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A nurse is assisting with the care for a client who is in active labor, irritable, and reports the urge to have a bowel movement. The client vomits and states, "I've had enough. I can't do this anymore." Which of the following stages of labor is the client experiencing?
A. Second stage
B. Fourth Stage
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A nurse is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include?
A. Use a condom with sexual intercourse
B. Avoid bubble bath solution when take a tub bath
C. Wipe from the back to the front when performing perineal hygiene
D. Keep a daily record of fetal kick counts -
....ANSWER...Keep a daily record of fetal kick counts
C. Transition phase D. Latent Phase - ....ANSWER...Transition phase A nurse is assisting with the care for a client who is at 40 weeks of gestation and experiencing contractions every 3 to 5 min and becoming stronger. A vaginal client asks for pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply) A. Encourage use of patterned breathing techniques B. Insert an indwelling urinary catheter C. Administer opioid analgesic medication D. Suggest application of cold E. Provide ice chips - ....ANSWER...1. Encourage use of patterned breathing techniques
2. Administer opioid analgesic medication
3. Suggest application of cold
A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which of the following information should the nurse include?
A. An episiotomy is a perineal tear that is created while pushing during labor
B. A fourth degree episiotomy extends into the rectal area
C. An episiotomy is an incision that is made by the provider to facilitate
delivery of the fetus
exam by the registered nurse reveals that the
client's cervix is 3 cm dilated, 80% effaced, and - 1
station. The
A nurse is discussing intermittent fetal heart monitoring with a newly licensed nurse. Which of the following statements should the nurse include? A. "Count the fetal heart rate for 15 seconds to determine the baseline." determine baseline changes." D. "Auscultate the fetal heart rate every 30 minutes during the second stage of labor." - ....ANSWER..."Count the fetal heart rate after a contraction to determine baseline changes." A nurse is reinforcing teaching with a client about the (select all that apply) A. "It is considered a noninvasive procedure." B. "It can detect abnormal fetal heart tones early." C. "It can determine the amount of amniotic fluid you have." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity." - ....ANSWER...1. "It can detect abnormal fetal heart tones early."
2. "It allows for accurate readings with maternal movement."
B. "Auscultate the fetal heart rate every 5
minutes during the active phase of the first stage
of labor."
C. "Count the fetal heart rate after a contraction
to
benefits of internal fetal heart monitoring. Which of
the following statements should the nurse include?
3. "It can measure uterine contraction intensity."
A nurse is assisting in the care of a client who is in active labor. The nurse notes tachycardia on the external fetal monitor tracing. Which of the following conditions should the nurse identify as a potential cause of the heart rate?
A. Maternal fever
B. Fetal heart failure
C. Maternal hypoglycemia
D. Fetal head compression - ....ANSWER...Maternal fever
A nurse is assisting with caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should identify that the registered nurse should take?
A. Assist the client into the left-lateral position
B. Apply a fetal scalp electrode
C. Insert an IV catheter
D. Perform a vaginal exam - ....ANSWER...Assist the client into the left-lateral
position A nurse is assisting with performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie?
A nurse is reinforcing postpartum discharge
teaching to a client who had no immunity to
varicella and was given the varicella vaccine. Which
of the following statements by the client indicates
understanding?
A nurse is preparing to reinforce education to a
client who is 2 hr postpartum and has perineal
laceration.
D. Abnormally excessive lochia rubra flow -
....ANSWER...A normal postural discharge of lochia
A. "I will need to use contraception for 3 months before considering
pregnancy."
B. "I need a second vaccination at my postpartum visit."
C. "I was given the vaccine because my baby is O- positibe
D. "I will be tested in 3 months to see if I have developed immunity." -
....ANSWER..."I need a second vaccination at my postpartum visit." A nurse is reinforcing discharge instructions for a client. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
A. Scant, nonodorous white vaginal discharge
B. Uterine cramping during breastfeeding
C. Sore nipple with cracks and fissures
D. Decreased response with sexual activity -
....ANSWER...Sore nipple with cracks and fissures
Which of the following information should the nurse include? (select all that apply)
A. Use a perineal squeeze bottle to cleanse the perineum
B. Sit on the perineum while resting in bed
C. Apply a topical anesthetic cream or spray to the perineum
D. Wipe the perineum thoroughly with a back and forth motion
E. Apply cold or ice packs to the perineum -
....ANSWER...1. Use a perineal squeeze bottle to cleanse the perineum
2. Apply a topical anesthetic cream or spray to the perineum
3. Apply cold or ice packs to the perineum
COMPLICATIONS OF THE POSTPARTUM PERIOD -
....ANSWER...
A nurse is contributing to the plan of care for a client who is postpartum and has thrombophlebitis. Which of the following nursing interventions should the nurse recommend?
A. Apply cold compresses to the affected extremity
B. Massage the affected extremity
C. Allow the client to ambulate
D. Measure leg circumferences -
....ANSWER...Measure leg circumferences
A nurse is instructing a client who is taking an
oral contraceptive about manifestations to report
to the
following conditions are associated with these manifestations?
A. Postpartum fatigue
B. Postpartum psychosis
C. Letting-go phase
D. Postpartum blues - ....ANSWER...Postpartum blues
A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?
A. "A water-soluble lubricant should be used with condoms."
B. "A diaphragm should be removed 2 hours after intercourse."
C. "Oral contraceptives can worsen a case of acne."
D. "A contraceptive patch is replaced once a month." -
....ANSWER..."A water-soluble lubricant should be used with condoms." provider. Which of the following manifestations should the nurse include?
A. Reduced menstrual flow
B. Breast tenderness
C. Shortness of breath
D. Increased appetite - ....ANSWER...Shortness of breath
A nurse is reinforcing teaching with a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (select all that apply)
A. Tinnitus
B. Irregular vaginal bleeding
C. Weight gain
D. Nausea
E. Gingival hyperplasia - ....ANSWER...1. Irregular vaginal bleeding
2. Weight gain
3. Nausea
A nurse in an obstetrical clinic is reinforcing teaching with a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching?
A. "An IUD should be replaced annually during a pelvic exam."
B. "I cannot get an IUD until after I've had a child."
C. "I should plan on regaining fertility 5 months after the IUD is removed."
D. "I will check to be sure the strings of the IUD are still present after my
periods." - ....ANSWER..."I will check to be sure the strings of the IUD are still present after my periods."
A nurse in a prenatal clinic is caring for a client
who is pregnant and experiencing episodes of
maternal
should the nurse interpret this information? (select all that apply)
A. Client has delivered one newborn at term
B. Client has experienced no preterm labor
C. Client has been through active labor
D. Client has had two prior pregnancies
E. Client has one living child - ....ANSWER...1. Client has delivered one newborn
at term
2. Client has experienced no preterm labor
3. Client has had two prior pregnancies
4. Client has one living child
A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? (select all that apply)
A. Montgomery's glands
B. Goodell's sign
C. Ballottement
D. Chadwick's sign (a bluish discoloration of the cervix, vagina, and vulva)
E. Quickening - ....ANSWER...1. Goodell's sign (cervical softening).
2. Ballottement
3. Chadwick's sign
hypotension. The client asks the nurse what causes these episodes. Which of the following responses should the nurse make?
A. "This is due to an increase in blood volume."
B. "This is due to pressure from the uterus on the diaphragm."
C. "This is due to the weight of the uterus on the vena cava."
D. "This is due to increased cardiac output." -
....ANSWER..."This is due to the weight of the uterus on the vena cava." A nurse in a clinic receives a phone call from a client who would like information about pregnancy testing. Which of the following information should the nurse provide to the client?
A. "You should wait 4 weeks after conception to be tested for pregnancy."
B. "You should be off any medications for 24 hours prior to the pregnancy
test."
C. "You should not eat or drink for at least 8 hors prior to the pregnancy test."
D. "You should use your first morning urination specimen for a home
pregnancy test." - ....ANSWER..."You should use your first morning urination specimen for a home pregnancy test." PRENATAL CARE - ....ANSWER...
B. Awaken during the night to eat a snack
C. Skip breakfast and eat lunch after nausea has subsided
D. Eat a large evening meal - ....ANSWER...Eat crackers or plain toast
before getting out of bed A nurse is providing reinforcement to a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (select all that apply)
A. breast tenderness
B. Urinary frequency
C. Epistaxis
D. Dysuria
E. Epigastric pain - ....ANSWER...1. breast tenderness
2. Urinary frequency
3. Epistaxis
A client who is at 8 weeks of gestation tells the nurse, "I am not sure I am happy about being pregnant." Which of the following responses should the nurse make?
A. "I will inform the provider that you are having these feelings."
B. "It is normal to have these feelings during the first few months of pregnancy."
C. "You should be happy that you are going to bring new life into the world."
A nurse in a prenatal clinic is reinforcing education
to a client who is at weeks of gestation. The client
states, "I don't like milk." Which of the following
foods should the nurse recommend as a good
source of calcium?
D. "I am going to make an appointment with the counselor for you to
discuss these thoughts." - ....ANSWER..."It is normal to have these feelings during the first few months of pregnancy." NUTRITION DURING PREGNANCY - ....ANSWER...
A. Dark green leafy vegetables
B. Deep red or orange vegetables
C. White breads and rice
D. Meat, poultry, and fish - ....ANSWER...Dark green leafy vegetables
A nurse in a prenatal clinic is assisting with caring for four clients. Which of the following clients' weight gain should the nurse report to the provider?
A. 1.8 kg (4 lb) weight gain and in the first trimester
B. 3.6 kg (8 lb) weight gain and is in the first trimester
C. 6.8 kg (15 lb) weight gain and is in the second trimester
D. 11.3 kg (25 lb) weight gain and is in the third trimester - ....ANSWER...3.6 kg (
lb) weight gain and is in the first trimester
B. "I should take folic acid to increase my milk supply."
C. "I will continue adding 330 calories per day to my diet."
D. "I will continue my calcium supplements because I don't like milk." -
....ANSWER..."I will continue my calcium supplements because I don't like milk." DETERMINATION OF FETAL WELL-BEING - ....ANSWER... A nurse is reviewing findings of client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? (select all that apply)
A. Fetal weight
B. Fetal breathing movement
C. Fetal tone
D. Fetal position
E. Amniotic fluid volume - ....ANSWER...1. Fetal breathing movement
2. Fetal tone
3. Amniotic fluid volume
A nurse is assisting with the car of a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should review which of the following tests to check fetal lung maturity?
A. Alpha-fetoprotein (AFP)
B. Lecithin/sphingomyelin (L/S) ratio
C. Kleihauer-Betke test
D. Indirect Coombs' test -
....ANSWER...Lecithin/sphingomyelin (L/S) ratio A nurse is assisting with the care of a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make?
A. "It is used to stimulate uterine contractions."
B. "It will decrease the incidence of uterine contractions."
C. "It lulls the fetus to sleep."
D. "It awakens a sleeping fetus." - ....ANSWER..."It awakens a sleeping fetus."
A nurse is reinforcing teaching with a client who is of 22 weeks gestation about the amniocentesis procedure. Which of the following statements should the nurse make?
A. "You will lay on your right side during the procedure."
B. You should not eat anything for 24 hours prior to the procedure."
C. "You should empty your bladder prior to the procedure."
