NURS 220 HESI Maternity

NURS 220 HESI Maternity Practice Questions 1. The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? a. terbutaline (Brethine) 0.25 mg SubQ Q15 mins x 3 b. Betamethasone (Celestone) 12 mg deep IM c. Butorphanol 1 mg IV push q2h PRN pain d. Ampicillin 1-gram IV push q8h 2. A primigravida client confides in the nurse that her sister told her that she should eliminate all salt once she is at 26 weeks’ gestation because it will eliminate fluid retention and swelling. How should the nurse respond? a. Salt foods lightly during cooking but add no additional salt at the table. b. eliminate all added salt from the diet to improve kidney function during pregnancy c. limit grain, meat and milk products which are significant sources of sodium d. use canned food products to obtain salt because it is easier to monitor salt intake 3. A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication? a. jaundice* b. brain damage c. poor appetite d. hypoglycemia 4. The mother of a breastfeeding 24 hr old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is “doing it right.” She tells the nurse, “I just know my daughter is not getting enough to eat.” What response would be best for the nurse to make? a. feed your baby hourly until you feel confident that your child is receiving enough milk b. don’t worry, soon your milk will come in, and you will feel how full your breasts are c. since you are so concerned, you should probably supplement breastfeeding with formula d. if your baby’s urine is straw-colored, she is getting enough milk* 5. A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment finding warrants immediate intervention by the nurse? a. the onset of uterine contractions b. leaking amniotic fluid c. fetal heart rate 60 beats/min* d. ruptured amniotic membrane 6. A client at 40-weeks’ gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. What information is most important for the nurse to obtain first? a. the estimated amount of fluid b. time the membranes ruptured c. color and consistency of the fluid d. any odor noted when membranes ruptured. 7. A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action should the nurse take first? a. assess the urine for proteinuria b. record the finding on a flowsheet c. obtain blood pressure reading d. notify the healthcare provider 8. The nurse is preparing to draw blood from a newborn to obtain hemoglobin and hematocrit levels. What is the best method to obtain this blood sample? a. use a butterfly, small gauge needle to do a venous puncture on the hand b. draw blood from the infant's antecubital vein using a small gauge needle c. use a small gauge needle to puncture the vastus lateralis d. use a lancet to puncture the outer lateral aspect of the heel * 9. A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client? a. postpartum psychosis b. hard, painful uterine afterpains c. placenta accreta d. disseminated intravascular coagulation* 10. A primigravida client receives a prescription for an infusion of oxytocin (Pitocin) at 12 milliunits/minute. The available solution is ringers lactated 1,000 ml with Piton 10 units. The nurse should program the infusion pump to deliver how many ml/hour? 11. A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some “heart damage.” The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client’s history, which nursing diagnosis has the highest priority? a. sleep deprivation b. risk for infection c. fluid volume excess * d. nausea and vomiting 12. collard greens 13. A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse’s assessment reveals approximately 30 ml of bright red vaginal bleeding, FHR of 130 to 140 beats/min, no contraction, and no complaints of pain. What is the most likely case of this client’s bleeding? a. placenta previa b. a ruptured blood vessel in the vaginal vault c. normal bloody show indicating initiation of labor d. abruptio placenta 14. A client at 26 weeks gestation recently indicated a yellow discharge from her right breast. How should the nurse respond? a. you need to wear a good support bra b. you need to discuss this with your HCP c. you probably have an infection d. this is normal * 15. When assessing a pregnant woman at 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report to the HCP? a. +1 pedal edema b. 130/70 blood pressure c. 101.2 F oral temp * d. +1 proteinuria 16. When performing the daily head to toe assessment of a one-day old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take? a. review maternal medical records for blood type and Rh factor b. prepare the newborn for phototherapy c. evaluate cord blood Coombs’ test results d. measure bilirubin levels using transcutaneous bilirubinometer 17. A pregnant client mentions in her history that she changes a cat’s litter box daily. Which test should the nurse anticipate the HCP to prescribe? a. Biophysical profile b. TORCH screening c. Fern Test d. amniocentesis 18. Assessment findings of a 3-hour old newborn include: axillary temperature of 97.7 F, heart rate of 140 beats/min with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement? a. record findings in electronic medical record b. obtain venous blood sample for glucose level c. attach a pulse oximeter on the heel d. place the infant under the radiant warmer 19. Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum? a. pudendal block b. epidural block c. saddle block d. paracervical block 20. A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond? a. that is called a caput succedaneum. it will absorb and cause no problems* b. that is called a cephalohematoma. it can cause jaundice as it is absorbed c. that is called a cephalohematoma. it will cause no problems d. that is called a caput succedaneum. it will have to be drained 21. A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the hospital. Which instruction should the nurse include in the discharge teaching plan? a. breastfeed infant every 4 hours b. monitor skin and eyes for yellow tinge c. reposition the infant every 2 hours d. change diapers every hour 22. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/min, respiratory rate 16 breaths/min, and blood pressure 130/74. What action should the nurse implement? a. administer a PRN dose of acetaminophen b. report heart rate to HCP c. document the vital signs in the record d. assess the perineum for excessive lochia 23. A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin E drug. How should the nurse respond? a. you may have an increased chance of having preeclampsia b. this medication will have no effect on your unborn child c. you may experience postpartum hemorrhage after delivery d. you may be at higher risk for having a spontaneous miscarriage * 24. A pregnant woman who is at 10-weeks’ gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with Down Syndrome. Which information should the nurse provide this client? a. an amniocentesis conducted at 24 weeks’ gestation confirms or denies Down Syndrome in the fetus b. maternal serum Human Chorionic Gonadotropic (HCG) can identify Down Syndrome at 6 weeks of gestation c. Weekly fundal height measurements are a noninvasive method used to check for Down Syndrome d. Chorionic villus sampling at 12 weeks gestation is the earliest screening test used to identify Down Syndrome * 25. A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, menopur) and HCG. Which side effect should the nurse tell the client to report immediately? a. persistent daytime fatigue b. rapid increase in abdominal girth c. nausea and vomiting d. episodes of headache and irritability 26. The HCP prescribes 10 units/L of oxytocin (Pitocin) via IV drip to augment a client’s labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin? a. early decelerations of FHR b. uterus is soft c. Four contractions in 10 minutes d. contraction duration of 100 seconds * 27. The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority should the nurse address to ensure the newborn’s survival? a. fluid balance b. hypoglycemia c. heat loss d. bleeding tendencies 28. One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? a. check the differential, since the WBC is normal for this client * b. notify the HCP, since this finding is indicative of infection c. assess the client’s temperature, pulse and respirations q4h d. assess the clients perineal area for signs of perineal hematoma 29. The nurse is performing a newborn assessment. Which symptom, if present in a newborn would indicate respiratory distress? a. respiratory rate of 50 breaths per min b. flaring of the nares * c. shallow and irregular respirations d. abdominal breathing with synchronous chest movement 30. The nurse is caring for a client following an emergency cesarean delivery under a general anesthesia. Which assessment finding, occurring in the first 8 hours after delivery, is more critical and requires immediate intervention? a. mild nausea and anorexia b. uterine atony * c. a positive Homan’s sign d. Respiratory rate 12 31. The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision? a. give a PRN dose of liquid acetaminophen b. wrap the infant in warm receiving blankets c. place petrolatum gauze dressings on the site * d. offer a pacifier dipped in glucose water 32. The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first? a. palpate the client’s bladder b. check the pH of the vaginal fluid c. determine cervical dilation d. review the FHR pattern * 33. A 26-week gestation primigravida who is carrying twins is seen in the clinic today. Her final height is measured at 29 cm. Based on these findings, what action should the nurse implement? a. notify the HCP of the finding b. schedule the client for a biophysical profile c. document the finding in the medical record d. request another nurse measure the fundus 34. A client at 34 weeks gestation is scheduled to travel for business using a commercial airline. Which instruction is most important for the nurse to provide this client? a. explore the availability of medical care at the destination site b. request an aisle seat in a row that is not designated as an exit row * c. perform ankle flexion and extension several times throughout the trip d. wear non-constricting clothing to prevent edema of the feet and hands 35. Following a precipitous labor, a postpartum client has a continuous trickling of bright red blood from her vagina. Her uterus is firm, and her vital signs are within normal limits. The nurse determines that this sign may indicate which condition? a. expected course in the fourth stage of labor b. a full urinary bladder c. early postpartum hemorrhage d. the laceration on the cervix * 36. The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority? a. Hyperthermia b. polycythemia c. hyperbilirubinemia d. hypoglycemia 37. A postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client? a. RhoGAM is not necessary unless all her pregnancies are Rh-positive b. RhoGAM prevents maternal antibody formation for future Rh-positive babies c. the mother should receive RhoGAM when the baby is Rh-negative d. the R-positive factor from the fetus threatens her blood cells * 38. A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per minute. What intervention is most important for the nurse to perform? a. encourage the client to empty her bladder * b. determine the maternal pulse rate c. instruct the client to drink a glass a juice d. place the client in a supine position 39. Vaginal examination reveals that a laboring clients’ cervix is dilated to 2 cm, 70% effaced, with the presenting part at -2 stations. The client tells the nurse, “I need my epidural now! This hurt!” the nurses’ response to the client should be based on what information? a. the client should be dilated to at least 8 cm before receiving an epidural b. the baby needs to be at a zero station before an epidural can be administered c. Administering an epidural at this point would slow the labor process * d. the client will need to be catheterized before the epidural can be administered. 40. A client at 38 weeks gestation presents to the labor and delivery unit in active labor. Based on which assessment finding should the nurse notify the surgery team to prepare for a primary cesarean section? a. treated ten days ago for Chlamydia b. Group Beta Strep positive c. Positive western blot for HIV d. active herpes lesions on the perineum 41. A 6 weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? a. immediately, at six weeks gestation to protect this fetus b. early postpartum within 72 hours of delivery c. after the client stops breastfeeding d. after the client reaches 20-weeks’ gestation 42. The nurse is receiving a report for a laboring client who arrived in the ER with ruptured membranes that the client did not recognize. What is the priority nursing action to implement when the client is admitted to the labor and delivery suite? a. Prepare to start at IV * b. take the clients temp c. begin a pad count d. monitor amniotic fluid for meconium 43. A laboring client with gestation diabetes is receiving an IV infusion with regular insulin at five units/hour. The IV solution contains 100 units of regular insulin in 250 ml of 0.9% normal saline. The nurse should program the infusion pump to deliver how many ml/hours? 44. The nurse is conducting a postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control, which method should the nurse recommend to this client as best for her to use in preventing an unwanted pregnancy? a. combined estrogen- progesterone oral contraceptives b. breastfeed exclusively at least every 3 to 4 hours c. condoms and contraceptive foam or gel d. rhythm method (natural family planning) 45. A full-term infant is admitted to the newborn nursery 2 hours after delivery. The delivery record indicates that the mother is positive for HIV and received zidovudine AZT IV during labor. What action should the nurse implement? a. ensure that AZT is given within 6 hours after birth b. assess for the presence of the Moro reflex c. collect venous specimen for serum glucose level d. obtain consent for the Hep B vaccine 46. In determining the one-minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has a loud cry with stimulation, good muscle tone and his color is acrocyanotic. What Apgar score should the nurse assign? a. 7 b. 9 ** c. 10 d. 8 47. A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy? a. complaints of feeling tired all the time b. presence of amenorrhea for 2 months c. visualization of implantation by vaginal ultrasound d. maternal blood serum tests positive for alpha-fetoprotein 48. Four clients at full term present to the labor and delivery unit at the same time. which client should the nurse assess first? a. primipara with vaginal show and leaking membranes b. primipara with burning on urination and urinary frequency c. multipara scheduled for a non-stress test and biophysical profile d. multipara with contractions occurring every 3 minutes 49. A primigravida at 40 weeks gestation is contracting q2 minutes and her cervix is 9 cm dilated and 100% effaced. The FHR is 120 beats/minute. The client is screaming, and her husband is alarmed. Which intervention should the nurse implement? a. notify the rapid response team b. have delivery table set up * c. ask the husband to step out d. administer a PRN narcotic 50. The nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine demise protocol and identification procedures. What action is most important for the nurse to take? a. Explain reasons consent for an infant autopsy is needed b. create a memory box of a baby’s footprints and photographs c. determine if the mother desires a visit from the clergy d. encourage the mother to hold and spend time with her baby * 2017 HESI 1. One week after missing her menstrual period, a woman performs an OTC pregnancy test and it is positive. Which hormone is responsible for producing the positive result? a. HCG 2. The father of a 3-day old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no apparent reason. What information is most important for the nurse to provide this father? a. Contact the clinic if the behaviors continue for more than two weeks or become worse. 3. After amniocentesis monitor for signs of labor, since is increases the risk 4. Clients who are HIV positive are encouraged to bottle-feed their infants because: a. the HIV virus is transmitted through breastmilk. 5. When fetal movements or contractions compress the umbilical cord, variable decelerations can happen. Maternal repositioning can alleviate cord compressions 6. PKU- prenatal history. When both parents are carriers of an autosomal recessive gene, such as PKU, each child has a 25% change of being healthy. 7. A primigravida at 36 weeks gestation, who is Rh negative, experienced abdominal trauma in a motor vehicle collision. Which assessment finding is more important for the nurse to report to the HCP? a. Positive fetal hemoglobin testing 8. Calculated by Naegele’s rule, a primigravida client is at 28 weeks gestation. She is moderately obese and carrying twins and the nurse measures her fundal height at 27 cm. During the previous visit 3 weeks ago, the fundal height measured at 28 cm. Based on these findings, what should the nurse conclude? a. Fundal height measurement may indicate intrauterine growth retardation 9. The nurse is discussing involution with a postpartum client. Which statement best indicates that the client understands the effect of breastfeeding on the resumption of menstrual cycle? a. While i am breastfeeding, my period may be delayed 10.A A term multigravida who is receiving oxytocin (Pitocin) for labor augmentation, is requesting pain medication. Review of the client’s record indicates that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal exam reveals that the clients cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement? a. Instruct the client to use deep breathing during a contraction 11.While caring for a laboring client on continuous fetal monitoring. The nurse notes an FHR pattern that falls and rises abruptly with a “V” shaped appearance. What action should the nurse take first? a. Change the maternal position 12.During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. What action should the nurse implement? a. Notify the pediatrician of the cephalhematoma 13.The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client teaching plan? a. increase daily caloric intake is needed 14. A 38-week primigravida client who is positive for group A beta streptococcus receives a prescription for cefazolin 2grams IV to be infused over 30mins. The medications available in 2 grams/100ml of normal saline. The nurse should program the infusion pump to deliver how many ml/hours? 1.6ml/hr 15.When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum and abdomen. What action should the nurse take? a. measure bilirubin levels using transcutaneous bilirubinometer. b. review maternal medical records for blood type and Rh factor c. Prepare the newborn for phototherapy d. Evaluate cord Coombs test results 16.A A new mother asks the nurse about an area of swelling on her baby head near the posterior fontanel that lies across the suture lines. How should the nurse respond? a. That's called caput succedaneum. It will absorb and cause no problems. b. That is called a cephalhematoma. It will cause no problems. c. That is called a cephalhematoma. It can cause jaundice as it is. d. D)That is called caput succedaneum. It will have to be drained. 17.A A 39-week gestational multigravida is admitted to labor and delivery spontaneous rupture of membranes and contraction occurring 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6cm, 90% effaced and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate has ranged between 170 and 180 beats/minute. What action should the nurse implement? a. Obtain a blood specimen for hemoglobin b. Take an oral maternal temperature c. Straight Catheterize client d. Send amniotic fluid for analysis 18.An obviously pregnant woman walks into the hospital’s emergency department entrance shouting. “Help me! Help me! My baby is coming! Im so afraid!” The nurse determines if delivery is indeed imminent, what action is most important for the nurse to take? a. Determines the gestational age of fetus b. Assess the amount and color of the amniotic fluid c. Obtain peripheral IV access and begin administration of IV fluids d. Provide clear concise instructions in a calm, deliberate manner 19.A client who is 3 weeks postpartum tells the nurse. “I am so tired all the time. I didn't know having a baby would be so hard.” What response should the nurse provide. a. It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps. b. It is normal to feel tired for the first couple weeks. Be patient with yourself and rest more. c. You should not be doing any housework. Are any of your family members helping you? d. Adjusting to a new baby can be difficult. Tell me more about any help you are receiving. 20.The home health nurse visits a client who delivered a full-term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curl-like patches on the newborns oral mucous membranes. What action should the nurse implement? a. Discuss the need for medication to treat curl-like oral patches b. Suggest switching the infant’s formula c. Assess the baby’s blood glucose level d. Remind mother not put the baby to bed with a propped bottle 21.One hour after delivery the nurse is unable to palpate the uterine funds of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next. a. Document number of pad changes in the last hour b. Provide bedpans to void if unable to ambulate c. Palpate the supra cubic area for bladder distention d. Increases the rate of the oxytocin infusion 22.The father of a 3-day old infant who is breast feeding calls the postpartum help line to report that his wife is acting strangely. She is irritable, cannot cope with the baby, and frequently cries for no appeared reason. What information is most important for the nurse to provide the father? a. Contact the clinic if the behaviors continue for more than two weeks or becomes worse b. Tell the father count the newborns number of soiled diapers over the next few days. c. A fluctuation in hormones in the early postpartum period can cause mood changes. d. Recommend giving supplemental bottle feedings to the baby between breast feeding. 23.Which action should the nurse take if an infant, who was born yesterday weighing 7.5lbs (3,317grams) weights 7 lbs. (3,175grams) today. a. Monitor the stool and urine output of the neonate for the last 24 hours b. Inform and assure the mother that this is a normal weight loss c. Encourages the mother to increase frequency of breastfeeding. d. After verifying the accuracy of the weight, notify the healthcare provider. 24.A A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the clients record indication that she was medicated 30minutes ago with butorphanol (Stadol) 2mg and promethazine (Phenergan) 25mg IV push. Vaginal examination reveals that the client cervical dilation is 3cm, 70% effaced, and at a 0 station. What action should the nurse implement? a. Discontinue the Pitocin infusion b. Medicate the client with an additional 1mg of Stadol IV push c. Notify the healthcare provider d. Instruct the client to use deep breathing during contraction 25.A A woman who delivered a 9-pound baby boy by cesarean section under spinal anesthesia is recovering in the post anesthesia care unit. Her fundus is firm at the umbilicus and a continues to trickle bright red blood with no clots from the vagina in observed by the nurse. Which actions should the nurse implemented. a. Massage the fundus b. Assess her blood pressure c. Apply ice pack to perineum d. Let the infant breast feed 26.A A newborn infant is receiving immunization prior discharge. Which action should the nurse implement? a. Give the first dose of the vaccine for rotavirus if any have diarrhea now. b. Obtain signed consent from the mother for administration of hepatitis B vaccine c. Prepare the first dose for DTaP d. Ask the mother if she wants the infant immunized for 27.A A new mother, who is a lacto-ovo vegetarian, plans to breastfeed her infant. What information should the nurse provide prior to discharge. a. Continue prenatal vitamins with B12 while breast feeding 28.When teaching a gravid client how to perform kick (fetal movement) counts which instruction should the nurse includes. a. If 10 kicks are not felt within 1hr, drink orange juice and count for another hour. 29.A A client at 38- weeks’ gestation complaints of severe abdominal pain. Upon the nurse notes that the abdomen is rigid. a. Placenta previa b. Oligoamnios c. Abruptio placenta d. Chorioamnionitis 30.A A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height in measured at 29cm. Based on these findings what actions the nurse implement. a. Notify the healthcare provider of the finding b. Document the finding in the medical record c. Schedule the client for a biophysical profile d. Request another nurse measure the fundus 31.The nurse is performing a newborn assessment. Which symptoms if present in newborn, would indicate respiratory distress? a. Flaring of the nares 32.The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client? a. Administration of Pitocin b. Artificial rupture of the membrane c. Amnioinfusion for the baby d. Administration of antibodies 33.The nurse examines a client who is admitted in active labor and determines the cervix is 3cm dilated 50% effaced, and the presenting part is at 0 stations. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first. a. Check the pH of the vaginal fluid b. Review the fetal heart rate pattern c. Palpate the client’s bladder d. Determine cervical dilation 34.The nurse’s assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first? a. Position radiant warmer over the crib b. Assess the infants blood glucose level c. Nipple feed 1 ounce 1% glucose in water d. Place the infant in side-lying position 35.Which content should the nurse plan to include in a nutrition class for pregnant adolescents? (select all that apply) a. Take iron and calcium supplements daily b. Gain no more than 15 pounds during the pregnancy c. Increase food intake by 300 to 400 calorie /day d. Take folic acid supplement daily e. Maintain current protein intake 36.The healthcare provides prescribes 10units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin? a. uterus soft b. contraction duration of 100 seconds c. four contractions in 10 minutes d. Early deceleration of fetal heart rate 37.A A new mother who is breastfeeding her 4-week old infant and has type 1 diabetes, reports that her insulins needs have decreased since the birth of her child. What action should the nurse implement? a. Inform her that a decrease for insulin occurs while breastfeeding b. Advice the client to breastfeed more frequently c. Counsel her to increase her calories retake d. Schedule an appointment for the client with diabetic nurse educator 38.A A diabetic client delivers a full-term large for gestation- age (LGA) infant who is jittery action should the nurse take first? a. Obtain a blood glucose level 39. The postpartum admission prescription for a client who delivered a healthy newborn includes one liter of lactated ringers with oxytocin 20units to infuse over 8 hours. How many milliunits /minutes is the clients receiving??? 40.A A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement? a. Schedule weekly prenatal appointments 41.The nurse is planning a class for pregnant women in the first trimester of pregnancy. Which information is most important for the nurse to include in the class? a. Plan rest periods and increase sleep time to an hour per day when fatigue b. If any vaginal bleeding occurs, notify the healthcare provider immediately c. Since eating often relieves nausea, carry low fat snacks to eat whenever nausea occurs d. If morning dizziness occurs, rise slowly and sit on the side of the bed for one minute 42.When assessing a pregnant woman AT 39-weeks’ gestation who is admitted to labor and delivery which finding is most important to report to the health care provider? a. + proteinuria b. 130/70 blood pressure c. + pedal edema d. 101.2 oral temperature 43.A A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin C drug, how should the nurse respond? a. “You may be at risk for having a spontaneous miscarriage” b. “You may have an increased chance of having preeclampsia” c. “This medication will have no effect on your unborn child” d. “You may experience postpartum hemorrhaging after delivery” 44.Following the vaginal delivery of a large-for-gestation-age (LGA) infant a woman is admitted to the intensive care unit due to postpartum hemorrhaging. The client’s medical record lists have client’s religion as Jehovah’s Witness. What action should the nurse take? a. Inform the client of the critical need for a blood transfusion 45.After delivery of a normal infant, the mother tells the nurses that she would like to use oral contraceptive. Which finding in the client’s health history is a contraindication of the use of contraceptives? a. Previously used intrauterine device (IUD) b. Reported history of stroke within family c. Diagnosed with diabetes mellitus 2 years ago d. Smoked cigarettes prior to becoming pregnant 46.When planning care for a laboring client, the nurse identifies the need to withhold solids food while the client is in labored. What is the most important reasons for this nursing intervention? a. An increased risk of aspiration can occur if general anesthesia is needed 47.The parents of a male newborn have signed an informed consent for circumcision. which intervention should the nurse implement upon completion of the circumcision? a. Place petroleum gauze dressings on the site b. wrap the infant in warm receiving blankets c. Give a PRN dose of liquid acetaminophen d. Offer a pacifier dipped in glucose water 48.The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochia flow. On inspection the nurse finds that a perineal hematoma is beginning to form. Which assessment findings show the nurse obtain first? a. Abdominal contour and bowel sounds b. Hemoglobin and hematocrit c. Heart rate and blood pressure d. Urinary output and IV fluid intake 49.At 6 weeks gestation the rubella titer of a client medication indicates she is non- immune. When is the best time to administer a rubella vaccine to this client? a. After the client stops breastfeeding b. Immediately, at 6-weeks’ gestation to protect fetus c. After the client reaches 20-weeks gestations d. Early postpartum within 72 hours of delivery 50.The nurses assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indication that the infant is transitioning well to extrauterine life? a. Cries vigorously when stimulated 51.A A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and cervix dialed 3cm. The nurse’s assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor? a. Clients hourly blood pressure b. Preparation for emergency cesarean birth c. Intensity, interval, and length of contractions d. Checking the perineum for bulging 52.The nurse is caring for a newborn who is 18inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10inches. Based on these physical findings, assessment for which condition has the highest priority? a. Hyperthermia b. Hyperbilirubinemia c. Polycythemia d. Hypoglycemia 53.A A client who delivered a healthy newborn an hour ago asks the nurse when she can go home. Which information is most important for the nurse to provide the client? a. When there is no significant vaginal bleeding. 54.A A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, menopur), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately? a. Episodes of headache and irritability b. Nausea and vomiting c. Rapid increase in abdominal girth d. Persistent daytime fatigue 55.At 0600 while admitting a woman for a scheduled repeat Caesarean section (C- section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a. Inform the anesthesia care provider 56.Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30minutes and has a boggy uterus. What action should the nurse implement first? a. Perform fundal massage until firm 57.A A client at 20 weeks gestation comes to antepartal clinic complaining of vaginal warts (human papilloma virus HPV). What information should the nurse provide this client? a. This client should be treated with acyclovir (Zovirax) 58.A A 33-year-old client at 9 weeks gestation tells the nurse that while she has “cut down,” she still has at least one alcoholic drink every evening before bedtime. What intervention should the nurse implement? a. Notify child protective services of the client’s illicit drug use and probable child endangerment b. Praise the client for her actions and offer to discuss ways to decrease consumption even more c. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit