A charge nurse is teaching a newly licensed nurse about substance use disorders during
pregnancy. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching? - Encourage client who are prescribed methadone to
breas eed.
-The nurse should encourage clients who are prescribed methadone during pregnancy to
breas eed their newborns to help with withdrawal symptoms.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following
findings is an indica on the medica on was effec ve? - Decreased frequency of contrac ons.
-Terbutaline is a tocoly c medica on that is used to halt preterm labor. Terbutaline cause
relaxa on of smooth muscle, which decrease uterine ac vity. Therefore, the nurse should
iden fy that a decrease in frequency of contrac ons is an indica on that terbutaline was
effec ve.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which
of the following ac ons should the charge nurse include in the teaching regarding situa ons
requiring an amniotomy? - Placing a fetal scalp electrode.
-A fetal scalp electrode is a ached to the presen ng part of the fetus in order to provide
accurate con nuous monitoring of the fetal heart rate. If the client's membranes are intact, the
amnio c sac must be ar ficially ruptured prior to a aching the electrode to enable access to
the presen ng part.
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering
labetalol. For which of the following findings should the nurse withhold the medica on? - Heart
rate 54/min
,-The nurse should iden fy that a heart rate of 54/min is below the expected reference range of
60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased blood
volume and increase ssue demands for oxygen. Bradycardia is a contraindica on for the
administra on of labetalol, an an hypertensive medica on. Therefore, the nurse should
withhold the medica on and no fy the provider.
A nurse is caring for a client who is at 30 weeks of gesta on and observes the client choking
while ea ng lunch. The client is unable to speak or cough. Iden fy the sequence of steps the
nurse should take to clear the airway obstruc on. - 1. Stand posterior to the client.
2. Posi on arms under the client's axilla and across the client's chest.
3. Place thumb-side of a clenched fist to the client's mid-sternum area.
4. Ini ate chest thrust to the client using a backward mo on.
-If the client becomes unconscious, the nurse should perform CPR and ac vate emergency
medical services.
A nurse is preparing to administer an opioid analgesic to a client who is in ac ve labor. Which of
the following assessments should the nurse perform? (SATA) - Maternal blood pressure.
-Opioid analgesic can cause hypotension. The nurse should assess the clients blood pressure
before and a er administering opioids.
Pain level.
-The nurse should assess the clients baseline pain level prior to administering pain medica on
and again a er administering pain medica on to determine the effec veness of the medica on.
Opioid analgesic are indicated for the relief of moderate to sever labor pain.
Fetal heart rate.
-Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should
assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is within
the expedited reference range and to have a baseline for future assessments. The nurse should
provide ongoing assessments of fetal heart rate throughout labor according to facility protocol.
, A nurse is reviewing the medical records of a client who is at 8 wks. of gesta on. Which of the
following findings should the nurse iden fy as a risk factor for developing preeclampsia? -
Rheumatoid Arthri s.
-The presence of a connec ve ssue disease, such as rheumatoid arthri s or systemic lupus
erythematosus, increase a clients risk for developing preeclampsia.
A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for
deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor? -
Interna onal normalized ra o (INR).
-The nurse should monitor the INR of a client who is taking warfarin. Prothrombin me(PT) is
also measure to regulate warfarin therapy. However, PT values are more difficult to interpret.
INR determined by mul plying the PT by a correc on factor based on the specific
thromboplas n prepara on used for the test, as a way of equalizing laboratory to laboratory
varia ons.
A nurse is monitoring a client who is in the ac ve phase of labor and has an intrauterine
pressure catheter and fetal scalp electrode. Which of the following findings should the nurse
expect? - Montevideo units (MVU) of 220 mm Hg.
- The nurse should iden fy that an MVU of 220 mm Hg is within the expected range during the
ac ve phase of labor. MVUs generally range between 100 to 250 mm Hg during the first stage of
labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs are calculated
by subtrac ng the baseline uterine pressure from the peak contrac on pressure for every
contrac on that occurs during a 10-min period. The nurse then adds the pressure produced by
each contrac on during that me to determine the MVUs.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural
morphine for postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is
10/min. Which of the following ac ons should the nurse take first? - Administer oxygen by
nonrebreather face mask.
-The first ac on the nurse should take when using the airway, breathing, circula on approach to
client care is to administer oxygen by nonrebreather mask to treat manifesta ons of respiratory
depression due to morphine administra on.
pregnancy. Which of the following statements by the newly licensed nurse indicates an
understanding of the teaching? - Encourage client who are prescribed methadone to
breas eed.
-The nurse should encourage clients who are prescribed methadone during pregnancy to
breas eed their newborns to help with withdrawal symptoms.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following
findings is an indica on the medica on was effec ve? - Decreased frequency of contrac ons.
-Terbutaline is a tocoly c medica on that is used to halt preterm labor. Terbutaline cause
relaxa on of smooth muscle, which decrease uterine ac vity. Therefore, the nurse should
iden fy that a decrease in frequency of contrac ons is an indica on that terbutaline was
effec ve.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which
of the following ac ons should the charge nurse include in the teaching regarding situa ons
requiring an amniotomy? - Placing a fetal scalp electrode.
-A fetal scalp electrode is a ached to the presen ng part of the fetus in order to provide
accurate con nuous monitoring of the fetal heart rate. If the client's membranes are intact, the
amnio c sac must be ar ficially ruptured prior to a aching the electrode to enable access to
the presen ng part.
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering
labetalol. For which of the following findings should the nurse withhold the medica on? - Heart
rate 54/min
,-The nurse should iden fy that a heart rate of 54/min is below the expected reference range of
60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased blood
volume and increase ssue demands for oxygen. Bradycardia is a contraindica on for the
administra on of labetalol, an an hypertensive medica on. Therefore, the nurse should
withhold the medica on and no fy the provider.
A nurse is caring for a client who is at 30 weeks of gesta on and observes the client choking
while ea ng lunch. The client is unable to speak or cough. Iden fy the sequence of steps the
nurse should take to clear the airway obstruc on. - 1. Stand posterior to the client.
2. Posi on arms under the client's axilla and across the client's chest.
3. Place thumb-side of a clenched fist to the client's mid-sternum area.
4. Ini ate chest thrust to the client using a backward mo on.
-If the client becomes unconscious, the nurse should perform CPR and ac vate emergency
medical services.
A nurse is preparing to administer an opioid analgesic to a client who is in ac ve labor. Which of
the following assessments should the nurse perform? (SATA) - Maternal blood pressure.
-Opioid analgesic can cause hypotension. The nurse should assess the clients blood pressure
before and a er administering opioids.
Pain level.
-The nurse should assess the clients baseline pain level prior to administering pain medica on
and again a er administering pain medica on to determine the effec veness of the medica on.
Opioid analgesic are indicated for the relief of moderate to sever labor pain.
Fetal heart rate.
-Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should
assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is within
the expedited reference range and to have a baseline for future assessments. The nurse should
provide ongoing assessments of fetal heart rate throughout labor according to facility protocol.
, A nurse is reviewing the medical records of a client who is at 8 wks. of gesta on. Which of the
following findings should the nurse iden fy as a risk factor for developing preeclampsia? -
Rheumatoid Arthri s.
-The presence of a connec ve ssue disease, such as rheumatoid arthri s or systemic lupus
erythematosus, increase a clients risk for developing preeclampsia.
A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for
deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor? -
Interna onal normalized ra o (INR).
-The nurse should monitor the INR of a client who is taking warfarin. Prothrombin me(PT) is
also measure to regulate warfarin therapy. However, PT values are more difficult to interpret.
INR determined by mul plying the PT by a correc on factor based on the specific
thromboplas n prepara on used for the test, as a way of equalizing laboratory to laboratory
varia ons.
A nurse is monitoring a client who is in the ac ve phase of labor and has an intrauterine
pressure catheter and fetal scalp electrode. Which of the following findings should the nurse
expect? - Montevideo units (MVU) of 220 mm Hg.
- The nurse should iden fy that an MVU of 220 mm Hg is within the expected range during the
ac ve phase of labor. MVUs generally range between 100 to 250 mm Hg during the first stage of
labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs are calculated
by subtrac ng the baseline uterine pressure from the peak contrac on pressure for every
contrac on that occurs during a 10-min period. The nurse then adds the pressure produced by
each contrac on during that me to determine the MVUs.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural
morphine for postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is
10/min. Which of the following ac ons should the nurse take first? - Administer oxygen by
nonrebreather face mask.
-The first ac on the nurse should take when using the airway, breathing, circula on approach to
client care is to administer oxygen by nonrebreather mask to treat manifesta ons of respiratory
depression due to morphine administra on.
