Saunders NCLEX-RN Exam (5th Ed.) – Maternity Nursing

question

A nursing student is preparing a prenatal class on the process of fetal circulation. The nursing instructor asks the student specifically to describe the process through the umbilical cord. Which of the following statements from the student is correct?
answer

“The two arteries in the umbilical cord carry deoxygenated blood & waste products away from the fetus to the placenta.”
question

A nursing student is assigned to care for a client in labor. A nursing instructor asks the student to describe fetal circulation, specifically the ductus venous. The nursing instructor determines that the student understands fetal circulation if the student states that the ductus venous:
answer

Connects the umbilical vein to the inferior vena cava.
question

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse understands that he client should be able to find out at 12 weeks’ gestation because by the end of the twelfth week:
answer

The sex of the fetus can be determined by the appearance of the external genitalia.
question

A nurse is performing as assessment on a client who is at 38 weeks’ gestation & notes that the fetal heart rate is 174 beats/min. On the basis of this finding, the appropriate nursing action is to:
answer

Notify the physician.
question

A nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, the nurse responds that the reason for this is that it:
answer

Promotes the fertilized ovum’s normal implantation in the top portion of the uterus.
question

A nursing instructor is reviewing the menstrual cycle with a nursing student who will be conducting a prenatal teaching session. The instructor asks the student to describe the follicle-stimulating hormone (FSH) & the luteinizing hormone (LH). The student accurately responds by stating that:
answer

FSH & LH are released from the anterior pituitary gland.
question

A couple comes to the family planning clinic & asks about sterilization procedures. Which question by the nurse would determine if this method of family planning would be appropriate?
answer

“Do you plan to have any other children?”
question

A nurse should explain which of the following to a pregnant client found to have a gynecoid pelvis?
answer

That her type of pelvis is the most favorable for labor & birth.
question

A nurse explains some of the purposes of the placenta to a client during a prenatal visit. The nurse determines that the client understands some of these purposes when the client states that the placenta:
answer

Is the way the baby gets food & oxygen.
question

A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid:
answer

* Allows for fetal movement * Is a measure of kidney function * Surrounds, cushions, & protects the fetus. * Maintains the body temperature of the fetus.
question

A nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters & expects the finding to be which of the following?
answer

30 cm
question

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks & tells the nurse that she does not have a Hx of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as
answer

G=2, T=1, P=0, A=0, L=1
question

A pregnant client is seen in a health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, & the nurse determines that she is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
answer

Inform the client that these contractions are common & may occur throughout the pregnancy.
question

A nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. The nurse tells the client that:
answer

A cesarean section will be necessary if vaginal lesions are present at the time of labor.
question

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of Goodell’s sign. The nurse determines that this sign indicates:
answer

A softening of the cervix.
question

A client arrives at the clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was Oct. 19, 2012. Using Nagele’s rule, the nurse determines the estimated date of confinement is:
answer

July 26, 2013
question

A nurse-midwife is assessing a pregnant client for the presence of ballottement. To make this determination, the nurse-midwife does which of the following?
answer

Initiates a gentle upward tap on the cervix.
question

A pregnant client asks a nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which of the following weeks of gestation?
answer

16 & 20
question

A nurse is performing as assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding that necessitates further testing?
answer

Fetal heart rate of 180 beats / min
question

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant & is checking the client for probable signs of pregnancy. Which of the following are probable signs of pregnancy.
answer

* Ballotement * Chadwicks sign * Uterine enlargement * Braxton Hick’s contractions/
question

A nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. The nurse tells the client that:
answer

An informed consent needs to be signed before the procedure.
question

A pregnant client in the first trimester calls nurse at a health care clinic & reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which assessment to the client?
answer

“The vaginal discharge may be bothersome, but is a normal occurrence.”
question

A nurse has performed a non-stress test on a pregnant client & is reviewing the fetal monitor strip. The nurse interprets the test as reactive & understands that this indicates:
answer

Normal findings
question

A non-stress test is performed on a client who is pregnant, & the results of the test indicate non-reactive findings. The physician prescribes a contraction stress test, & the results are documented as negative. A nurse interprets the finding of the contraction stress test as indicating:
answer

A normal test result.
question

A pregnant client tells a nurse that she has been craving “unusual foods.” The nurse gathers additional assessment data from the client & discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed on the client. The nurse reviews the results * determines that which of the following indicates a physiological consequence of the client’s practice?
answer

Hemoglobin 9.1 g/dL
question

A pregnant client asks a nurse about the types of exercises that are allowable during pregnancy. The nurse should instruct the client that the safest exercise to engage in is which of the following?
answer

Swimming
question

A physician has prescribed transvaginal ultra-sonography for a client in the 1st trimester of pregnancy & the client asks a nurse about the procedure. The nurse tells the client that:
answer

The probe that will be inserted into the vagina will be covered with a disposable cover & coated with a gel.
question

A clinic nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions?
answer

“I should wear knee-high hose, but I should not leave them on longer than 8 hours.”
question

A pregnant client calls a clinic & tells a nurse that she is experiencing leg cramps that awaken her at night. To provide relief from the leg cramps, the nurse tells the client the following:
answer

“Bend your foot toward your body while extending the knee when the cramps occur.”
question

A clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions?
answer

“I should avoid eating foods that produce gas, such as beans & some vegetables, & fatty foods such as deep-dried chicken.”
question

A nurse in a health care clinic is instructing a pregnant client how to perform “kick counts.” Which statement by the client indicates a need for further instructions?
answer

“I need to lie flat on my back to perform the procedure.”
question

A nurse is providing instructions regarding treatment if hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction?
answer

“I should apply hear packs to the hemorrhoids to help the hemorrhoids shrink.”
question

A nurse providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. The nurse tells the client to:
answer

Wash the breasts with warm water & keep them dry.
question

A nurse is describing cardiovascular system changes that occur during pregnancy to a client & understands that which finding would be normal for a client in the 2nd trimester?
answer

Increase in pulse rate.
question

A rubella titer result of a 1-day postpartum client is less than 1:8, & a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information t the client about the vaccine?
answer

* Pregnancy needs to be avoided for 1 to 3 months. * The vaccine is administered by the subcutaneous route. * A hypersensitivity reaction can occur if the client has an allergy to eggs. * Exposure to immuno-suppressed individuals needs to be avoided.
question

A nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn infant after delivery. The client asks the nurse about the feeding options that are available. The best response by the nurse is:
answer

“You will need to bottle-feed the newborn infant.”
question

A home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia & the need to notify the physician?
answer

The client complains of a headache & blurred vision.
question

A stillborn infant was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding & touching the infant. Which statement by the nurse would further assist the family in their initial period of grief?
answer

“What can I do for you?”
question

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?
answer

“I should avoid exercise because of the negative effects on insulin production.”
question

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis & assesses the client for:
answer

Evidence of bleeding, such as in gums, petechiae, & purpura.
question

A nurse in a maternity unit is reviewing the records of the clients on the unit. Which client would the nurse identify as being at the greatest risk for developing disseminated intravascular coagulation (DIC)?
answer

A gravida II who has just been diagnosed with dead fetus syndrome
question

A client in the 1st trimester of pregnancy arrives at a health care clinic & reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, & the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instructions?
answer

“I will maintain strict bedrest throughout the remainder of the pregnancy.”
question

The nurse is assessing a pregnant client with type I diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that teaching is needed if the client makes which statement?
answer

“I will need to increase my insulin dosage during the first 3 months of pregnancy.”
question

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, & fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained & identifies Mycobacterium tuberculosis. The nurse provides instructions to the client regarding therapeutic management of the tuberculosis & the nurse tells the client that:
answer

Isoniazid (INH) plus rifampin (Rifadin) will be required for 9 months.
question

A nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?
answer

“I should drink adequate fluids & increase my intake of high-fiber foods.”
question

A clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at high risk for contracting HIV?
answer

A client who has a history of intravenous drug use.
question

A nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?
answer

“We want to attend a support group.”
question

A nurse evaluates the ability of a hepatitis B- positive mother to provide safe bottle-feeding to her infant during postpartum hospitalization. Which maternal action best exemplifies the mother’s knowledge of potential disease transmission to the infant?
answer

The mother washes & dries her hands before & after self-care of the perineum & asks for a pair of gloves before feeding.
question

A home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia?
answer

* Proteinuria * Hypertension * Generalized Edema
question

A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following assessments is noted?
answer

The cervix is dilated completely.
question

A nurse in the labor room is caring or a client in the active stage of labor. The nurse is assessing the fetal patterns and notes a late deceleration.on the monitor strip. The appropriate nursing action is to:
answer

Administer oxygen via face mask.
question

A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician?
answer

Fetal heart rateof 180 beats/min
question

A nurse is reviewing the record of a client in the labor room & notes that the nurse-midwife has documented that the fetus is at – 1 station. The nurse determines that the fetal presenting part is:
answer

1cm above the ischial spine
question

A client arrives at a birthing center in active labor. Her membranes are still intact, & the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client tat after this procedure, she will most likely have:
answer

Increased efficiency of contractions
question

A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?
answer

Variable Decelerations
question

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, a nurse places her in:
answer

Supine position with a wedge under the right hip. ***(this helps keep the baby off of the vena cava).
question

A nurse has provided discharge instructions to a client who delivered a healthy infant by cesarean delivery. Which statement made by the client indicates a need for further instructinos?
answer

“I will begin abdominal exercises immediately.”
question

A nurse is monitoring a client in active labor & notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/min. Which of the following nursing actions is appropriate?
answer

Notify the physcian or nurse-midwife. ***(The HR is too slow).
question

A nurse is caring for a client in labor & is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is appropriate?
answer

Document the findings & tell the mother that the patter on the monitor indicates fetal well-being.
question

A nurse is admitting a pregnant client to the labor room & attaches an external electronic fetal monitor to the client’s abdomen. After attachment of the electronic fetal monitor, the initial nursing assessment is which of the following?
answer

Assess the baseline fetal heart rate.
question

A nurse is reviewing true & false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?
answer

“My contractions will increase in duration & intensity.”
question

After an amniotomy has been performed, a nurse should first assess:
answer

The fetal heart rate pattern.
question

A client in labor has been pushing effectively for 1 hour. A nurse determines that the client’s primary physiological need at this time is to:
answer

Rest between contractions.
question

A nurse is monitoring a client in labor who is receiving oxytocin (Pitocin) and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes.
answer

1. Stop the oxytocin infusion. 2. Reposition the client. 3. Administer oxygen by face mask at 8 to 10 L/min. 4. Perform a vaginal examination. 5. Check the client’s blood pressure. 6. Administer medication as prescribed to reduce uterine activity.
question

A nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?
answer

Uterine tenderness
question

A maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding & has a suspected diagnosis of placenta previa. The nurse reviews the physician’s prescriptions & would question which prescription?
answer

Obtain equipment for a manual pelvic examination. ***(Nothing needs to go inside)
question

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. Based on these findings, the nurse would prepare the client for:
answer

Delivery of the fetus
question

A nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding would indicate that the client is at risk for preterm labor?
answer

The client has a history of cardiac disease.
question

A nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, & weak. The nurse documents that the client is experiencing which type of labor dystocia?
answer

Hypotonic
question

After a preciptious delivery, a nurse notes that the new mother is passive & only touches her newborn infant briefly with her fingertips. The nurse should do which of the following to help the woman process what has happened?
answer

Support the mother in her reaction to the newborn infant.
question

A nurse in a labor room is monitoring a client with dysfunctional labor signs of fetal or maternal compromise. Which of the following assessment findings would alert the nurse to a compromise?
answer

Persistent non-reassuring fetal heart rate.
question

A nurse in a labor room is preparing to care for a client with hypotonic uterine contractions. The nurse is told that he client is experiencing uncoordinated contractions that are erratic in their frequency, duration, & intensity. The priority nursing intervention in caring for the client is to:
answer

Provide pain relief measures.
question

A nurse is reviewing the physician’s prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which physician’s prescription should the nurse question?
answer

Perform a vaginal examination every shift.
question

A nurse has developed a plan of care for a client experiencing dystocia & includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care & selects which intervention as the highest priority?
answer

Monitoring the fetal heart rate.
question

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what other intervention should be performed?
answer

Administer oxygen, 8 to 10 L/min, via face mask.
question

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care & prepares to monitor the client for which risk associated with placenta previa?
answer

Hemorrhage.
question

A nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is an initial nursing action?
answer

Place the client in Trendelenburg’s position.
question

A nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note?
answer

*Bright red vaginal bleeding *Soft, relaxed, non-tender uterus *Fundal height may be greater than expected for gestational age.
question

A postpartum nurse is taking the vital signs of a client who delivered a healthy infant 4 hours ago. The nurse notes that the client’s temperature is 100.2 F. Which of the following actions would be appropriate?
answer

Increase hydration by encouraging oral fluids. ***(Dehydration could be the cause)
question

A nurse is assessing a client who is 6 hours postpartum after delivering a full-term health infant. The client complains to the nurse of feelings of faintness & dizziness. Which nursing action would b most appropriate?
answer

Instruct the client to request help when getting out of bed.
question

A postpartum nurse is providing instructions to a client after delivery of a healthy infant. The nurse instructs the client that she should expect normal bowel elimination to return.
answer

3 days postpartum
question

A nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a mid-line episiotomy & has several hemorrhoids. What is the primary nursing diagnosis for this client?
answer

Acute pain
question

A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum & notes that the client has saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as:
answer

Heavy
question

A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions should the nurse include?
answer

The diet should include additional fluids.
question

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
answer

Ask the client to urinate & empty her bladder.
question

A nurse is caring for four 1-day postpartum clients. Which client has an abnormal finding that would require further intervention?
answer

The client with lochia that is red & has a foul-smelling odor.
question

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots & notes that they are larger than 1cm. Which nursing action is appropriate?
answer

Notify the physician. *( Clots that are larger than 1 cm, are big!)
question

A nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which of the following statements?
answer

* “I should wear a bra that provides support.” * “Drinking alcohol can affect my milk supply.” * “The use of caffeine can decrease my milk supply.” * “I plan on having bottled water available in the refrigerator so I can get additional fluids easily.”
question

A nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which of the following sign, if noted, would be an early sign of excessive blood loss?
answer

An increase in the pulse rate from 88 to 102 beats/min.
question

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft & boggy. Which nursing intervention would be appropriate initially?
answer

Massage the fundus until it’s firm.
question

A nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which of the following, if stated by the client, would indicate a need for further instructions?
answer

“I should wash my nipples daily with soap & water.”
question

A postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs & symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present?
answer

Enlarged, hardened veins.
question

A client in a postpartum unit complains of sudden sharp chest pain & dyspnea. The nurse notes that the client is tachycardic & the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which of the following would be the initial nursing action?
answer

Administer oxygen, 8 to 10 L/min, by face mask.
question

A nurse is assessing a client in the fourth stage of labor & notes that the fundus is firm, but that bleeding is excessive. Which of the following would be the initial nursing action?
answer

Notify the physician.
question

A nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage?
answer

A multiparous client who delivered a large fetus after oxytocin (Pitocin) induction.
question

A postpartum client is diagnosed with cystitis. The nurse plans for which priority nursing intervention in the care of the client?
answer

Encouraging fluid intake.
question

A nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which of the following assessment findings would best indicate the presence of hematoma?
answer

Changes in vital signs.
question

A nurse is developing a plan of care for a pospartum client with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours after delivery?
answer

Prepare an ice pack for application to the area.
question

A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which of the following instructions would be included on the list?
answer

* Wear a supportive bra. * Rest during the acute phase. * Maintain a fluid intake of at least 3000mL. * Continue to breast-feed if the breasts are not too sore.
question

A nurse in a delivery room is assisting with the delivery of a newborn. After delivery, the nurse prepares to prevent heat loss in the newborn resulting fro evaporation by:
answer

Drying the infant with a warm blanket.
question

The mother of a newborn calls a clinic & reports to a nurse that when cleaning the umbilical cord, the mother noticed that the cord was moist & that discharge was present. The appropriate nursing instruction to the mother is which of the following?
answer

Bring the infant to the clinic. *(Infection)
question

A nurse in a newborn nursery receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 & 4. In planning for admission of this newborn, the nurse’s highest priority should be to:
answer

Connect the resuscitation bag to the oxygen outlet.
question

A nurse is assessing a newborn infant after circumcision & notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions is appropriate?
answer

Document the findings.
question

A nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment signs noted in the newborn would alert the nurse to the possibility of this syndrome?
answer

Tachypnea & retractions
question

A postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse provides which appropriate instruction to he mother?
answer

Continue to breast-feed every 2 to 4 hours.
question

A nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn?
answer

Incessant crying.
question

A nurse notes hypotonia, irritability, & a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome & is aware that which additional sign would be consistent with fetal alcohol syndrome.
answer

Abnormal palmar creases.
question

A nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care?
answer

Monitor he newborn’s response to feedings & weight gain pattern.
question

A nurse administers erythromycin ointment (0.5%) to the eyes of a newborn & the mother asks the nurse why this is performed. The nurse explains to the mother that this is routinely done to:
answer

Prevent opthalmia neonatum from occurring after delivery in a newborn with an untreated gonococcal infections.
question

A nurse prepares to administer a vitamin K injection to a newborn, & the mother asks the nurse why her infant needs the injection. The best response by the nurse would be:
answer

“Newborns are deficient in vitamin K, & the injection prevents your newborn from bleeding.”
question

A nurse develops a plan of care for a woman with HIV infection & her newborn. The nurse includes which intervention in the plan of care?
answer

Maintaining standard precautions at all times while caring for the newborn.
question

A nurse is planning care for a newborn of a diabetic mother. A priority nursing diagnosis for this infant is:
answer

Risk for Injury related to low blood glucose levels.
question

The nurse determines that a new mother understands the teaching about prevention of newborn abduction is she states:
answer

“I will ask the nurse to attend to my infant if I am napping & my husband is not here.”
question

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate?
answer

* Monitor skin temperature closely. * Reposition the newborn every 2 hours. * Cover the newborn’s eyes with eye shields or patches.
question

A nurse is caring for a client who is receiving oxytocin (Pitocin) to induce labor. The nurse discontinues the oxytocin infusion if which of the following is noted on assessment of the client?
answer

Uterine hyperstimulation *V *C E H A O L P
question

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines that e client is experiencing toxicity from the medication if which of the following is noted on assessment?
answer

Respiration’s of 10 breaths/min
question

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which condition is documented in the client’s medical history?
answer

Peripheral vascular disease *(can cause a blood clot)
question

A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. The instructor determines that the student needs to research this procedure further if the student states that:
answer

“I will flush the eyes after instilling the ointment.”
question

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate & contractions have stopped. If the client’s labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be prescribed?
answer

Betamethasone
question

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, the priority nursing assessment is to check the:
answer

Blood pressure
question

A nurse is preparing to administer beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which of the following routes?
answer

Intratracheal
question

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs?
answer

Naloxone (Narcan)
question

Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following?
answer

Being affected by Rh incompatibility.
question

A nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse monitors for which adverse reactions of this medication?
answer

* Flushing * Depressed respiration’s *Extreme muscle weakness

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