OB HESI Exam Preparation: Essential Nursing Care and Definitions

A primipara has delivered a stillborn fetus at 30-weeks gestation. To assist the parents with the

grieving process, which intervention is most important for the nurse to implement?

a. Provide an opportunity for the parents to hold their infant in privacy.

b. Assist the couple in completing a request for autopsy.

c. Encourage the couple to seek family counseling within the next few weeks.

d. Explain the possible causes of fetal demise.

a. Provide an opportunity for the parents to hold their infant in privacy.

What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?

a. Body temperature.

b. Level of pain.

c. Time of first void.

d. Number of vessels in the cord.

a. Body temperature.

What is the most important assessment for the nurse to conduct following the administration of

epidural anesthesia to a client who is at 40-weeks gestation?

a. Maternal blood pressure.

b. Level of pain sensation

c. Station of presenting part.

d. Variability of fetal heart rate.

a. Maternal blood pressure.

34-week primigravida woman with preeclampsia is receiving Lactated Ringer's 500ml with

magnesium sulfate 20 grams at the rate of 3g/hr. How many ml/hr should the nurse program the

infusion pump? (Enter numeric value only.)

75ml/hr

A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is

more important for the nurse to implement?

a. Graph the daily weight for the past week.

FIF

b. Decrease IV flow rate.

c. Assess bilateral lung sounds.

d. Restrict intake of oral fluids.

c. Assess bilateral lung sounds.

A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse,

"Why is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all

that apply.)

a. Explain that newborns get milk from their mothers in this way.

b. Reassure the older brother that is does not hurt his mother.

c. Remind him that his mother breastfed him too.

d. Suggest that the baby can also drink from a bottle.

e. Clarify the breastfeeding is his mother's choice.

a. Explain that newborns get milk from their mothers in this way.

b. Reassure the older brother that is does not hurt his mother.

c. Remind him that his mother breastfed him too.

The nurse is examining an infant for possible cryptorchidism. Which exam technique should be

used?

a. Place the infant in side-lying position to facilitate the exam.

b. Hold the penis and retract the foreskin gently.

c. Cleanse the penis with an antiseptic-soaked pad.

d. Place the infant in a warm room and use a calm approach.

d. Place the infant in a warm room and use a calm approach.

The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor.

What maternal prescription is most important in preventing this fetus from developing

respiratory syndrome?

a. Betamethasone (Celestone) 12mg deep IM.

b. Butorphanol 1mg IV push q2h PRN pain.

c. Ampicillin 1g IV push q8h.

d. Terbutaline (Brethine) 0.25mg subcutaneously q15 minutes x3.

a. Betamethasone (Celestone) 12mg deep IM.

Insulin therapy isinitiated for a 12-year-old child who is admitted with diabetic ketoacidosis

(DKA). Which action is most important for the nurse it include in the child's plan of care?

a. Monitor serum glucose for adjustment in infusion rate of regular insulin (Novolin R).

b. Determine the child's compliance schedule for subcutaneous NPH insulin (Humulin N).

c. Demonstrate to parents how to program an insulin pen for daily glucose regulation.

d. Consult with healthcare provider about use of insulin detemir (Levemir Flex Pen).

a. Monitor serum glucose for adjustment in infusion rate of regular insulin (Novolin R).

A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent

urinary retention. The home health nurse notes that the child has developed episodes of

sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for

the nurse to take?

a. Auscultate the lungs for respiratory pneumonia.

b. Change to latex-free gloves when handling infant.

c. Draw blood to analyze forstreptococcal infection.

d. Apply zinc oxide to perineum with each diaper change.

b. Change to latex-free gloves when handling infant.

The healthcare provider prescribes Amoxicillin 500mg PO every 8hrs for a child who weighs 22

pounds. The available suspension is labeled, Amoxicillin Suspension 250mg/5ml. The

recommended maximum dose is 50mg/kg/24hr. How many mlshould the nurse administer in a

single dose based on the child's weight? (Enter numerical value only. If rounding is required,

round to the whole number.)

10 ml

The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2

proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a sever

frontal headache. Which medication should the nurse anticipate for this client?

a. Clonidine hydrochloride.

b. Carbamazepine

c. Furosemide

d. Magnesium sulfate.

d. Magnesium sulfate.

A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment,

the nurse notes the client'stemperature to be 101.2 F (38.4 C), with severe abdominal or uterine

tenderness on palpation. The nurse knows that these findings are indicative of what condition?

a. Round ligamentstrain.

b. Chorioamnionitis.

c. Abruptio placenta.

d. Viral infection.

b. Chorioamnionitis.

A 4-year-old boy wasrecently diagnosed with Duchenne muscular dystrophy (DMD). Which

characteristic of the disease is most important for the nurse to focus on during the initial

teaching?

a. Lower legs become progressively weaker, causing a waddling, unsteady gait.

b. Growth and development have been abnormal since birth.

c. Muscularstrength can be regained with physical exercise and therapy.

d. Respiratory dysfunction and aspiration are prime concerns at this stage of disease.

a. Lower legs become progressively weaker, causing a waddling, unsteady gait.

A male infant with a 2-day- history of fever and diarrhea is brought to the clinic by his mother

who tells the nurse that the child refuses to drink anything. The nurse determines that the child

has a weak cry with no tears. Which prescription is more important to implement?

a. Provide a bottle of electrolyte solution.

b. Infuse normalsaline intravenously.

c. Administer an antipyretic rectally.

d. Apply external cooling blanket.

b. Infuse normalsaline intravenously.

After administering varicella vaccine to a 5-year-old child, which instruction should the nurse

provide the child's parent?

a. Chewable children's aspirin will help prevent inflammation.

b. Keep the child home from daycare for the next two days.

c. Any level of fever is serious and should be reported right away.

d. Apply a cool pack to the injection site to reduce discomfort.

d. Apply a cool pack to the injection site to reduce discomfort.

The nurse is planning care for a 4-year-old girl who is diagnosed as having a developmental

disability. What should be the primary focus of treatment for this child?

a. Teach hersocialskills.

b. Assist in preventing further disability.

c. Ensure her participation in group activities.

d. Help her achieve her maximum potential.

d. Help her achieve her maximum potential.

A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing

intervention should the nurse plan to implement?

a. Obtain the healthcare provider's advice as to when the restraintsshould be removed.

b. Remove restraints one at a time to provide range of motion exercises.

c. Record observation of the restraints q2h and ensure that they are in place at all times.

d. Remove restraints q4h for 30 minutes and place gloves on the child's hands.

b. Remove restraints one at a time to provide range of motion exercises.

A new mother calls the nurse stating that she wants to start feeding her 6-month-old child

something besides breast milk, but is concerned that the infant is too young to start eating solid

foods. How should the nurse respond?

a. Advise the mother to wait at least another month before starting any solid foods.

b. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.

c. Reassure the mother that the infant is old enough to eat iron-fortified cereal.

d. Encourage the mother to schedule a developmental assessment of the infant.

c. Reassure the mother that the infant is old enough to eat iron-fortified cereal.

A 10-year-old is admitted to the orthopedic unit with a diagnosis ofslipped femoral capital

epiphysis (SFCE). What focus should the nurse include in this child's plan of care?

a. Ambulation with a walking cast.

b. Pin and incisional care after surgery.

c. Use of injections for pain control.

d. Administration of growth hormone.

b. Pin and incisional care after surgery.

While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart

rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the

nurse take first?

a. Change the maternal position.

b. Administer oxygen at 10/l by mask.

c. Prepare for a potential cesarean.

d. Allow the client to begin pushing.

a. Change the maternal position.

A postpartum client who is Rh-negative refuses to receive RhoGAM after delivery of an infant

who is Rh-positive. Which information should the nurse provide this client?

a. RhoGAM prevents maternal antibody formation for future Rh-positive babies.

b. RhoGAM is not necessary unless all her pregnancies are Rh-positive.

c. The R-positive factor from the fetus threatens her blood cells.

d. The mother should receive RhoGAM when the baby is Rh-negative.

a. RhoGAM prevents maternal antibody formation for future Rh-positive babies.

24. The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2

ounces of orange juice. What should the nurse do next?

a. Tell the mother to follow the iron drops with infant formula instead of orange juice.

b. Suggest placing the iron drops in the orange juice and then feeding the infant.

c. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.

d. Give the mother positive feedback about the way she administered the medication.

d. Give the mother positive feedback about the way she administered the medication.

A 6-week-old infant diagnosed with pyloric stenosis hasrecently developed projectile vomiting.

Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

a. Weak cry without any tears.

b. Bulging fontanel.

c. Visible peristaltic wave.

d. Palpable mass in the right upper quadrant.

a. Weak cry without any tears.

A full term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What

should the nurse do first?

a. Suction the oral and nasal passages.

b. Give oxygen by positive pressure.

c. Stimulate the infant to cry.

d. Turn the infant onto the right side.

c. Stimulate the infant to cry.

A client at 40-weeks- gestation presents to the obstetrical floor and indicates that the amniotic

membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear

down and push. What information is most important for the nurse to obtain first?

a. Estimated amount of fluid.

b. Any odor noted when membranes ruptured.

c. Color and consistency of fluid.

d. Time the membranes ruptured.

c. Color and consistency of fluid.

An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should

the nurse implement first?

a. Place the infant in a knee-chest position.

b. Administer morphine sulfate.

c. Start intravenousfluids.

d. Provide 100% oxygen by face mask.

a. Place the infant in a knee-chest position.

A one-day-old neonate develops a cephalahematoma. The nurse should closely assess this

neonate for which common complication?

a. Jaundice.

b. Poor appetite.

c. Brain damage.

d. Hypoglycemia.

a. Jaundice.

The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital

adrenal hyperplasia. Which laboratory resultsshould be reported to the healthcare provider

immediately?

a. Bilirubin of 1.5 mg/dl.

b. Glucose of 80 mg/dl.

c. Potassium of 4.5 mEq/L.

d. Sodium of 119 mEq/L.

d. Sodium of 119 mEq/L.

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of

thyroxine (t4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation

for this finding?

a. The thyroxine level is low because the TSH level is high.

b. High thyroxine levels normally occur in breastfeeding infants.

c. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.

d. The TSH is high because of the low production of t4 by the thyroid.

d. The TSH is high because of the low production of t4 by the thyroid.

The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation.

Which assessment finding should receive the highest priority when planning the infant's care?

a. Blood pressure 76/42 mmhG.

b. Faint heart murmur.

c. Respiratory rate of 76 breaths/minute.

d. Blood glucose 45mg/gl.

c. Respiratory rate of 76 breaths/minute.

The parents of a newborn tell the nurse that their baby is already trying to walk. How should the

nurse respond?

a. Encourage the parentsto report thisto the healthcare provider.

b. Acknowledge the parents observation.

c. Schedule the newborn for further neurological testing.

d. Explain the newborn's normalstepping reflex.

d. Explain the newborn's normalstepping reflex.

During the admission procedure of a 6-year-old, the child states, "I'm going to have an

operation." Which response is best for the nurse to provide to this child?

a. "Are you scared?"

b. "We're going to do everything we can to take very good care of you."

c. "Tell me what an operation is."

d. "I'm glad your mother told you why you were coming to the hospital."

c. "Tell me what an operation is."

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is

15,000/mm3. What action should the nurse take first?

a. Check the differential, since the WBC is normal for this client.

b. Assessthe client's temperature, pulse, and respirations q4h.

c. Notify the healthcare provider, since thisfinding is indicative of infection.

d. Assess the client's perineal area forsigns of a perineal hematoma.

a. Check the differential, since the WBC is normal for this client.

The mother of a preschool-aged child calls the school nurse to report that her child was bitten by

a tick while on a school outing last week. The mother tells the nurse that she removed the tick

and flushed it down the toilet. What action should the school nurse take?

a. Refer the mother to the center for disease control.

b. Report the incident to the school principal.

c. Culture the site when the child returns to school.

d. Schedule a test for Lyme disease if rash appears.

d. Schedule a test for Lyme disease if rash appears.

37. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding

indicates to the nurse that the medication is having desired effect?

a. Weight gain.

b. Reduction of fever.

c. Improved caloric intake.

d. Reduction of edema.

d. Reduction of edema.

The nurse is conduction postpartum teaching with a mother who is breastfeeding her infant.

When discussing birth control which method should the nurse recommend to this client as best

for her to use in preventing unwanted pregnancy?

a. Breastfeed exclusively at least every 3 to 4 hours.

b. Condoms and contraceptive foam or gel.

c. Rhythm method (natural family planning).

d. Combined estrogen-progesterone oral contraceptives.

b. Condoms and contraceptive foam or gel.

A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant

with her first child and is at 32-weeks gestation. The client tells the nurse that she has been

having intermittent back pain since the night before. What is the priority nursing intervention?

a. Ask the client's mother to call an ambulance for transport to the hospital immediately.

b. Determine what physical activates the client has performed for the past 24hrs.

c. Teach the client how to perform pelvic rock exercises and observe for correct feedback.

d. Ask the client if she has experienced any recent changes in vaginal discharge.

d. Ask the client if she has experienced any recent changes in vaginal discharge.

A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above

the level of her heart. Which assessment finding should the nurse report to the healthcare

provider immediately?

a. Itching sensation under the cast.

b. Swelling of fingers with brisk capillary refill.

c. Numbness and inability to move fingers.

d. Visible bruising above the cast.

c. Numbness and inability to move fingers.

At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR)

has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action

should the nurse implement?

a. Initiate an intravenousinfusion.

b. Observe the FHR pattern for 30 more minutes.

c. Schedule a biophysical profile.

d. Place an acoustic stimulator on the abdomen.

d. Place an acoustic stimulator on the abdomen.

A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a

hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet?

a. Carrots

b. Chicken

c. Yogurt

d. Cheese

b. Chicken

43. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum

client. Based on what assessment finding should the nurse withhold the drug?

a. Respiratory rate of 22 breaths/min

b. A large amount of lochia rubra

c. Blood pressure 149/90

d. Positive Homan'ssign

c. Blood pressure 149/90

The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The

nurse includes activitiesto strengthen and mobilize the joints and surrounding muscle. Which

physical therapy regimen should the nurse encourage the adolescent to implement?

a. Begin a training program lifting weights and running

b. Splint affected joints during activity

c. Exercise in a swimming pool

d. Perform passive range of motion exercises twice daily

c. Exercise in a swimming pool

A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important

for the nurse to obtain each time the infusion rate is increased?

a. Pain level

b. Blood pressure

c. Infusion site

d. Contraction pattern

d. Contraction pattern

A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia.

What is the primary nursing consideration when supporting the parents of a child with this

anomaly?

a. Discussthe need for cortisol and aldosterone replacement therapy after discharge

b. Support the parents in their decision to assign sex of their child according to their preference

c. Offer information about ultrasonography and genotyping to determine sex assignment

d. Explain that corrective surgical procedures consistent with sex assignment can be delayed

a. Discussthe need for cortisol and aldosterone replacement therapy after discharge

A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright

red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90

beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse

implement first?

a. Alert the neonatal team and prepare for neonatal resuscitation

b. Notify the healthcare provider from the client's bedside

c. Obtain written consent for an emergency cesarean section

d. Draw a blood sample for stat hemoglobin and hematocrit

b. Notify the healthcare provider from the client's bedside

A laboring client's membranes rupture spontaneously. The nurse noticesthat the amniotic fluid

is greenish-brown. What intervention should the nurse implement first?

a. Turn the client to her left side

b. Contact the healthcare provider

c. Assess the fetal heart rate

d. Check the cervical dilation

c. Assess the fetal heart rate

A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural

for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical

dilation, 60% effacement, and a 2-station. What action should the nurse implement first?

a. Decrease the oxytocin infusion rate

b. Determine current cervical dilation

c. Request placement of the epidural

d. Give a bolus of intravenous fluids

d. Give a bolus of intravenous fluids

58. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes

that the FOC has increased 5 inches since birth and the child's head appears large in relation to

body size. Which action is most important for the nurse to take next?

a. Measure the infant's head to heel length

b. Observe the infant forsunset eyes

c. Palpate the anterior fontanel for tension and bulging

d. Plot the measurement on the infant's growth chart

c. Palpate the anterior fontanel for tension and bulging

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of

eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include

in this client's nursing care plan?

a. Keep airway equipment at the bedside.

b. Allow liberal family visitation

c. Monitor blood pressure, pulse, and respirations q4h

d. Assess temperature q1h

a. Keep airway equipment at the bedside.

The nurse is caring for a one-year-old child following surgical correction of hypospadias. The

nursing action has the highest priority?

a. Monitor urinary output

b. Auscultate bowel sounds

c. Observe appearance ofstool

d. Record percent of diet eaten

a. Monitor urinary output

Patient with Duchenne Disease. The nurse hasto explain to the mother that:

a. This condition isinherited in an X-linked recessive chromosome pattern.

Primipara patient. What is the pet to share time a, home that is not recommended?

kitty cat

The parents of a 3 year-old boy who has Duchenne muscular dystrophy (DMD) ask "how can our

son have this disease? We are wondering if we should have any more children" What

information should the nurse provide these parents?

Thisis an inherited X-linked recessive disorder, which primarily affects male children in the

family.

A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3

days and woke up this morning with a hacking cough and difficulty breathing. Which additional

assessment finding should alert the nurse that the child is in acute respiratory distress?

a. Bilateral bronchial breath sounds

b. Diaphragmatic respiration

c. A resting respiratory rate of 35 breathe per minute

d. Flaring of the nares

d. Flaring of the nares

A two year old child with a heart failure (HF) is admitted for replacement of a graft for

coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse

obtains an apical heart rate of 128 bpm. What action should the nurse implement?

a. Determine the pulse deficit

b. Administer the schedule dose

c. Calculate the safe dose range

d. Review the serum digoxin level

b. Administer the schedule dose

A client delivers a viable infant, but beginsto have excessive uncontrolled vaginal bleeding after

the IV Pitocin is infused. When notifying the healthcare provider of the condition, what

information is most important for the nurse to provide?

a. Maternal blood pressure

A new mother is having trouble breast feeding her newborn son. He is making frantic rooting

motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Ask the mother to stop feeding, confront the infant, and then assist the mother to help the

baby latch on.

A woman with mastitis

ice. pack

Belling

Change the client position before call the doctor.

A pregnant woman with hyperemesis gravidarium, what is the best nurse intervention.

Administered prescribed IV solution.

A newborn yellow abdomen and chest

Assess bilirubin level

Child HIV

Assessrespiratory system

Glomerulonephritis

- Strawberry

To confirm RDS in a newborn

- Diaphragmatic breathing

ADHD

Encourage the parents to help the baby with homework

Watery vaginal white in the

first trimester is normal.

Propanol

Decreases headache

Palirizumab (synagis)

Is given to high risk baby

1 The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse documents in the medical record?

A Caput succedaneum

B Hydrocephalus

C Cephalhematoma

D Microcephalic

C Cephalhematoma

2 A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse assessment reveals approximately 30ML of bright red vaginal bleeding.

Fetal rate of 130 - 140 beats per minute, no contractions and no complaints of pain what is the most likely cause of these client's bleeding.

A Abruptio Placenta

B Placenta Previa

C Normal bloody show indicting induction of labor

D A ruptured blood vessel in the vaginal vault.

B Placenta Previa

3 A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. which assessment warrants immediate intervention by the nurse.

A Fetal Heart rate 60 beats per minute

B Ruptured amniotic membrane

C onset of uterine contractions

D leaking amniotic fluid.

A Fetal Heart rate 60 beats per minute

A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. the nurse should recognize the clients is prohibiting symptoms of which condition?

A Genital Warts

B Syphilis

C Herpes Simplex Virus

D German Measles

C. herpes simplex virus.

The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor which maternity description is most important in preventing this fetus from developing respiratory distress syndrome.

A Ampicillin 1 gram IV push q8h

B Betamethasone 12 mg deep IM

Terbutaline 0.25 mg subcutaneously q 15 minutes X 3

Butorphanol tartrate 1mg IV push q2h PRN.

B Betamethasone 12 mg deep IM

you will pass!!!!

yes you will!!!!

A 16 year old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

A Allow liberal family visitation

B Keep an airway at the bedside

C Assess temperature every hour

D Monitor blood pressure, pulse, and respiration every 4 hours.

B Keep an airway at the bedside

At 12 hours after the birth of a healthy infant the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. which action should nurse take?

A Check the suprapubic area for distention.

B Inform the client to take a warm sitz bath

C Inspect clients perineal and rectal areas

D Apply a fresh pad and check in 1 hour.

C Inspect clients perineal and rectal areas

If primigravida at 36 weeks gestation who is RH negative experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider?

A Fetal heart rate at 162 beats /minute

B Mild contractions every 10 minutes.

C Trace of protein in the urine

D. Positive fetal hemoglobin testing

D

The Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old infant as a gestational age of 42 weeks. Based on this finding which intervention is most important for the nurse to implement.

A Provide blow by oxygen

B Provide a capillary blood glucose

C draw arterial blood gases

D Apply a pulse oximeter to the foot.

B Provide a capillary blood glucose

A new mother who is a lacto-ovo vegetarian plans to breast feed her infant. which

information should the nurse provide prior to discharge.

A Continue prenatal vitamins with B12 While breastfeeding

B Avoid using Lanolin-based nipple cream or ointment.

C Offer iron fortified supplemental formula daily.

D Weigh the baby weekly to evaluate the newborns growth.

Continue prenatal vitamins with B12 while breastfeeding

What should be the primary focus of nursing care in the transitional phase of Labor for a client who anticipates an unmedicated delivery.

A Assessing the strength of uterine contractions

B Re-evaluate the need for medication

C Remind her to push 3 times with each contraction.

D Assessing her to maintain control.

A Assessing the strength of uterine contractions

A care provider prescribes a maintenance dose of magnesium sulfate 2 grams per hour intravenously for clients with preeclampsia. The IV bag contains magnesium sulfate 20 grams how much in ml/Hr. should a nurse program the infusion pump enter numerical value only.

if the IV bag is 1000 ml the answer is 100 ml per hour

A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contraction 5 minutes apart while the client is in the bathroom changing into a hospital gown the nurse hears the noise of a baby what should the nurse take first?

A Push the call light for help

B Inspect the clients perineum

C Notify a health care provider

D Turn on the infant warmer

A Push the call light for help

The nurse is caring for a multiparous client who is 8 centimeters dilated 100% effaced and the fetal head is at 0 station. The clients is shivering and states extreme discomfort with the urge to bear down. which intervention should the nurse implement?

A Administer IV pain medication

B Perform a vaginal exam

C Reposition to side lying

D Encourage pushing with each contraction.

D Encourage pushing with each contraction.

Following a traumatic delivery an infant receives an initial Apgar score of 3. which intervention is most important for the nurse to implement.

A Page the pediatrician STAT

B Continue resuscitative efforts

C Repeat the Apgar assessment in 5 minutes

D Inform the parents of the infant's condition

B Continue resuscitative efforts

A 3-hour old male infants hands and feet as cyanotic, and has an axillary temperature of 96.5 degrees Fahrenheit 35.8 degrees centigrade a respiratory rate of 40 breaths per minute and a heart rate of 165 beats per minute what nursing action should nurse implement.

A Administer oxygen by mouth at 2L/min

B Gradually warm the infant under a radiant heat source.

C Notify the pediatrician of the infant's vital signs

D Perform a heel-stick to maintain blood glucose level

B Gradually warm the infant under a radiant heat source.

A new born nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a new born admission. What action should the nurse take to ensure adequate installation of the client.

A Instill a thin ribbon into each lower conjunctival sac

B Occlude the inner canthus after retracting the eyelids

C Mummy wrap the infant before instilling the ointment

D Stabilize the instilling hand on the neonate's head

A Instill a thin ribbon into each lower conjunctival sac

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. which action should the nurse implement first.

A Turn off the oxytocin infusion

B Assess cervical dilation

C Change the client's position

D Administer oxygen via facemask

C Change the client's position

The nurse places one hand above the symphysis while massaging the fundus of a multiparous client who's uterine tone is boggy 15 minutes after delivering a 7 pounds 10 ounces 3220 grams infant which information should the nurse try to provide the client about those finding.

A The uterus should be firm to prevent an intrauterine infection

B Both the lower uterine segment and the fundus must be massaged

C A firm uterus prevents the endometrial lining from being sloughed

D Clots may form inside a boggy uterus and needs to be expelled

B. Both the lower uterine segment and the fundus must be massaged.

A newborn assessment reveals spina bifida occulta. Which maternity factors should nurse identify as having the greatest impact on the development of this newborn complication.

A Short interval pregnancy

B Folic acid deficiency

C Preeclampsia

D Tobacco use

B Folic acid deficiency

A primigravida client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is lactated ringer's 1,000 ml with oxytocin 20 units. The nurse should program the machine to deliver how many ML per hour.

Answer: 12 ml per hour will give 4 mu per minute.

A client who delivered a healthy newborn an hour ago asked the nurse when can she go home. Which information is most important for the nurse to provide the client.

A After the baby no longer demonstrates acrocyanosis.

B After the vitamin K injection is given to the baby.

C When ambulating to avoid does not cause dizziness.

D When there is no significant vaginal bleeding.

D When there is no significant vaginal bleeding.

A 17 year old client gave birth 12 hours ago she states that she doesn't know how to care for her baby. To promote parent infant attachment behaviors which intervention should the nurse implement.

A. Ask if she has help to care for the baby at home.

B. Provide a video on newborn safety and care.

C. Explored the basis of fears with the client.

D. Encourage rooming in while in the hospital

D. Encourage rooming in while in the hospital

A pregnant client mentions in a history that she changes cats litter box daily. Which test should the nurse anticipate the health care provider to prescribe.

A Biophysical profile.

B Fern test.

C Amniocentesis.

D Torch screening.

D Torch screening.

The nurse is receiving report for a laboring client who arrived in the emergency center which ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client his admitted to the labor and delivery suite?

A Begin a pad count.

B Prepare to start an IV.

C Take the clients temperature.

D Monitor amniotic fluid for meconium

D Monitor amniotic fluid for meconium

Four client at full term present to the labor and delivery unit at the same time. which client should a nurse access first.

A Multipara with contractions occurring every three minutes.

B Multiple scheduled for non stress test and biophysical profile.

C Primipara with vaginal show and leaking membranes.

D Primipara with burning on urination and urinary frequency.

Multipara with contractions occurring every three minutes.

The nurse is preparing to administer phytonadione to a newborn. Which statement makes made by the parents indicates understanding why the nurse is administering this medication.

Improve insufficient dietary intake.

Stimulates the immune system

Help an immature liver.

Prevent hemorrhagic disorders.

Prevent hemorrhagic disorders.

The nurse is planning discharge teaching for four mothers. Which postpartum client is at

highest risk for psychological difficulties during the postpartum period?

A primiparous woman who has recently migrated to the US with a spouse.

A multiparous client who lives with her husband and his family members.

A multiparous female with a large family living in a community.

A primiparous adolescent living at home with their parents and significant other.

A primiparous woman who has recently migrated to the US with a spouse.

On the first postpartum day the nurse examines the breast of a new mother. Which

condition is the nurse most likely to find.

A Firm larger and very tender to touch.

B Slightly firm with immediate let-down response.

C Soft with no change from before delivery.

D Filling and secreting colostrum.

D Filling and secreting colostrum.

A client at 31 weeks gestation with a fundal height measurement of 25 c is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide.

Assessment for congenital anomalies.

Recalculation of gestational age.

Evaluation of fetal growth.

Determination of fetal presentation.

Evaluation of fetal growth.

A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7

pounds infant 4 hours ago by cesarean delivery. Which nursing problem has the highest priority?

Risk for injury related to uterine atony.

Ineffective breastfeeding related to fatigue.

Acute pain related to abdominal incision.

Impaired parenting related to inexperience.

Risk for injury related to uterine atony.