion and reports pain in her lower back. Which intervention should the nurse implement? Discontinue the oxytocin infusion. Place the client in a semi-Fowler's position. Inform the healthcare provider. Apply firm pressure to the sacral area. A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be the most effective in preventing the pooling of blood in the lower extremities? Wear support stockings. Reduce salt in her diet. Move about every hour. Avoid constrictive clothing. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? Encourage the mother to provide total care for her infant. Provide privacy so the mother can develop a relationship with the infant. Encourage the father to provide most of the infant's care during hospitalization. Meet the mother's physical needs and demonstrate warmth toward the infant.. The nurse is preparing to do a vaginal exam during labor. Which client would require the most caution when carrying out this procedure? A gravida 6, para 5 who is 38 years of age and in early labor. A 37-week primigravida who presents at 100% effacement, 3-cm cervical dilatation, and a -1 station. A gravida 2, para 1 who is at 1-cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. A 40-week primigravida who is at 6-cm cervical dilatation and the presenting part is not engaged. The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, FHR 110 beats/minute, BP 110/68 mmHg, cervix 1 cm dilated and uneffaced. Based on these assessment findings, which intervention should the nurse implement? Insert an internal fetal monitor. Assess for cervical changes every 1 hour. Monitor bleeding from IV sites. Perform Leopold's maneuvers. A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup, and hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent? Back pain. Abdominal pain. Shoulder pain. Leg cramps. The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? Herpes. Staphylococcus. Gonorrhea. Syphilis. A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. When preparing to document the client's delivery history, it is important for the nurse to document in the client's record which GTPAL history? 3-1-2-0-3. 4-1-2-0-3. 2-1-2-1-2. 3-1-1-0-3. Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? Have the client empty her bladder. Request the client lie on her left side. Perform Leopold's maneuvers first. Give the client some cold juice to drink. A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. Which intervention should the nurse implement first? Raise the foot of the bed. Assess for vaginal bleeding. Evaluate the fetal heart rate. Take the client's blood pressure. A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. Which findings should the charge nurse expect the client to demonstrate? (Select all that apply.) Select all that apply Dark, red vaginal bleeding. Lower back pain. Premature rupture of membranes. Increased uterine irritability. Bilateral pitting edema. A rigid abdomen. Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? Assess the husband's feelings about his wife's decision to breastfeed their baby. Ask the client to describe why she was unsuccessful with breastfeeding her last child. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. One hour after giving birth to an 8-pound infant, a client’s lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and her blood pressure is 156/96 mmHg. The healthcare provider prescribes Methergine 0.2 mg IM x 1. Which action should the nurse take immediately? Give the medication as prescribed and monitor for efficacy. Encourage the client to breastfeed rather than bottle feed. Have the client empty her bladder and massage the fundus. Call the healthcare provider to question the prescription. A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is the most important for the nurse to implement? Describe diet changes that can improve the management of her diabetes. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. Demonstrate self-administration of insulin. Evaluate the client's ability to do glucose monitoring. When evaluating maternal bonding, which of the following maternal behaviors exhibited by the client would the nurse most likely expect to see when a new mother receives her infant for the first time? She eagerly reaches for the infant, undresses the infant, and examines the infant completely. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Her arms and hands receive the infant and she then cuddles the infant to her own body. She eagerly reaches for the infant and then holds the infant close to her own body. A client in active labor complains of cramps in her leg. Which intervention should the nurse implement? Ask if she takes a daily calcium tablet. Extend the leg and dorsiflex the foot. Lower the leg off the side of the bed. Elevate the leg above the heart. The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) Select all that apply Admission weight of 4 pounds, 15 ounces ( 2230 grams). Head-to-heel length of 17 inches (43.18 cm). Frontal occipital circumference of 12.5 inches (31.75 cm). Skin smooth with visible veins and abundant vernix. Anterior plantar crease and smooth heel surfaces. Full flexion of all extremities in a resting supine position. A client at 30 weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. A vaginal examination reveals that her cervix is closed, thick, and high. Based on this data, which intervention should the nurse implement first? Provide oral hydration. Have a complete blood count (CBC) drawn. Obtain a specimen for urine analysis. Place the client on strict bedrest. A 28-year-old G1 P0 client who is currently 32 weeks pregnant is started on IV magnesium sulfate after being diagnosed with severe preeclampsia. After determining the serum magnesium level to be 15 mEq/L, the nurse should expect which of the following manifestations in the client? ECG changes. Loss of reflexes. Respiratory distress. Cardiac arrest. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on which of the following pieces of information? Anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. Anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. Anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. Anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot." "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb their hair." Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on the successful teaching of the gravid client? The client's readiness to learn. The client's educational background. The order in which the information is presented. The extent to which the pregnancy was planned. The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs when? Two weeks before menstruation. Immediately after menstruation. Immediately before menstruation. Three weeks before menstruation. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is started on an IV solution of terbutaline. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. Maternal and fetal heart rates. Hourly urinary output. Deep tendon reflexes. A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best? "This is not an unusually shaped head, especially for a first baby." "It may look funny to you, but newborn babies are often born with heads like your baby's." "That is normal. The head will return to a round shape within 3 to 4 days." "Your pelvis was too small, so the baby's head had to adjust to the birth canal." An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? Use a thread to tie off the umbilical cord. Provide as much privacy as possible for the woman. Reassure the husband and try to keep him calm. Put the newborn to breast. A 42-week gestational client is receiving an intravenous infusion of oxytocin to augment early labor. Which pattern of contractions should alert the nurse to discontinue the oxytocin infusion? Transition labor with contractions every 2 minutes, lasting 90 seconds each. Early labor with contractions every 5 minutes, lasting 40 seconds each. Active labor with contractions every 31 minutes, lasting 60 seconds each. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each. A client at 28 weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? Come to the clinic today for an ultrasound. Go immediately to the emergency room. Lie on your left side for about one hour and see if the bleeding stops. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection. On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be? November 22. November 8. December 22. October 22. During a prenatal visit, the client is concerned about the effects smoking can have on the fetus. Which response by the nurse is most accurate regarding infants of mothers who smoke during pregnancy? These infants have lower Apgar scores when born. These infants have lower birth weights. Respiratory distress is seen initially. A higher rate of congenital anomalies. The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? Edema, basilar rales, and an irregular pulse. Increased urinary output and tachycardia. Shortness of breath, bradycardia, and hypertension. Regular heart rate and hypertension. A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? 3+ deep tendon reflexes. Periorbital edema. Epigastric pain. Decreased urine output. A primigravida at 40 weeks gestation is receiving oxytocin to augment labor. Which adverse effect should the nurse monitor for during the infusion of oxytocin? Dehydration. Uterine Tachysystole (hyperstimulation). Galactorrhea. Fetal tachycardia. A 30-year-old multiparous woman who has a 3-year-old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter, I don’t know how I’ll ever manage both children when I get home." How should the nurse respond? "Tell the older child that he is a big boy now and should love his new sister." "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him." "Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn." "Regression in behaviors in the older child is a typical reaction so he needs attention at this time." Which assessment finding should the nursery nurse report to the pediatric healthcare provider? Blood glucose level of 45 mg/dL. Blood pressure of 82/45 mmHg. Non-bulging anterior fontanel. Central cyanosis when crying. The nurse is calculating the estimated date of birth (EDB) using Naegele’s rule for a client whose last menstrual period started on December 1. Which date is most accurate? August 1. August 10. September 3. September 8. The nurse is counseling a client who wants to become pregnant. The client tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. Which date accurately reflects the calculation of the client's next fertile period? January 14 to 15. January 22 to 23. January 30 to 31. February 6 to 7. The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? Reduce activity level and notify the healthcare provider. Go to bed and assume the knee-chest position. Massage the uterus and go to the emergency room. Do not worry as this is a normal occurrence. A full-term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have esophageal atresia. Which symptoms are this newborn likely to exhibit? Choking, coughing, and cyanosis. Projectile vomiting and cyanosis. Apneic spells and grunting. Scaphoid abdomen and anorexia. A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate? "A home pregnancy test can be used right after your first missed period." "These tests are most accurate after you have missed your second period." "Home pregnancy tests often give false positives and should not be trusted." "The test can provide accurate information when used right after ovulation." A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? Cleanse the perineum. Obtain a blood pressure. Palpate the firmness of the fundus. Inspect the perineum for lacerations. The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply Litmus paper. Fetal scalp electrode. A sterile glove. An amniotic hook. Sterile vaginal speculum. A Doppler. While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? The infant should be positioned to reduce the swelling. The swelling is a subperiosteal collection of blood. The pediatrician will aspirate the blood if it gets larger. The scalp edema will subside in a few days after birth. The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? Two vessels: one artery and one vein. Two vessels: two arteries and no veins. Three vessels: two arteries and one vein. Three vessels: two veins and one artery. Which action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? Monitor urinary output via an indwelling catheter. Assess the abdominal dressings for drainage. Give the Ringer's Lactated infusion at 125 mL/hr. Check the firmness of the uterus every 15 minutes. The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? Between the time the temperature falls and rises. Between 36 and 48 hours after the temperature rises. When the temperature falls and remains low for 36 hours. Within 72 hours before the temperature falls. At 14 weeks gestation, a client arrives at the Emergency Center complaining of dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling sharp abdominal pain and shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48 mmHg. Which action should the nurse implement next? Check the hematocrit results. Administer pain medication. Increase the rate of IV fluids. Monitor client for contractions. The nurse is assessing a client who is having a non-stress test (NST) at 41 weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 beats per minute, and no FHR accelerations are occurring. Which action should the nurse take? Check the client for urinary bladder distention. Notify the healthcare provider of the nonreactive results. Have the mother stimulate the fetus to move. Ask the client if she has felt any fetal movement.