GUARANTEE A+
✔✔27. During an assessment of a multiparous client who delivered an 8-lb 7-oz infant 4
hours ago, the nurse notes the client's perineal pad is completely saturated within 15
minutes. What action should the nurse implement next?
A. Encourage the client to avoid.
B. Perform fundal massage.
C. Notify the healthcare provider.
D. Assess blood pressure. - ✔✔B. Perform fundal massage.
✔✔28. The nurse is assessing a full-term newborn's breathing pattern. Which findings
should the nurse assess further? *(Select all that apply.)*
A. Grunting heard with a stethoscope.
B. Diaphragmatic with chest retraction.
C. Abdominal with synchronous chest movements.
D. Shallow with an irregular rhythm.
E. Chest breathing with nasal flaring.
F. Rate of 58 breaths per minute. - ✔✔A. Grunting heard with a stethoscope.
B. Diaphragmatic with chest retraction.
E. Chest breathing with nasal flaring.
✔✔29. What action should the nurse implement when caring for a newborn receiving
phototherapy?
A. Reposition every 6 hours.
B. Apply an oil-based lotion to the skin.
C. Limit the intake of formula.
D. Place an eyeshield over the eyes. - ✔✔D. Place an eyeshield over the eyes.
✔✔30. Which finding indicates to the nurse that a 4-day-old infant is receiving adequate
breast milk?
A. Gains 1 to 2 ounces per week.
B. Defecates at least once per 24 hours.
C. Saturates 6 to 8 diapers per day.
D. Rests for 6 hours between feedings. - ✔✔C. Saturates 6 to 8 diapers per day.
✔✔31. The nurse is providing discharge teaching for a gravid client who is being
released from the hospital after placement of cerclage. Which instruction is the most
important for the client to understand?
A. Arrange for home uterine monitoring.
, B. Plan for a possible cesarean birth.
C. Report uterine cramping or low backache.
D. Make arrangements for care at home. - ✔✔C. Report uterine cramping or low
backache.
✔✔32. A client at 28-weeks gestation arrives at the labor and delivery unit with a
complaint of bright red, painless vaginal bleeding. For which diagnostic procedure
should the nurse prepare the client?
A. Contraction stress test.
B. Lecithin-sphingomyelin ratio.
C. Abdominal ultrasound.
D. Internal fetal monitoring. - ✔✔C. Abdominal ultrasound.
✔✔33. A nurse is planning for the care of a 30-year-old primigravida with pre-
gestational diabetes. What is the most important factor affecting the clients pregnancy
outcome?
A. Degree of glycemic control during pregnancy.
B. Mother's age.
C. Amount of insulin required prenatally.
D. Number of years since diabetes was diagnosed. - ✔✔A. Degree of glycemic control
during pregnancy.
✔✔34. A client with asthma who is 8-hours post-delivery is experiencing postpartum
hemorrhage. Which prescription should the nurse administer?
A. Oxytocin (Pitocin).
B. Ibuprofen (Motrin).
C. Fentanyl (Sublimaze).
D. Hemabate (Carboprost). - ✔✔A. Oxytocin (Pitocin).
✔✔35. The nurse is assisting with the insertion of a pulmonary artery catheter (PAC)for
a client at 32-weeks gestation who has severe preeclampsia with edema. As the PAC
enters the right ventricle, what is the priority nursing assessment?
A. Observe for maternal blood pressure changes.
B. Assess fetal response to the procedure.
C. Monitor for premature ventricular contractions.
D. Note to any complaint of sudden chest pain. - ✔✔C. Monitor for premature
ventricular contractions.
✔✔36. A client at 28-weeks gestation experiences blunt abdominal trauma. Which
parameter should the nurse assess first for signs of internal hemorrhage?