question

A woman who is 4 months pregnant asks what can be done to alleviate frequent heart palpitations and leg cramps. Which nursing diagnosis would be applicable to the patient at this time? Select one: a. Pain related to severe complications of pregnancy b. Health-seeking behaviors related to ways to relieve discomforts of pregnancy c. Risk for ineffective breathing pattern related to pressure of the growing uterus d. Impaired urinary elimination related to inability to excrete creatine from the muscles

answer

b. Health-seeking behaviors related to ways to relieve discomforts of pregnancy

question

The nurse is visiting the family of a newly pregnant patient whose spouse was ambivalent about the pregnancy during the first prenatal visit. Which observation indicates that the spouse is accepting the pregnancy? Select one: a. Spouse leaves the house when the nurse arrives. b. Spouse sits with the pregnant patient during the nurse's visit. c. Spouse shouts down the stairs about the location of clean laundry. d. Spouse tells the patient what needs to be obtained from the grocery store.

answer

b. Spouse sits with the pregnant patient during the nurse's visit.

question

A patient enjoys exercising and wants to know if it can continue to be done while pregnant. What should the nurse instruct the patient about exercising at this time? (Select all that apply.) Select one or more: a. Drink plenty of liquids to prevent dehydration. b. Limit strenuous exercise to no longer than 20 minutes. c. Eat a low-protein, simple carbohydrate snack before exercising. d. Warm up for 5 minutes by walking or cycling on low resistance. e. Avoid exercises that require jumping or rapid changes in direction.

answer

a,d,e

question

The nurse is providing care in an organization that supports the maternal and child care continuum. Which type of patient care area is an example of this approach? Select one: a. Primary care b. Team nursing c. Case management d. Family-centered care

answer

d. Family-centered care Correct

question

A patient who is 6 months pregnant is complaining of a lumbar backache. What actions should the nurse suggest to help this patient? (Select all that apply.) Select one or more: a. Do pelvic rocking. b. Walk with head high. c. Rest and elevate the feet. d. Wear higher heeled shoes. e. Twist the spine at the hips.

answer

a,c

question

When explaining what will occur during the first prenatal visit physical examination, a pregnant patient asks why a Papanicolaou smear is being done at this time. What should the nurse respond to the patient? Select one: a. It helps to date the pregnancy. b. It detects if uterine cancer is present. c. It predicts whether cervical cancer will occur. d. It detects cancer cells of the cervix, vulva, or vagina.

answer

d. It detects cancer cells of the cervix, vulva, or vagina. Correct

question

The nurse is concerned that a pregnant patient is not adjusting emotionally to being pregnant. Which statement indicates that the patient may need additional counseling? Select one: a. "I cannot wait to lose all of this excess weight." b. "I need to get right back to work after delivery." c. "My mother has been so helpful during this time." d. "My dad has already purchased toys for the baby!"

answer

b. "I need to get right back to work after delivery."

question

A pregnant patient tells the nurse that drinking enough fluids has always been a problem for her. What should the nurse counsel the patient as being an adequate daily amount of fluid to drink while pregnant? Select one: a. Two glasses b. Four glasses c. Eight glasses d. Ten glasses

answer

c. Eight glasses Correct

question

A pregnant patient enjoys exercising at a local health spa once a week. Which patient comment indicates to the nurse that additional health teaching is needed? Select one: a. "I'm learning to play table tennis." b. "I limit exercising to low-impact aerobics." c. "The gym gets hot and stuffy by midmorning." d. "Nothing feels nicer than a hot tub soak after exercise."

answer

d. "Nothing feels nicer than a hot tub soak after exercise."

question

After an examination, an advanced practice nurse confirms that a patient is pregnant. What did the nurse assess in this patient? (Select all that apply.) Select one or more: a. Painful breast tissue b. Positive pregnancy test c. Fetal movements felt by the nurse d. Visualization of the fetus by ultrasound e. Fetal heart rate separate from the patient's

answer

c,d,e

question

The nurse teaches a pregnant patient the manifestations associated with complications while pregnant. Which statement indicates that additional patient teaching is needed? Select one: a. "Pain with urination is expected during pregnancy." b. "I should call the doctor if I have any vaginal bleeding." c. "A sudden rush of fluid means that my membranes ruptured. d. "I should not worry if I vomit once a day for the first 12 weeks."

answer

a. "Pain with urination is expected during pregnancy."

question

A pregnant patient asks the nurse what can be done for constipation. What should the nurse recommend to the patient? Select one: a. Mineral oil b. Increased fiber intake c. Eating more meat products d. Stopping prenatal vitamins temporarily

answer

b. Increased fiber intake

question

The nurse is reviewing the signs of labor with a patient entering the last phase of the third trimester of pregnancy. What should the nurse include as an indication that the labor is beginning? Select one: a. Excessive fatigue and headache b. Sharp, right-sided abdominal pain c. Sudden gush of clear fluid from the vagina d. An increased pulse rate and upper abdominal pain

answer

c. Sudden gush of clear fluid from the vagina

question

At the conclusion of a prenatal assessment, the nurse determines that a patient is at risk during the pregnancy. Which data from the patient's past illness history does the nurse use to make this decision? (Select all that apply.) Select one or more: a. Seizure disorder b. Previous cesarean birth c. Hypertension for 10 years d. History of abnormal Pap smear e. Previous treatment for gonorrhea

answer

a,c,e

question

A woman who is 6 weeks pregnant is concerned because she is nauseated every morning. Which measure should the nurse suggest the patient use to help relieve nausea? Select one: a. Take two aspirin on arising. b. Delay toothbrushing until noon. c. Delay breakfast until midmorning. d. Take a teaspoon of baking soda before breakfast.

answer

c. Delay breakfast until midmorning.

question

The nurse is assessing a patient who is 3 months pregnant. Which breast changes would the nurse expect to assess in this patient? Select one: a. Enlarged lymph nodes b. Slack, soft breast tissue c. Deeply fissured nipples d. Darkened breast areolae

answer

d. Darkened breast areolae

question

What advice should the nurse provide to a pregnant patient who admits to continuing to drink alcohol one to two times a week? Select one: a. Avoid all alcohol while pregnant. b. Avoid alcohol in the first trimester. c. The effects of alcohol on the fetus are not fully understood. d. An occasional drink is permitted only after the first trimester.

answer

a. Avoid all alcohol while pregnant.

question

The nurse is instructing a pregnant patient to consume a diet high in complete proteins. Which food item should the nurse recommend as an example of a complete protein? Select one: a. A boiled or fried egg b. Green, leafy vegetables c. A slice of whole grain toast d. Applesauce or a whole apple

answer

a. A boiled or fried egg

question

The nurse is collecting a urine specimen from a pregnant patient during a prenatal visit. For what will the nurse test this patient's urine? (Select all that apply.) Select one or more: a. Protein b. Glucose c. Bacteria d. Drug levels e. White blood cells

answer

a,b,c,e

question

During an assessment, a patient who is 5 months pregnant tells the nurse that she has to change her diet because she is just becoming too fat. Which nursing diagnosis should the nurse use to guide interventions for the patient at this time? Select one: a. Powerlessness b. Imbalanced nutrition c. Deficient knowledge d. Disturbed body image

answer

d. Disturbed body image

question

A pregnant patient has a history of genital herpes lesions and has experienced outbreaks periodically throughout the pregnancy. What should the nurse instruct the patient regarding this virus if lesions are present at the time of delivery? Select one: a. A cesarean section will be advised at the time of birth. b. There are no precautions needed at the time of birth. c. The patient will need medication immediately after birth. d. The baby will be given a vaccination against the virus at birth.

answer

a. A cesarean section will be advised at the time of birth.

question

Which question should the nurse include when conducting a review of systems with a patient during the first prenatal visit? Select one: a. "Do you have a peptic ulcer?" b. "Have you ever had a heart attack?" c. "Have you ever had a heart attack?" d. "Have you had any urinary tract infections?"

answer

d. "Have you had any urinary tract infections?"

question

A pregnant patient is experiencing a vaginal discharge and wants to douche. What should the nurse instruct the patient about this health practice? Select one: a. Avoid routine douching. b. Use an alkaline solution. c. Use only a commercial solution. d. Use a solution that has been chilled.

answer

a. Avoid routine douching.

question

A patient who is 4 months pregnant is experiencing pyrosis. Which suggestion should the nurse make to the patient to help with this health problem? Select one: a. Try to include complex carbohydrates in meals. b. Eat small meals and do not lie down after meals. c. Increase vitamin intake by adding more citrus fruit. d. Take 30 ml of milk of magnesia after every meal.

answer

b. Eat small meals and do not lie down after meals.

question

The nurse is explaining the process of fertilization to a patient who has just learned of being pregnant. On which day during pregnancy should the nurse explain that the embryo implants on the uterine surface? Select one: a. Four days after fertilization b. Eight to 10 days after fertilization c. The 14th day of a "typical" menstrual cycle d. Ten days after the start of the menstrual flow

answer

b. Eight to 10 days after fertilization

question

A pregnant patient is planning travel to a foreign country as part of a work assignment and needs immunizations. What should the nurse instruct the patient about immunizations while pregnant? Select one: a. Immunizations should be restricted to live viruses only. b. There are no restrictions on immunizations while pregnant. c. The only immunization that should be avoided is for the flu. d. Live virus immunizations are contraindicated while pregnant.

answer

d. Live virus immunizations are contraindicated while pregnant.

question

The nurse provides instructions to a patient with hyperemesis gravidarum. Which outcome indicates that teaching has been effective? Select one: a. Patient has vomiting episodes only in the morning. b. Patient is able to tolerate soft foods after episodes of vomiting. c. Patient is able to ingest clear liquids between episodes of vomiting. d. Patient is able to ingest a regular diet after progressing through clear liquids and soft foods.

answer

d. Patient is able to ingest a regular diet after progressing through clear liquids and soft foods.

question

A pregnant patient from a nondominant culture explains that milk and dairy products cannot be consumed for 2 months during the pregnancy because of the need to fast for her religion. Which response should the nurse make after learning this information? Select one: a. "I'm sure that you don't need to follow this while you are pregnant." b. "Avoiding milk and dairy products for 2 months will harm the fetus." c. "There are other food sources where you can obtain the nutrients that are in milk." d. "You must have a great deal of will power to avoid milk and dairy products for 2 months."

answer

c. "There are other food sources where you can obtain the nutrients that are in milk."

question

A father is preparing a 4-year-old son for the arrival of a new baby. Which statement should the nurse suggest the father use to explain this to the child? Select one: a. "Mother will need to spend a lot of time with the new baby." b. "It will be fun to have a sister or brother to give your old toys to." c. "The new baby will need your bed so we're buying you a new one." d. "A new baby will make our family bigger but not change our love for you."

answer

d. "A new baby will make our family bigger but not change our love for you."

question

During a family assessment, it is identified that the mother is unemployed but stays at home to prepare meals, monitor medication doses, and comfort the children with emotional issues. The father works outside of the home and pays the bills. Which terms should the nurse use to document the role of the father in this family? (Select all that apply) Select one or more: a. Provider b. Nurturer c. Culture bearer d. Health manager e. Financial manager

answer

a,e

question

While conducting the first prenatal health history visit, the nurse learns that a pregnant patient is taking various herbal remedies and over-the-counter medications for minor ailments. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time? Select one: a. Risk for injury to fetus related to lifestyle choices b. Deficient knowledge regarding exposure to teratogens during pregnancy c. Health-seeking behaviors related to strong cultural desire to have a healthy child d. Health-seeking behaviors related to guidelines for nutrition and activity during pregnancy

answer

b. Deficient knowledge regarding exposure to teratogens during pregnancy

question

A woman of normal weight learns that she is pregnant and asks the nurse how much weight she should gain until delivery. What should the nurse respond to this patient? Select one: a. Do not gain over 20 lb. b. Any gain over 30 lb is ideal. c. Twenty-five to 35 lb is ideal. d. The amount of weight gain is not important.

answer

c. Twenty-five to 35 lb is ideal.

question

A patient who is 16 weeks pregnant has a lower blood pressure than that of prepregnancy levels. What should the nurse realize as being the cause for this lower blood pressure? Select one: a. Prepregnancy blood pressure measurements were inaccurate. b. Blood pressure progressively decreases throughout the entire pregnancy. c. A decrease in the second trimester may occur because of placental growth. d. Dehydration because blood pressure increases steadily throughout pregnancy.

answer

c. A decrease in the second trimester may occur because of placental growth.

question

The nurse is emphasizing the importance of adequate rest and sleep with a pregnant patient. Which position should the nurse suggest the patient use? Select one: a. On the back with a pillow under the head b. On the stomach with a pillow under her breasts c. On the back with a pillow under the knees and hips d. On the side with the weight of the uterus on the bed

answer

d. On the side with the weight of the uterus on the bed

question

A patient who is 2 months pregnant is concerned about frequent urination. What should the nurse instruct the patient about this occurrence? Select one: a. This means urine is more concentrated. b. The fetus is adding urine to the patient's bladder. c. It is caused by pressure on the bladder from the uterus. d. There is a decrease in the glomerular cells of the kidney.

answer

c. It is caused by pressure on the bladder from the uterus.

question

A pregnant patient scheduled for an amniocentesis asks the nurse how the placenta is not punctured during the procedure. What should the nurse respond to the patient? Select one: a. "A uterus feels soft over the placenta site." b. "A sonogram to locate it will be done first." c. "It would not be harmful even if it were punctured." d. "Placentas always form on the posterior uterine wall."

answer

b. "A sonogram to locate it will be done first."

question

A patient makes an appointment at the prenatal clinic because she thinks she might be pregnant. Which assessment is a probable sign of pregnancy? Select one: a. Amenorrhea b. Enlargement and darkening of areola c. Nausea and vomiting d. A positive pregnancy test

answer

d. A positive pregnancy test

question

A pregnant patient has an anthropoid pelvis. How should the nurse explain this finding to the patient? Select one: a. Transverse narrow b. Ideal for childbearing c. Similar in shape to a male d. Has weaker bones than normal

answer

a. Transverse narrow

question

A pregnant patient reports feeling pain similar to menstrual cramps. What should the nurse explain about this patient's symptoms? Select one: a. Exercise helps reduce the frequency of them. b. If rhythmical, they could indicate preterm labor. c. Lying down for a few hours will help them stop. d. They are false labor and do not need to be reported.

answer

b. If rhythmical, they could indicate preterm labor.

question

The nurse has identified the diagnosis of imbalanced nutrition for a pregnant patient. Which assessment data did the nurse use to identify this diagnosis for the patient? Select one: a. Patient eats salads at least twice a day. b. Patient does not like potatoes or bread. c. Patient eats red meat several times a week. d. Patient does not want to gain any weight while pregnant.

answer

d. Patient does not want to gain any weight while pregnant.

question

The nurse is planning a seminar that focuses on the 2020 National Health Goals during pregnancy for patients who are in the first trimester of pregnancy. Which information should the nurse include in this seminar? (Select all that apply.) Select one or more: a. Refusing alcohol b. Importance to stop smoking c. Maintaining health appointments d. Seeking alternative care approaches e. Abstaining from drugs and substances

answer

a,b,c,e

question

A pregnant patient tells the nurse that she is not happy to learn about the pregnancy. At which point in the pregnancy does the nurse realize that the patient will change her mind about the pregnancy? Select one: a. Around the third month b. After the seventh month c. When quickening occurs d. After lightening happens

answer

c. When quickening occurs

question

What advice should the nurse provide to a patient who is 4 months pregnant and owns a cat? Select one: a. Give it away until after delivery. b. Refrain from cleaning the cat's dish. c. Be careful that it doesn't scratch the skin. d. Ask someone else to change the cat litter.

answer

d. Ask someone else to change the cat litter.

question

A newly wed young adult patient tells the nurse that she hopes to become pregnant soon. What should the nurse recommend to this patient to support the 2020 National Health Goals for pregnancy? (Select all that apply.) Select one or more: a. Stop smoking. b. Increase exercise. c. Eat a healthy diet. d. Reduce work hours. e. Limit alcohol intake.

answer

a,c,e

question

During a physical assessment, the nurse palpates a pregnant patient's fundus at the level of the umbilicus. What statement should the nurse make to the patient about this assessment finding? Select one: a. "You are at 12 weeks of your pregnancy." b. "You are at 20 weeks of your pregnancy." c. "You are at 36 weeks of your pregnancy." d. "You can go into labor at any time now."

answer

b. "You are at 20 weeks of your pregnancy."

question

An adolescent asks which sport would be safe for her to learn during pregnancy. Which activity should the nurse suggest to the patient? Select one: a. Skiing b. Jogging c. Bicycling d. Swimming

answer

d. Swimming

question

A pregnant patient is concerned that orgasm will be harmful to the developing fetus. What should the nurse include when responding to this patient's concern? Select one: a. Orgasm during pregnancy is potentially harmful. b. Venous congestion in the pelvis makes orgasm painful. c. Most women do not experience orgasm during pregnancy. d. Some women experience orgasm intensely during pregnancy.

answer

d. Some women experience orgasm intensely during pregnancy.

question

The nurse instructs a pregnant patient on the need to increase foods containing folic acid. Which patient statement indicates that teaching has been effective? Select one: a. "Eating an extra orange a day is important." b. "I need to drink two glasses of milk each day." c. "I will add spinach to my salad every evening." d. "Cabbage and cauliflower are important for me to eat."

answer

c. "I will add spinach to my salad every evening."

question

A pregnant patient asks if an over-the-counter vitamin can be taken during pregnancy instead of the prescribed prenatal vitamin. What should the nurse explain as the chief ingredient in prenatal vitamins that makes them important for pregnancy nutrition? Select one: a. Folic acid b. Vitamin C c. Potassium d. Vitamin B12

answer

a. Folic acid

question

The patient has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction birth. What finding is expected? Select one: a. The head is delivered after eight pulls during contractions. b. A bruise is present on the occiput that does not cross the suture line. c. The location of the vacuum is apparent on the fetal scalp after birth. d. Positive pressure is applied by the vacuum extraction during contractions.

answer

c. The location of the vacuum is apparent on the fetal scalp after birth.

question

The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? (Select all that apply.) Select one or more: a. False labor contractions are irregular. b. True labor contractions disappear when asleep. c. False labor contractions lead to cervical dilation. d. True labor contractions occur in the abdomen and groin. e. False labor contractions do not increase in duration, frequency, and intensity.

answer

a,e

question

The nurse is responding to phone calls. Which call should the nurse return first? Select one: a. 37 weeks' gestation, reports no fetal movement for 24 hours b. 29 weeks' gestation, reports increased fetal movement c. 32 weeks' gestation, reports decreased fetal movement for 2 days d. 35 weeks' gestation, reports decreased fetal movement for 4 hours

answer

a. 37 weeks' gestation, reports no fetal movement for 24 hours

question

The primigravida in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150, with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the patient understands the nurse's teaching? "The most important part of fetal heart monitoring is the Select one: a. absence of variable decelerations." b. presence of variability." c. fetal heart rate baseline." d. depth of decelerations."

answer

b. presence of variability."

question

A patient in labor has a spinal cord injury and is unable to effectively push with contractions. Forceps will be used. What should the nurse do to prepare the patient for this type of delivery? (Select all that apply.) Select one or more: a. Provide oxygen 2 L via face mask. b. Validate that the cervix is fully dilated. c. Determine that the patient's bladder is empty. d. Begin an intravenous infusion of replacement fluid e. Ensure that the patient's membranes have ruptured.

answer

b, c, e

question

The nurse is caring for a patient in labor whose fetus is in an occiput posterior position. Which intervention should the nurse use to reduce this patient's discomfort? Select one: a. Massage the lower back and encourage hands and knees positioning b. Place in a prone position. c. Apply ice packs to the lower back. d. Place in the Trendelenburg position.

answer

a. Massage the lower back and encourage hands and knees positioning

question

A pregnant patient nearing her due date expresses anxiety over the labor and delivery process. Which outcome should the nurse select as appropriate for the patient during the delivery process? Select one: a. Patient requests pain medication throughout the labor process. b. Patient uses breathing techniques to control anxiety and pain during labor. c. Patient tolerates the use of sanitary napkins to absorb vaginal secretions during labor. d. Patient refuses complementary and alternative techniques to control pain during labor.

answer

b. Patient uses breathing techniques to control anxiety and pain during labor.

question

The nurse assists while a pregnant patient has an amniotomy. Which action should the nurse take immediately at the conclusion of the procedure? Select one: a. Assess fetal heart rate. b. Adjust intravenous fluid infusion rate. c. Assist the patient to wash the perineum. d. Assist the patient to wash the perineum.

answer

a. Assess fetal heart rate.

question

The primiparous patient at 39 weeks' gestation calls the clinic and reports increased bladder pressure but easier breathing and irregular, mild contractions. She also states that she just cleaned the entire house. Which statement should the nurse make? Select one: a. You shouldn't work so much at this point in pregnancy." b. "Your body may be telling you it is going into labor soon." c. "Your body may be telling you it is going into labor soon." d. "If the bladder pressure continues, come in to the clinic tomorrow."

answer

b. "Your body may be telling you it is going into labor soon."

question

A 32-year-old laboring patient demonstrates cervical dilatation of 9 cm. Her contractions are 2 minutes apart and 60 to 90 seconds in duration. She complains of excruciating rectal pressure. How should the nurse interpret this complaint? Select one: a. The patient's complaint is congruent with her current stage of labor. b. The patient's complaint may indicate the need for delivery via cesarean section. c. Based upon the patient's complaint, she is experiencing the active phase of labor. d. The patient's complaint is consistent with placental separation, which is normal for her current stage of labor.

answer

a. The patient's complaint is congruent with her current stage of labor.

question

A pregnant patient is planning to give birth to the baby at home. Which patient statement indicates to the nurse that this patient is a good candidate for this birthing option? Select one: a. "All women in my family have had easy labors." b. "I want to have a baby without boring prenatal care." c. "I know nothing about birth so a hospital intimidates me." d. "I have no health problems and follow good self-care practices."

answer

d. "I have no health problems and follow good self-care practices."

question

A laboring patient has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, the nurse would expect to do which of the following? Select one: a. Observe fetal heart rate variability. b. Rapidly infuse 500-1,000 mL of intravenous fluids. c. Place the patient in the semi-Fowler's position. d. Teach the patient appropriate breathing techniques.

answer

b. Rapidly infuse 500-1,000 mL of intravenous fluids.

question

The baseline fetal heart rate is 135 beats per minute. Following contractions, the fetus develops late decelerations. Which nursing intervention should be implemented first? Select one: a. Alert the physician/CNM of the fetal status. b. Administer oxygen to the patient at 4 liters per minute via nasal cannula. c. Decrease the rate of infusion of intravenous fluids. d. Facilitate a maternal left lateral position.

answer

d. Facilitate a maternal left lateral position.

question

A patient whose fetus is presenting breech is scheduled to have a cesarean birth. What should the nurse anticipate this patient will need to ensure maximum postoperative care? Select one: a. Bed rest for the first 4 days b. Insertion of a nasogastric tube c. Maintenance of an indwelling catheter d. Separation from the infant for 72 hours

answer

c. Maintenance of an indwelling catheter

question

During active labor, the nurse observes the patient crying during contractions and not using breathing techniques learned during prenatal classes. Which nursing diagnosis would be appropriate for the patient at this time? Select one: a. Risk for fluid volume deficit b. Anxiety related to stress of labor c. Risk for ineffective breathing pattern related to breathing exercises d. Powerlessness related to duration of labor

answer

c. Risk for ineffective breathing pattern related to breathing exercises

question

The laboring patient has been found to be having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a-2 station. The cervix is 6 cm and 100% effaced. The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? Select one: a. Encourage the husband to remain in the room. b. Keep the patient on bed rest at this time. c. Apply an internal fetal scalp electrode. d. Obtain a clean-catch urine specimen.

answer

b. Keep the patient on bed rest at this time.

question

A pregnant patient in labor is being encouraged to push with contractions. In which position should the nurse assist to help the patient at this time? Select one: a. Semi-Fowler's position with legs bent against the abdomen b. Lying supine with legs in lithotomy stirrups c. Lying on side, arms grasped on abdomen d. Squatting while holding the breath

answer

a. Semi-Fowler's position with legs bent against the abdomen

question

A patient scheduled for a cesarean birth asks if there are any difficulties with breastfeeding after this type of delivery. What should the nurse include when responding to this patient? Select one: a. Breastfeeding is not recommended after a cesarean birth. b. It is hard to find a comfortable position to hold a newborn to breastfeed. c. A comfortable position can be found to support breastfeeding the infant. d. The patient will have too much analgesia postoperatively to make breastfeeding safe.

answer

c. A comfortable position can be found to support breastfeeding the infant.

question

The patient presents to labor and delivery stating that her water broke 2 hours ago. Indicators of normal labor include (Select all that apply.) Select one or more: a. fetal heart rate of 130 with average variability. b. blood pressure of 130/80. c. maternal pulse of 160. d. protein of +1 in urine. e. odorless, clear fluid on underwear.

answer

a,b,e

question

When the membranes of a pregnant patient rupture during labor, the nurse determines that the patient and fetus are in danger. What did the nurse assess at the time of membrane rupture? Select one: a. Meconium-stained amniotic fluid b. Fetus presenting in an LOA position c. Maternal pulse of 90 to 95 beats/min d. Blood-tinged vaginal discharge at full dilation

answer

a. Meconium-stained amniotic fluid

question

A woman is in labor. The fetus is in vertex position. When the patient's membranes rupture, the nurse sees that the amniotic fluid is meconium-stained. The nurse should immediately Select one: a. notify the physician that birth is imminent. b. change the patient's position in bed. c. administer oxygen at 2 liters per minute. d. continue continuous fetal heart rate monitoring.

answer

d. continue continuous fetal heart rate monitoring.

question

Which of the following nursing actions can prevent or detect common side effects of epidural anesthesia? (Select all that apply.) Select one or more: a. Preloading the patient with a rapid infusion of IV fluids b. Continuing the patient on p.o. fluids only to prevent hypotension Incorrect c. Monitoring the FHR for late deceleration and decrease in rate d. Use of intermittent FHR monitoring so that the patient can use the birthing ball e. Use of intermittent FHR monitoring so that the patient can practice relaxing breathing techniques.

answer

a,c

question

A patient who is newly pregnant and her spouse have decided to use the Bradley method of childbirth. Which outcome indicates that this couple is adhering to the principles of this birthing method? Select one: a. The patient and spouse are ingesting a high-fat, low-carbohydrate diet. b. The patient identifies that lying in bed will be the position to use during labor. c. The spouse encourages the patient's mother to coach the patient during breathing exercises. d. The patient performs muscle-toning exercises.

answer

d. The patient performs muscle-toning exercises.

question

While caring for a labor patient, the nurse determines during a vaginal exam that the baby's head has internally rotated. This information is given to the family. The labor support person asks the nurse, "What other position changes will the baby undertake during labor and birth?" How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation? Select one: a. Flexion, extension, restitution, external rotation, and expulsion b. Expulsion, external rotation, and restitution c. Restitution, flexion, external rotation, and expulsion d. Extension, restitution, external rotation, and expulsion

answer

d. Extension, restitution, external rotation, and expulsion

question

A patient is experiencing dysfunctional labor, which is prolonging the descent of the fetus. Which teaching should the nurse prepare to provide to this patient? Select one: a. Oxytocin augmentation b. Fluid replacement c. Pain management d. Increasing activity

answer

a. Oxytocin augmentation

question

A pregnant patient asks the nurse to explain the Lamaze philosophy of childbirth. What should the nurse include when responding to this patient's request? (Select all that apply.) Select one or more: a. Labor should be induced. b. Breathing patterns block pain sensations. c. It is based on the gating control theory of pain relief. d. Patients should be maintained on bed rest during labor. e. Actions that are not medically necessary should be avoided.

answer

b,c,e

question

During the active stage of labor, a patient's membranes spontaneously rupture. Which action should the nurse do first after this occurs? Select one: a. Turn the patient onto the left side. b. Assess fetal heart rate for fetal safety. c. Test a sample of amniotic fluid for protein. d. Instruct to bear down with the next contraction.

answer

b. Assess fetal heart rate for fetal safety.

question

After delivery of the placenta, a patient's uterus is sluggish to contract. What should the nurse prepare to do to assist the patient at this time? Select one: a. Administer intravenous fluids. b. Measure blood pressure every 15 minutes. c. Administer Postpartum Pitocin via IV d. Prepare to administer blood products as prescribed.

answer

c. Administer Postpartum Pitocin via IV

question

A patient in labor who is dilated 7 cm reports that narcotic pain medication given 3 hours ago has worn off and is asking for another dose. How should the nurse respond to this request? Select one: a. "I will get permission from your doctor." b. "Your stage of labor makes giving another dose unsafe." c. "It is too early as the medication should be given only every 4 hours." d. "Since it has been over 3 hours, you should be able to have more of the medication."

answer

b. "Your stage of labor makes giving another dose unsafe."

question

The nurse is admitting a patient to the labor and delivery unit. Which aspect of the patient's history requires notifying the physician? Select one: a. Blood pressure 120/88 b. Father is a carrier of sickle-cell trait c. Dark red vaginal bleeding d. History of domestic abuse

answer

c. Dark red vaginal bleeding

question

During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing should the nurse assess on the monitor to confirm this finding? Select one: a. Variable decelerations that are too unpredictable to count b. Fetal baseline rate increasing at least 5 mmHg with contractions c. A shallow deceleration occurring with the beginning of contractions d. Fetal heart rate declining late with contractions and remaining depressed

answer

d. Fetal heart rate declining late with contractions and remaining depressed

question

The primiparous patient at 40 weeks' gestation reports to the nurse that she has had increased pelvic pressure and increased urinary frequency. Which response by the nurse is best? Select one: a. "Unless you have pain with urination, we don't need to worry about it." b. "These symptoms usually mean the baby's head has descended further." c. "Come in for an appointment today and we'll check everything out." d. "This might indicate that the baby is no longer in a head down position."

answer

b. "These symptoms usually mean the baby's head has descended further."

question

The patient has been pushing for 2 hours and is exhausted. The fetal head is visible between contractions. The physician informs the patient that a vacuum extractor could be used to facilitate the delivery. Which statement indicates that the patient needs additional information about vacuum extraction assistance? Select one: a. "A small cup will be put onto the baby's head, and a gentle suction will be applied." b. "I can stop pushing and just rest if the vacuum extractor is used." c. "The baby's head might have a bruise from the vacuum cup." d. "The vacuum will be applied for a total of 10 minutes or less."

answer

b. "I can stop pushing and just rest if the vacuum extractor is used."

question

A pregnant patient tells the nurse about practicing different positions to use when labor begins. What should the nurse counsel the patient to avoid during these practice sessions? Select one: a. Pushing b. Bending over c. Pointing the toes d. Breathing normally

answer

a. Pushing

question

Following spinal anesthesia for delivery of her baby, a woman reports an inability to void urine. As the nurse palpates the woman's bladder the woman says, "It's been 5 hours since I had my spinal and I still can't empty my bladder. Do I have nerve damage?" How should the nurse respond? Select one: a. "Spinal anesthesia can sometimes cause nerve damage." b. "It may be several hours before you're able to control your urination." c. "You should be able to control your bladder by now. I'll ask the anesthesia provider to visit with you." d. "You are probably dehydrated. Please increase your water intake."

answer

b. "It may be several hours before you're able to control your urination."

question

The laboring patient and her partner have arrived at the birthing unit. Which step of the admission process should be undertaken first? Select one: a. The sterile vaginal exam b. Welcoming the couple c. Auscultation of the fetal heart rate d. Checking for ruptured membranes

answer

b. Welcoming the couple

question

Which patient requires immediate intervention by the labor and delivery nurse? Select one: a. Multip at 8 cm, systolic blood pressure has increased 35 mm Hg b. Primip that delivered 1 hour ago with a white blood cell count of 50,000 c. Multip at 5 cm with a respiratory rate of 22 between contractions d. Primip in active labor with urine output of 100 ml/hour

answer

b. Primip that delivered 1 hour ago with a white blood cell count of 50,000

question

Prior to receiving lumbar epidural anesthesia, the nurse would anticipate placing the laboring patient in which of the following positions? Select one: a. On her right side in the center of the bed with her back curved b. Lying prone with a pillow under her chest c. On her left side with the bottom leg straight and the top leg slightly flexed d. Sitting on the edge of the bed with her back slightly curved and her feet on a stool

answer

d. Sitting on the edge of the bed with her back slightly curved and her feet on a stool

question

The fetal heart rate baseline is 140 beats per minute. When contractions begin, the fetal heart rate drops suddenly to 120 and rapidly returns to 140 before the end of the contraction. Which nursing intervention is best? Select one: a. Assist the patient to change from Fowler's to left lateral position. b. Apply oxygen to the patient at 2 liters per nasal cannula. c. Notify the operating room of the need for a cesarean birth. d. Determine the color of the leaking amniotic fluid.

answer

a. Assist the patient to change from Fowler's to left lateral position.

question

The nurse is instructing a pregnant patient on tailor sitting. What is the purpose of this exercise in pregnancy? Select one: a. Stretches perineal muscles b. Decreases respiratory effort c. Strengthens abdominal muscles d. Improves the blood supply to the uterus

answer

a. Stretches perineal muscles

question

The clinical nurse coordinator is meeting with a group of nursing students in post conference to teach about caring for women who undergo artificial rupture of membranes (AROM) by way of amniotomy. Which nursing student's statement indicates that the teaching has been effective? Select one: a. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited." b. "In most cases, it is appropriate to assess the fetal heart rate (FHR) right after the artificial rupture of membranes is performed." c. "Amniotomy is contraindicated for use in labor augmentation." d. "Women who undergo artificial rupture of membranes should be advised that they will experience a 'dry birth.'"

answer

a. "For women who undergo artificial rupture of membranes, vaginal examinations should be limited."

question

During prenatal classes, the nurse teaches pregnant patients how to perform pelvic rocking. What should the nurse explain to the class as being the purpose of this action? Select one: a. Helps to relieve backache b. Stretches perineal muscles c. Enhances respiratory excursion d. Improves abdominal muscle tone

answer

a. Helps to relieve backache

question

During her hospital admission, the laboring patient explicitly refused all pain medications and a labor epidural. Once dilated to 5 cm, the patient complains of intolerable discomfort and asks the nurse, "If I have an epidural, how will you make sure it doesn't hurt my baby?" The best response by the nurse is which of the following? Select one: a. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural." b. "Epidural anesthesia is very safe and there are no potential side effects that can affect your baby." c. "We'll assess your blood pressure every 15 minutes to make sure the epidural is not having any negative effects on your baby." d. "Before your epidural is placed, we'll administer IV fluid to you in order to prevent the epidural from causing you problems."

answer

a. "We'll monitor your baby continuously so we can recognize and treat any changes that may be related to the epidural."

question

A patient who had a previous cesarean birth asks the nurse if all future births must occur the same way. Which response should the nurse make to support the 2020 National Health Goals regarding cesarean births? Select one: a. "All future births must be done through cesarean." b. "Not if you fulfill the criteria for vaginal birth after cesarean." c. "Your health care provider will let you know what kind of birth you can have." d. "Most women prefer cesarean births because they are quicker and cause less pain."

answer

b. "Not if you fulfill the criteria for vaginal birth after cesarean."

question

The primiparous patient has asked the nurse why her cervix has only changed from 1 to 2 cm in 3 hours of contractions occurring every 5 minutes. The best response by the nurse is Select one: a. Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." b. "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." c. "What did you expect? You've only had contractions for a few hours. Labor takes time." d. "The hormones that cause labor to begin are just getting to be at levels that will change your cervix."

answer

a. Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."

question

During admission, a laboring patient tells the nurse, "I'm so afraid I'll need a cesarean section. I don't want to be asleep for surgery when my baby is born!" Which of the following nursing responses is most appropriate? Select one: a. "If a cesarean section is needed, that doesn't necessarily mean you'll need to go to sleep for surgery." b. "Your anesthesia provider will require that you go to sleep for surgery." c. "We'll do our best to make sure you deliver vaginally, so you don't need to have a cesarean section." d. "If you need a cesarean section, the anesthesia provider will awaken you as soon as possible after delivery so that you can see your baby quickly."

answer

a. "If a cesarean section is needed, that doesn't necessarily mean you'll need to go to sleep for surgery."

question

The nurse is determining care for a patient entering the active phase of labor. Which outcome would be the most appropriate for the patient at this time? Select one: a. Patient will develop an irresistible urge to push. b. Patient will adjust body to attain the most comfortable position. c. Patient will remain in the supine position during contractions. d. Patient will combat feelings of nausea to prevent vomiting.

answer

b. Patient will adjust body to attain the most comfortable position.

question

When entering the second phase of labor, a patient tells the nurse that the pain is severe and is unsure if pain medication should be used. Which nursing diagnosis should the nurse use to guide the care of the patient at this time? Select one: a. Pain related to labor contractions b. Powerlessness related to the duration and intensity of labor c. Decision conflict related to the use of analgesia during labor d. Anxiety related to lack of knowledge about normal labor processes

answer

c. Decision conflict related to the use of analgesia during labor

question

The nurse identifies the diagnosis of "Anxiety related to absence of significant other" as appropriate for a pregnant patient. For which assessment finding is this diagnosis appropriate? Select one: a. Spouse works the night shift. b. Mother is recovering from a total hip replacement. c. Oldest daughter is preparing for a school dance recital. d. Spouse is in the military and is stationed in the Middle East.

answer

d. Spouse is in the military and is stationed in the Middle East.

question

The nurse is preparing to assess the frequency of contractions for a patient in labor. Which process should the nurse use to time the contractions? Select one: a. Number of contractions that occur in 5 minutes b. The end of one contraction to the beginning of the next c. The interval between the acmes of two consecutive contractions d. The interval between the beginning of one contraction to the beginning of the next contraction

answer

d. The interval between the beginning of one contraction to the beginning of the next contraction

question

To assess healing of the uterus at the placental site, the nurse assesses Select one: a. lab values. b. blood pressure. c. uterine size. d. type, amount, and consistency of lochia.

answer

d

question

Which assessment finding would lead you to suspect a postpartal complication? Select one: a. Lochia rubra 12 hours after birth b. Temperture less than 100.4 F b to c. Blood loss of less than 300 ml/hours d. 24 to 26 perineal pads saturated/24 hours

answer

d

question

A pregnant patient in labor asks the nurse how soon the baby can be breastfed after delivery. What should the nurse respond to the patient? Select one: a. Immediately after birth b. After the infant is allowed to rest c. In 24 hours after her infant is given water d. Once the infant has a first feeding of formula

answer

a

question

A new mother asks the nurse to explain the difference between breastfeeding and formula when feeding a newborn. What should the nurse respond as an advantage of breastfeeding for the infant? Select one: a. Breast milk leads to firmer stools, increasing bowel tone. b. It takes less effort for an infant to suck at a breast than from a bottle. c. Breast milk is more difficult to digest, so it makes the infant feel fuller longer. d. Breast milk contains antibodies and decreases the possibility of gastrointestinal illnesses.

answer

d

question

Every time the nurse enters the room of a postpartum patient who gave birth 3 hours ago, the patient asks something else about her birth experience. The nurse would Select one: a. answer questions quickly and try to divert her attention to other subjects. b. review documentation of the birth experience and discuss it with her. c. contact the physician to warn him the patient might want to file a lawsuit due to her preoccupation with her birth experience. d. submit a referral to Social Services because you are concerned about obsessive behavior.

answer

b

question

The nurse is evaluating the effectiveness of teaching on perineal care provided to a postpartum patient. Which outcome indicates that teaching has been effective? Select one: a. Patient performs perineal care independently with every morning shower. b. Patient explains the purpose of performing perineal care at least once a day. c. Patient flushes the commode before standing when performing perineal care. d. Patient washes the perineum from back to front when performing perineal care.

answer

a

question

A new mother is distraught because the baby has a white discharge coming from the breasts. What should the nurse explain to the mother about this discharge? Select one: a. It is caused by exposure to cool air. b. It is caused by the mother's hormones. c. The baby may need chromosomal studies. d. It is a sign that the baby has a pituitary tumor.

answer

b

question

A postpartal patient is being treated for a separated symphysis pubis. Which outcome should the nurse identify when planning care for this patient? Select one: a. Patient plans to return to work in 2 weeks. b. Patient has coordinated child care assistance. c. Patient picks up the infant from the bassinette. d. Patient has a urine output of 30 ml per hour or greater.

answer

b

question

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital? Select one: a. Baby has a changing area. b. Kitchen has a refrigerator. c. Windows are covered with screens. d. Baby sleeps with the mother in bed.

answer

d

question

Which of the following is the most frequent reason for postpartum hemorrhage? Select one: a. Endometritis b. Uterine atony c. Perineal lacerations d. Disseminated intravascular coagulation

answer

b

question

The nurse is to begin the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? Select one: a. Describe the likely reaction of siblings to the new baby. b. Discuss adaptation to grandparenthood by her parents. c. Determine if father-infant attachment is taking place. d. Assist the mother in identifying behavior cues of the baby.

answer

d

question

A postpartal woman is having difficulty voiding following delivery. What should the nurse expect as the most reasonable cause for the difficulty voiding? Select one: a. The bladder fills slowly following childbirth. b. She is not trying hard enough. c. She must have a cervical tear, reducing bladder sensation. d. Perineal edema makes voiding difficult.

answer

d

question

The nurse has received an end of shift report on the postpartum unit. Which patient should she see first? Select one: a. Multip, second day post-cesarean, moderate lochia serosa b. Primip, day of delivery, fundus firm 2 cm above umbilicus c. Multip, first postpartum day, 4 cm diastasis recti abdominis d. Primip, first postpartum day, hypoactive bowel sounds all quadrants

answer

B

question

During her interactions with a primipara mother, the nurse notices that the mother rarely interacts with the infant unless the infant begins to cry vigorously. She appears relieved when a nurse comes to check on the infant. What is the appropriate nursing intervention for this patient? Select one: a. Ask the mother if she has previous experience caring for babies, and then teach her how to interact appropriately with her infant. b. Contact Social Services with concerns of neglect. c. Provide the care the infant needs while continuing to evaluate the mother's actions. d. Take the infant to the nursery so it can receive more consistent care.

answer

A

question

The nurse is assessing the fundus of a patient on postpartum day 3. What should the nurse expect when palpating the fundus? Select one: a. Fundus 4 cm above symphysis pubis and firm b. Fundus three fingerbreadths below umbilicus and firm c. Fundus two fingerbreadths below umbilicus and firm d. Fundus three fingerbreadths above symphysis pubis and hard

answer

B

question

A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? Select one: a. Assess vital signs. b. Assess the fundus. c. Notify the health care provider. d. Begin an IV infusion of Ringer's lactate solution.

answer

B

question

The nurse is concerned that a postpartum patient with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this patient? Select one: a. Weak and rapid pulse b. Warm and flushed skin c. Elevated blood pressure d. Decreased respiratory rate

answer

A

question

When performing eye prophylaxis at birth, which of the following would you do? Select one or more: a. Use a single-use tube or package of ointment b. Ensure the newborn's face is slightly wet c. Shade the newborn's eyes from the overhead light d. Open one eye at a time using pressure on the lower and upper lid e. Squeeze the ointment along the lower conjuctival sac from the inner canthus to the outward canthus f. Close the newborn's eye and wait about 5 seconds before wiping away any excess ointment

answer

A,d,E

question

A postpartum patient has a swollen area of purplish discoloration in the perineal area that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for this patient? Select one: a. Acute pain b. Risk for injury c. Risk for infection d. Ineffective peripheral tissue perfusion

answer

a

question

On the first postpartum day, the nurse teaches the patient about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be due to Select one: a. the taking-hold phase. b. postpartum hemorrhage. c. the taking-in phase. d. epidural anesthesia.

answer

c

question

A new mother asks the nurse what medications she can and cannot take into her body because it might affect breast milk. What should the nurse respond to this mother's request? Select one: a. Almost all drugs are excreted to some extent in breast milk. b. A mother should halt breastfeeding for 1 week after taking any drug. c. A mother can plan on taking common over-the-counter drugs without difficulty. d. A mother has to limit her exposure to narcotics and sedatives while breastfeeding.

answer

a

question

A new mother is concerned that she will not have enough breast milk because of small breasts. What should the nurse respond to the mother? Select one: a. "Have you discussed this concern with your physician?" b. "The size of breasts does not impact the amount of breast milk that is made." c. "The baby's diet can be supplemented with formula beginning on the second day." d. "No woman has to worry about milk production as long as she feeds the baby frequently."

answer

b

question

Which is the most appropriate method for assessing the uterine fundus? Select one: a. Massage the uterus between the thumb and middle finger until firm, then use a ruler to measure location. b. Palpate the fundus while the woman has a full bladder to facilitate detection of the uterus. c. Place both hands below the symphysis pubis and push upward until the lower end of the fundus is located d. Support the lower segment of the uterus while palpating the fundus to prevent inversion.

answer

d

question

During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate? Select one: a. "Current research suggests there are no physical risks related to cosleeping, and this is recommended as a healthy psychological approach to family bonding. b. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on his stomach." c. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." d. "If you practice cosleeping, your baby should be placed on a comforter, as opposed to directly on the mattress."

answer

c

question

A postpartal woman calls you into her room because she is having very heavy lochia that also contains large clots. Your first action would be to Select one: a. Assess her blood pressure b. Palpate her fundus c. Have her turn on her left side d. Assess her perineum

answer

b

question

A mother is concerned because her daughter has lost 8 oz 3 days after birth. Which response by the nurse is appropriate? Select one: a. "Your baby needs to be checked for a viral illness." b. "This is a normal and expected finding." c. "Your baby is probably just dehydrated." d. "You need to give your baby formula since she has lost weight during breastfeeding."

answer

b

question

Assisting in the initiation of breastfeeding is a role of the nurse. When should the nurse recommend that a newborn have the initial feeding? Select one: a. After the first bath b. Once the temperature has stabilized c. After newborn labs are drawn d. Within the first 30 minutes after birth

answer

d

question

The nurse understands which to be the reason vitamin K is routinely administered to newborns? Select one: a. Lack of vitamin K leads to faulty blood clotting. b. Vitamin K is important for digestion of milk. c. Vitamin K is important for lung maturity. d. Lack of vitamin K is caused by immature liver action.

answer

a

question

During the fourth stage of labor, your patient's assessment includes a blood pressure (BP) of 110/60, a pulse of 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. The priority action of the nurse should be to Select one: a. Turn the patient onto her left side. b. Place the bed in Trendelenburg position. c. Massage the fundus. d. Continue to monitor.

answer

d

question

The nurse notices that a new mother who is beginning postpartum day 2 handles the newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior? Select one: a. Disappointment with the child's sex b. Difficulty accepting the role changes c. Reacting normally to accepting a new child d. Cultural customs do not include kissing children

answer

c

question

The nurse is caring for a newborn that weighed 7 lb 3 oz at birth. What action should the nurse take first based on this weight? Select one: a. Plot the weight on a gestational age graph. b. Ask for a physician to examine the newborn. c. Draw additional blood work for cholesterol level. d. Turn off the radiant heat warmer for physical assessment.

answer

a

question

The nurse instructs a patient on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective? Select one: a. Patient complains of fatigue. b. Patient appears disheveled and listless. c. Patient is chatting on the telephone with a friend. d. Patient is cleaning the kitchen while the baby naps.

answer

c

question

A new mother asks the nurse how to determine if the baby is receiving enough breast milk. What response should the nurse make to the mother? Select one: a. "The infant should not become constipated." b. "The infant should sleep at least 3 hours between feedings." c. "You need to weigh the infant before and after each feeding." d. "The infant should gain weight and have six wet diapers daily."

answer

d

question

You assess a postpartal woman's fundal height every 15 minutes during the first hour postpartum. At which of the following locations would you expect to assess the height of her fundus? Select one: a. Two fingerbreadths under the umbilicus b. One fingerbreadth under the umbilicus c. At the umbilicus d. Two fingerbreadths above the symphysis pubis

answer

c

question

The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours. Her fundus was boggy, and firmed with massage to 1 fingerbreadths below the umblicus, moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 1-10. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this patient? Select one: a. Acute pain related to perineal trauma b. Risk for deficient fluid volume related to uterine bleeding and nausea c. Readiness for enhanced family coping d. Knowledge deficit related to newborn care

answer

b

question

The postpartum patient delivered 4 hours ago. She has a mediolateral episiotomy and large hemorrhoids. She is rating her pain at 7 on a scale of 1-10. She has a history of anaphylactic reaction to Tylenol (acetaminophen). Which nursing action would be best? Select one: a. Offer the patient 800 mg Advil (ibuprofen) orally with food. b. Provide two Percocet (oxycodone with acetaminophen) by mouth. c. Encourage use of Dermoplast topical anesthetic spray. d. Run very warm water into the tub and assist her into the bath.

answer

a

question

Which of the following is an appropiate nursing diagnosis for a postpartal mother with an episiotomy during the first 5 days postpartum? Select one: a. Anxiety related to vaginal scar formation and decreased body image b. Imbalance nutrition: more than body requirements related to increase appetite c. Risk for infection related to lochia and decreased perineal skin integrity d. Self-care deficit related to poor opportunity for independence

answer

c

question

The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing? Select one: a. Providing a sitz bath b. Administering an enema c. Urging to drink all the milk provided during meals d. Administering acetaminophen and codeine for pain

answer

b

question

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears? Select one: a. Only people who are known to the staff are permitted in the nursery. b. Keeping the baby in the mother's room at all times is the best approach. c. Both the mother and infant have identification bands that need to match. d. Security questions everyone before permitting them access to the hospital.

answer

c

question

The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing? Select one: a. Providing a sitz bath b. Administering an enema c. Urging to drink all the milk provided during meals d. Administering acetaminophen and codeine for pain

answer

b

question

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears? Select one: a. Only people who are known to the staff are permitted in the nursery. b. Keeping the baby in the mother's room at all times is the best approach. c. Both the mother and infant have identification bands that need to match. d. Security questions everyone before permitting them access to the hospital.

answer

c

question

During a home visit, a new mother tells the nurse that her nipples are sore from breastfeeding. What should the nurse instruct the mother at this time? (Select all that apply.) Select one or more: a. Insert plastic liners into the nursing bra. b. Apply lanolin to nipples after air exposure. c. Expose the nipples to air so the nipple dries. d. Position the baby differently for each feeding. e. Massage a few drops of breast milk to the areola.

answer

b,d

question

The nurse is explaining the process of breast milk production with a patient pregnant with her first child. What should the nurse include when providing this teaching? (Select all that apply.) Select one or more: a. Breast milk is thin, yellow, and watery. b. For the first 3 to 4 days, the breast milk is colostrum. c. Uterine cramping is a contraindication to breastfeeding. d. True breast milk comes in by the 10th day after giving birth. e. Most mothers have breast milk by the first day after giving birth.

answer

d

question

The nurse assesses a postpartum patient's discharge as being pink or browish. How should the nurse document the appearance of the lochia? Select one: a. Lochia alba b. Lochia rubra c. Lochia serosa d. Lochia normalia

answer

c

question

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn? Select one: a. Administer the medication in the deltoid muscle. b. Administer the medication into the anterolateral muscle. c. Provide the medication immediately before breastfeeding. d. Notify the physician for swelling and irritation at the injection site.

answer

b

question

During a home visit, a postpartum patient is complaining of a painful area on one breast. The nurse notes a local area on one breast to be red and warm to touch. For which health problem should the nurse plan care for this patient? Select one: a. Mastitis b. Breast cancer c. Engorgement d. Plugged milk duct

answer

a

question

A postpartum patient is prescribed methylergonovine (Methergine) 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient? Select one: a. Assess ambulation. b. Measure urine output. c. Measure blood pressure. d. Evaluate current hematocrit level.

answer

c

question

When examining a postpartal woman, you should immediately report which condition? Select one: a. A fundus that is palpated 2 cm below the umbilicus on the second postpartal day b. A fundus that cannot be located by palpation on the ninth postpartal day c. A soft, spongy uterine fundus noted during the first hour of the postpartum period d. Red, bloddy vaginal discharge on the perineal pad on the first day postpartum

answer

c

question

Which would be an appriopiate goal for a postpartal client who complains of being exhausted and unable to sleep? Select one: a. Abstains from performing self-care and rests instead b. States she feels rested during the postpartal period c. Sleeps during the night in order to stay awake all day d. Sleeps 8 hours every night after discharge from the hospital

answer

b

question

Which medication would you expect to adminster as ordered for a client who is experiencing postpartum hemorrhage from uterine atony? Select one: a. Apresoline b. Zaroxolyn c. Methergine d. Proventil

answer

c

question

During a home visit, the nurse learns that a new mother is experiencing breast engorgement. What should the nurse recommend to help alleviate this problem? Select one: a. Discontinuing breastfeeding for 24 hours b. Having her apply lanolin cream to each breast c. Encouraging her to continue regular breastfeeding d. Decreasing her fluid intake to below 500 ml per 24 hours

answer

c

question

The nurse has been hired to provide care to patients on a maternal and child unit. What will the nurse use to as a guide to legally provide care to this patient population? Select one: a. Code of ethics b. Nursing research c. Standards of practice d. Evidence-based guidelines

answer

c

question

A patient who learns of being 9 weeks pregnant asks the nurse to explain the changes that are occurring with her body. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time? Select one: a. Anxiety b. Impaired coping c. Deficient knowledge d. Readiness for enhanced knowledge

answer

d

question

Mrs. Smith asks the nurse to compute her expected due date. Based on the fact that her last menstrual flow began on Jan 17, which due date would the nurse estimate? Select one: a. October 17 b. September 24 c. October 24 d. November 24

answer

c

question

During a family assessment, it is identified that the mother is unemployed but stays at home to prepare meals, monitor medication doses, and comfort the children with emotional issues. The father works outside of the home and pays the bills. Which terms should the nurse use to document the role of the father in this family? (Select all that apply.) Select one or more: a. Provider b. Nurturer c. Culture bearer d. Health manager e. Financial manager

answer

a,e

question

The nurse is beginning an assessment with a pregnant patient from a non-English-speaking culture. The interpreter is having difficulty understanding what the patient is trying to say and the patient is becoming frustrated. Which nursing diagnosis would be the most appropriate for this situation? Select one: a. Fear b. Anxiety c. Powerlessness d. Impaired verbal communication

answer

d

question

A pregnant patient scheduled for an amniocentesis asks the nurse how the placenta is not punctured during the procedure. What should the nurse respond to the patient? Select one: a. "A uterus feels soft over the placenta site." b. "A sonogram to locate it will be done first." c. "It would not be harmful even if it were punctured." d. "Placentas always form on the posterior uterine wall."

answer

b

question

The advance practice nurse is conducting health histories and physicals for a local high school football team. Joel Peterson mentions to you that he considers his grandmother as his primary caregiver and wants her as his emergency contact. From this remark, the nurse knows which is his most likely family structure? Select one: a. A dyad family b. A nuclear family c. A cohabitation family d. An extended family

answer

d

question

Which of these actions would be most likely to promote family-centered care? Select one: a. Restrict hospital visting hours so patients can rest b. Place a limit on the number of visitors per patient to improve patient security c. Solicit parent's preferences about the way education is delivered d. Restrict the pediatric play area to specific times

answer

c

question

The primary focus of which of these phases of health care is that of education related to preventing complications? Select one: a. Health promation b. Health maintenance c. Health restoration d. Health rehabilitation

answer

d

question

The nurse is explaining the process of fertilization to a patient who has just learned of being pregnant. On which day during pregnancy should the nurse explain that the embryo implants on the uterine surface? Select one: a. Four days after fertilization b. Eight to 10 days after fertilization c. The 14th day of a "typical" menstrual cycle d. Ten days after the start of the menstrual flow

answer

b

question

A nurse at an anterpartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Whic of the following complications should the nurse suspect? Select one: a. Hyperemesis gravidarum b. Threatened abortion c. Hydatidiform mole d. Preterm labor

answer

c

question

A patient is admitted with a diagnosis of ectopic pregnancy. For what should the nurse anticipate preparing the patient? Select one: a. Immediate surgery b. Internal uterine monitoring c. Bed rest for the next 4 weeks d. Intravenous administration of a tocolytic

answer

a

question

A patient who is 16 weeks pregnant is passing pieces of body tissue along with blood clots and dark red blood from the vagina. What should the nurse direct the patient to do at this time? Select one: a. Begin immediate bed rest. b. Count the number of perineal pads that are saturated with blood. c. Continue with normal daily activity and monitor pulse rate every hour. d. Seek immediate medical attention and bring the expressed vaginal material

answer

d

question

A patient with diabetes is in the first trimester of pregnancy and is currently having difficulty keeping blood glucose levels within normal limits. The patient explains that she has been "eating for two" so the baby is healthy. What should the nurse respond to the patient? Select one: a. "Elevated blood glucose levels cause low birth weights in infants." b. "Elevated blood glucose levels ensure the baby has mature lungs at birth." c. "Elevated blood glucose levels hasten the development of the fetus in utero." d. "Elevated blood glucose levels in the first trimester have been linked to congenital anomalies."

answer

d

question

A patient with diabetes who is in the second trimester of pregnancy notes that the usual dose of insulin to maintain blood glucose levels has been increasing over the last few weeks. What should the nurse explain to the patient about insulin during pregnancy? Select one: a. The fetus is using insulin to maintain blood glucose level in utero. b. Insulin resistance develops because of placenta and other hormones. c. An increase in circulating blood volume during pregnancy deactivates insulin. d. The change in diet causes an increased need for insulin to maintain blood glucose levels.

answer

b

question

A patient with type 2 diabetes mellitus is planning to become pregnant within the next several months. What should the nurse instruct the patient to support the 2020 National Health Goals of reducing the complications of pregnancy from diabetes? Select one: a. Avoid episodes of hyperglycemia. b. Reduce the current exercise regimen by half. c. Limit the intake of carbohydrates and fats in the diet. d. Reduce the use of insulin for blood glucose coverage.

answer

a

question

A pregnant patient is being admitted for severe preeclampsia. In which room location should the nurse place this patient? Select one: a. Near the nursery b. Next to the elevator c. In the back private room d. Across from the nurse's station

answer

d

question

The nurse is concerned that a pregnant patient is experiencing abruptio placentae. What did the nurse assess in this patient? Select one: a. Increased blood pressure and oliguria b. Pain in a lower quadrant and increased pulse rate c. Painless vaginal bleeding and a fall in blood pressure d. Sharp fundal pain and discomfort between contractions

answer

d

question

The nurse is identifying nursing diagnoses for a patient with gestational hypertension. Which diagnosis would be the most appropriate for this patient? Select one: a. Risk for injury related to fetal distress b. Imbalanced nutrition related to decreased sodium levels c. Ineffective tissue perfusion related to poor heart contraction d. Ineffective tissue perfusion related to vasoconstriction of blood vessels

answer

d

question

What type of milk is present in the breasts 7 to 10 days postpartum? Select one: a. Colostrum b. Hind milk c. Mature milk d. Transitional milk

answer

d

question

When instructing your patient on the proper way to take a pregnancy test, the nurse should advise the patient of the following: Select one or more: a. Perform the test with your first morning urine b. Receiving a "postive" home pregnancy test confirms pregnancy c. When the test is completed, you must wait between 3-5 minutes in order to check results d. There are only two test in order to confirm a pregnancy e. The main hormone detected by the pregnacy test is FH.

answer

a,c

question

Name two inteventions provided to mothers after an episiotomy.

answer

1. Ice pack 2. Peri-bottle

question

Name the three most common childbirth methods used during natural childbirth.

answer

1. Lamaze 2. Dick-Reed method 3. Bradley method

question

Name the three characterstic of post-partum depression

answer

1.irritability 2.anxiety 3.insomnia

question

Name the two (2) cervical riping agents?

answer

1. cervadil 2. cytotec

question

Colstrum is hard to digest because it's high in fat. Select one: True False

answer

false

question

If a car seat has been in a car accident, as long as there has been no damange to the seat itself, it is recommended that you still use it. Select one: True False

answer

false

question

What are the 5 cervix criteria the Bishop score mesure to assess cervical favorability during an induction? Select one or more: a. Position Correct b. Consistency Correct c. Location d. Effacement Correct e. Softness f. Dilation Correct g. Station Correct

answer

a,b,d,f

question

Name two types of episiotomies?

answer

1.medio-lateral 2.midline

question

What is the best position to use while in labor to increases fetal circulation and placental perfusion? Select one: a. Trendelenberg position b. Left lateral/tilt position c. Supine Position d. Chin-to-chest Position

answer

b

question

Newborn values: length

answer

46-54

question

head circumference

answer

34-35

question

chest circumference

answer

32-33

question

temperature

answer

97.6-98.6 axillary

question

heart rate

answer

110-160 bpm

question

respirations

answer

30-60

question

weight

answer

2.5-3.4 kg

question

flow of heat from a newborns body to cooler surrounding air. Eliminating drafts, such as air conditioners is a way to reduce _____ heat loss.

answer

convection

question

the transfer of body heat to a cooler solid object not in contact with the baby, such as an airconditioner.

answer

radiation

question

transfer of body heat to a cooler solid object in direct contact with the baby, such as placing a baby on a metal table.

answer

conduction

question

loss of heat through conversion of a liquid to a vapor. To prevent lay baby on mom skin to skin immediately after birth and cover with warm blanket.

answer

evaporation

question

For breastfed babies:

answer

-initiate breastfeeding within half an hour after birth -encourage breastfeeding on demand -stools tend to be yellow-light/bright green and appear seedy

question

For formula fed babies:

answer

-stools are more formed/solid & darker in color -infants should have 6-8 wet diapers per day after one week old -the first stool of a newborn is usually passed within 24 hours -the 2nd or 3rd day of life, the newborn changes from meconium to stool. bowel contents appear both loose and green:they may resemble diarrhea. -normal weight for a newborn in the hospital is 10%

question

For circumcisions:

answer

-keep lubed -loose diapers, change every 4 hours -clean with warm water every diaper change -notify provider of swelling, odor, discharge, and excessive crying -do not submerge in tub -do not wash yellow mucus formed at day 2. Leave it to heal

question

For umbilical cord:

answer

-do not cover -leave open to air and fold diaper down -no baths, keep dry

question

this should be given in the first hour of life IM in the vastus lateralis. (clotting factor)

answer

Vitamin K

question

caput succedaneum

answer

crosses midline and disappears at the 3rd day of life. no treatment neccessary.

question

cephalohematoma

answer

blood collected. takes 2 weeks to resolve. baby needs to be observed for jaundice.

question

"liquid gold" -thin, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and antibodies. Production begins the 4th month of pregnancy. It is excreted until the 4th day postpartum.

answer

colostrum

question

produced the 2nd-4th day postpartum

answer

transitional milk

question

breast milk that is produced on the 10th day

answer

true/mature milk

question

constantly forming milk

answer

fore milk

question

formed after the let down reflex; higher in fat than fore milk. This makes the infant grow most rapidly.

answer

hind-milk

question

Small for gestational age infant (SGA)/Microsomia

answer

-experienced growth restriction -22-44 weeks gestation -<10th percentile birth weight -strong possibility of congenital malformation -risk: meconium aspiration, pulmonary hemorrhage, penumothorax, hyperbilirubemia, apnea, poor nutrition -high risk for hypoglycemia, intracranial hemorrhage -likely feeding problems because of hypoglycemia -future growth will likely always be <10%

question

track ovulation through calendar/rhythm method, basal body temp, cervical mucus method, or cycle beads and practices abstinence during this period

answer

natural family planning

question

kill spermicide and raises vaginal pH to strong acid level which is not conducive to sperm survival

answer

spermicide

question

first stage of labor

answer

3 phases -latent phase: 0-3 cm -active phase: 4-7 cm -transition phase: 8-10 cm

question

second stage of labor

answer

10cm-delivery of baby

question

third stage of labor

answer

delivery of baby to delivery of placenta

question

fourth stage

answer

placental delivery to four hours pospartum

question

veal

answer

v-variable e-early decels a-acceleration l-late decelerations

question

chop

answer

c-cord compression h-head compression o-okay p-placental insufficiency

question

lion

answer

l-left lying position i-increase fluids, stop pitocin o-oxygen n-notify provider

question

FHR:

answer

minimal- 5 bpm or fewer moderate- 5-25 bpm marked- greater than 25bpm

question

postpartum assessment BUBBLEHE

answer

b-breast u-uterus b-bleeding b-bottom/perineum l-lacerations e-episiotomy h-hemorhoids e-emotional state

question

miscarriage in 1st trimester; abnormal fetal development

answer

spontaneous miscarriage

question

1st trimester > surgical removal

answer

ectopic pregnancy

question

uterine contractions and dilation occur

answer

imminent miscarriage

question

gestational trophoblastic disease/ hydatiform mole occurs in:

answer

2nd trimester miscarriage

question

cervical insufficiency/premature cervical dilation occurs

answer

20 weeks gestation

question

painless bleeding caused by low lying placenta; 3rd trimester miscarriage

answer

placenta previa

question

sharp stabbing pain as the placental seperation occurs, accompanied by heavy bleeding

answer

premature seperation of placenta/abruptio placentae

question

MEDICATIONS FOR PRETERM LABOR: PROCARDIA/NIFEDIPINE

answer

DECREASES CONTRACTILITY AND STOPS LABOR. DOSE 30 MG PO; 10-20 MG EVERY 4-6 HOURS

question

INDOCIN

answer

DECREASES PRODUCTION OF PROSTAGLANDINS. NOT GIVEN AFTER 32 WEEKS GESTATION

question

CELESTONE/BETAMETHASONE

answer

STEROID GIVEN TO ACCELERATE FETAL LUNG MATURITY VIA SURFACTANT PRODUCTION. DOSE 12 MG IM; REPEAT DOSE 24 HOURS, MAY REPEAT IN 12 HOURS IF DELIVERY IS IMMINENT. DELIVERY DELAYED 24-48 HOURS AFTER 1ST DOSE.

question

INDUCTION/AUGMENTATION METHODS: CYTOTEC:

answer

CERVICAL RIPENING AGENT; 1/4 CIRCULAR TAB PLACED ON CERVIX EVERY 4-6 HOURS, 25 MCG PLACED ANALLY IF BLEEDING POSTPARTUM HEMORRHAGE 800-1000 MG. MONITOR FOR DIARRHEA. DO NOT BREASTFEED! DO NOT ADMIN IF UTERUS IS TACHYSYSTOLE. MAY BE GIVEN FOR INDUCTION OF INTRA UTERINE FETAL DEMISE.

question

CERVIDIL

answer

CERVICAL RIPENING AGENT AND INDUCTION OF LABOR. TAMPON SHAPED. PLACED ON CERVIX FOR UP TO 12 HOURS, THEN PULLED OUT. REMOVED WHEN LABOR BEGINS, WHEN FETAL HR DOESN'T TOLERATE IT. MUST BE REMOVED 30 MINUTES PRIOR TO THE START OF PITOCIN

question

PITOCIN (OXYTOCIN)

answer

USED FOR INDUCTION AND AUGMENTATION OF LABOR AND TO DECREASE POSTPARTUM BLEEDING. 1MUNIT OR 2MUNIT IN 500 ML OF LACTATED RINGERS; MAX 20 UNITS OR 30 UNITS

question

TOCOLYTICS>RELAX UTERUS: MAGNESIUM SULFATE

answer

CNS DEPRESSANT, RELAXES ALL MUSCLE. RELAXES UTERINE MUSCLE. USE: STOP PRETERM LABOR, PREVENT SEIZURES IN PRE-ECLAMPTIC PATIENTS. CAUSES INITIAL DROP IN BP. DOSE: 4-6 GRAM BOLUS IV OVER 20-30 MINUTES. MAINTENANCE DOSE 2-3GRAMS/HOUR -MEASURE BP EVERY 5 MINUTES, PULSE OX, LISTEN TO LUNG AND HEART SOUNDS, CHECK REFLEXES, HIGH RISK FOR POSTPARTUM HEMORRHAGE!!! -TOXICITY:CNS DEPRESSION, HYPOREFLEXIA, FLACCID PARALYSIS, DECREASED DEEP TENDON REFLEXES, DEC. RESP RATE, AND VISUAL DISTURBANCES -ANTIDOTE: 10% CALCIUM GLUCONATE VIA 10 ML IV PUSH OVER 5 MINUTES

question

BRETHINE

answer

STOPS CONTRACTIONS FOR PRETERM LABOR OR TOO MANY CONTRACTIONS DURING DELIVERY -DOSE IV 0.125MG: SUBCUTANEOUS 0.25 -CONTRATINDICATED IN PATIENTS WITH HR OVER 120 BPM, BP LOWER THAN 90/60, OR FHR OVER 160

question

DRUGS GIVEN POSTPARTUM:

answer

PITOCIN CYTOTEC

question

DRUGS GIVEN FOR POSTPARTUM HEMORRHAGE

answer

500 ML + VAGINAL DELIVERY; 1000ML + CSECTION PITOCIN CYTOTEC METHERGINE-MONITOR BP AND HR. CONTRAINDICATED IN PATIENTS WITH RESP PROBLEMS AND HTN. HEMABATE- GIVEN WITH LOMOTIL (FOR DIARRHEA)

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