Maternity & Pediatric HESI Practice

1. The nurse is providing care for a newborn who was delivered vaginally assisted by forceps.

The nurseobserves 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. Microcephaly

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

4. 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

5. The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor which maternity prescription 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

C. Terbutaline 0.25 mg subcutaneously q 15 minutes X 3

D. Butorphanol tartrate 1mg IV push q2h PRN.

B. Betamethasone 12 mg deep IM

6. 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

7. 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

8. If primigravida at 36 weeks gestation who is RH negative experienced abdominal trauma ina 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

B. Mild contractions every 10 minutes.

9. In 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

10. 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.

A. Continue prenatal vitamins with B12 While breastfeeding

11. 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

12. 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

13. *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

14. 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

15. 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

16. A 3-hour old male infants' hands and feet are 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 heartrate 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.

17. A newborn nursery protocol includes a prescription for ophthalmic erythromycin 5%ointment to both eyes upon a newborn 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

18. 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

19. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pounds 10 ounces 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

20. A newborn assessment reveals spina bifida. 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

21. 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. Dose/Available stock x Quantity

(4mu/20,000 mu) x1000 ml=0.2 ml x 60 min = 12 ml

A client who delivered a healthy newborn an hour ago asked the nurse when can she go

home. Whichinformation 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 carefor 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.

24. 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.

25. 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.

A Multipara with contractions occurring every three minutes.

26. The nurse is preparing to administer phytonadione to a newborn. Which statement makes

made bythe parents indicates understanding why the nurse is administering this medication.

A Improve insufficient dietary intake.

B. Stimulates the immune system

C. Help an immature liver.

D. Prevent hemorrhagic disorders.

D. Prevent hemorrhagic disorders.

27. The nurse is planning discharge teaching for four mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

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

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

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

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

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

28. 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.

29. 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.

A. Assessment for congenital anomalies.

B. Recalculation of gestational age.

C. Evaluation of fetal growth.

D. Determination of fetal presentation.

C. Evaluation of fetal growth.

30. A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7pounds infant 4 hours ago by cesarean delivery. Which nursing problem has the highest priority?

A Risk for injury related to uterine atony.

B. Ineffective breastfeeding related to fatigue.

C. Acute pain related to abdominal incision.

D. Impaired parenting related to inexperience

D. Impaired parenting related to inexperience

31. Examination reveals that the laboring clients cervix is dilated to 2 centimeters, 70% effaced with the presenting part at -2 station the client tells the nurse I need my epidural now, this hurts, the nurses response to the client is based on which information?

A The client will need to be catheterized before the epidural can be administered.

B. Administering an epidural at this point would slow down labor process.

C. The client should be dilated to at least 8 centimeters before receiving an epidural.

D. The baby needs to be at a zero station before an epidural can be administered.

A. The client will need to be catheterized before the epidural can be administered.

32. The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right she tells the nurse, "Now my daughter is not getting enough to eat" which response would be best for the nurse to make.

A Feed your baby hourly until you feel confident that your child is receiving enough milk.

B. Don't worry soon your milk will come in and you will feel how full your breasts are.

C. Since you are so concerned you should probably supplement breastfeeding with formula.

D. If your baby's urine is straw colored, she's getting enough milk.

D. If your baby's urine is straw colored, she's getting enough milk.

33. A client in the first trimester of pregnancy calls the prenatal clinic to report she's nauseated, and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? select all that applies.

A Come to the clinic today.

B. Drink a full glass of tea with each iron tablet.

C. Increase the consumption of milk while taking iron.

D. Changes in color and consistency of stool are normal.

E. Take iron supplement at bedtime.

D. Changes in color and consistency of stool are normal

34. A primiparous woman presents in labor with the following labs. hemoglobin 10.9 g/dl (109g/dl) Hematocrit 29% (0.29) hepatitis surface antigen positive, Group B Streptococcus positive and rubella non-immune. which intervention should the

nurse implement?

A Transfuse 2 units packs red blood cells.

B. Give measles mumps rubella vaccine 0.5 ML.

C. Administer ampicillin 2 grams intravenously.

D. Inject hepatitis B immune globulin 0.5 milliliters.

C. Administer ampicillin 2 grams intravenously.

35. A mother spontaneously delivers a newborn infant in the taxicab while on the way to the hospital the emergency room nurse reported the mother as active herpes (H5V III) lesions on the vulva. Which intervention should the nurse implement first

when admitting the neonate to the nursery?

A Documents the temperature on the flow sheet.

B. Place the newborn in the isolation area of the nursery.

C. Obtain blood specimen for serum glucose level.

D. Administer the vitamin K injection

B. Place the newborn in the isolation area of the nursery

36. The health care provider prescribes 10 units per liters of oxytocin via IV drip to augment a client's labor because she's experiencing a prolonged active phase.

Which finding would cause the nurse to immediately discontinue the oxytocin?

A Contraction duration of 100 seconds.

B. For contractions in 10 minutes.

C. Uterus is soft.

D. early deceleration of fetal heart rate.

A. Contraction duration of 100 seconds.

37. A client who is 24 weeks gestation arrives to the clinic reporting swollen hands. On examination the nurse notes the clients as had a rapid weight gain over six weeks. which action should a nurse implements next?

A Review previous blood pressures in the chart.

B. Obtain the clients blood pressure.

C. Observe and time the client's contractions. Examined the client for pedal edema.

D. examine the client for pedal edema

B. Obtain the clients blood pressure.

39. A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first?

A. increase the intravenous fluid to 150ML/hr.

B. Call the health care provider.

C. Encourage the client to void.

D. Administer ibuprofen 800 milligrams by mouth.

B. Call the health care provider.

40. The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of eight pounds 3629 grams at 36 weeks gestation. This

amniocentesis is being performed to obtain which information?

A. Presence of a neural tube defect.

B. Chromosomal abnormalities.

C. Gender of the fetus.

D. Fetal lung maturity

D. Fetal lung maturity

41. A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the

fetal heart rate is 140beats per minute and contraction occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor

at this time.

A. Membranes are intact.

B. 2+ pitting edema in lower extremities.

C. Contractions decrease with walking.

D. Cervical dilation is 1 centimeter

C. Contractions decrease with walking.

42. A newborn assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

A. Tobacco use.

B. Folic acid deficiency.

C. Short interval pregnancy.

C Preeclampsia.

B. Folic acid deficiency.

43. A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the health

care provider.

A. A pattern of fetal late decelerations.

B. Fetal heart rate accelerations with fetal movement.

C. Absence of uterine contractions within 20 minutes.

D. Spontaneous rupture of membranes.

D. Spontaneous rupture of membranes.

44. A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take.

A. Assess bowel sounds.

B. Continue to monitor.

C. Assist with intubation.

D. Rub the infant's back.

B. Continue to monitor.

45. client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant?

A. Morning sickness.

B. Breast tenderness

C. Amenorrhea.

D. Hegar's sign.

D. Hegar's sign.

46. A newborns head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches(33 centimeters). The nurse notes that this infant has no molding, and it was a bridge presentation delivered by cesarean section. What action should the nurse take

based on this data?

A. No action needs to be taken, it is normal for an infant born by caesarean section to have

a smallhead circumference.

B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.

C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.

D. Record the findings on the chart. They are within normal limits.

C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.

47. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a

30-hourlabor. What is priority nursing action for this client?

A. Assess the blood pressure for hypertension.

B. Gently massage fundus every four hours.

C. Observe for signs of uterine hemorrhage.

D. Encourage direct contacts with the infant.

C. Observe for signs of uterine hemorrhage.

48. A client with 26 weeks gestation was informed this morning that she has an elevated alpha fetal protein (AFP) level. After the health care provider leaves the room, the client asks what she should do next. What information should the nurse provide?

A. Reassured the client that the AFP results are likely to be a false reading.

B. Explain that his sonogram should be scheduled for definitive results.

C. Inform her that a repeat alpha fetoprotein AFP should be evaluated.

D. Discuss options for intrauterine surgical correction of congenital defects.

B. Explain that his sonogram should be scheduled for definitive results.

49.A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. which assessment finding warrants immediate intervention by the nurse?

A. Dizziness while standing

B. Sinus tachycardia

C. Lower Back pain

D. Absent Patellar reflexes.

D. Absent Patellar reflexes.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?

Breastfeed the infant, ensuring that both breasts are completely emptied.

An insulin-dependent client with gestational diabetes mellitus is in the second stage of labor. What supplies will the delivery nurse gather for care of the newborn? (Select all that apply.)

Erythromycin ointment

Scale

Measuring tape

Blood glucose testing kit

A client is admitted to the hospital at 28 weeks of gestation in preterm labor. The nurse administers three doses of terbutaline sulfate, 0.25 mg subcutaneously. Which side effects will the nurse anticipate for this client? (Select all that apply.)

Feeling of nervousness

Tachycardia

Restlessness

The nurse is interviewing a newly pregnancy client who is 16-years old. Which client statement indicates teaching is necessary for a safe pregnancy? (Select all that apply.)

"I hate milk."

"I only want to gain 10 pounds."

"I refuse to wear maternity clothes."

The nurse is preparing to administer an IV pain medication to a client in labor. What will the nurse include in this client's plan of care related to the administration of the medication? (Select all that apply.)

Administer the medication only when the client is having a contraction.

Assess the fetal heart rate (FHR) for 10 minutes prior to administering the pain medication.

The nurse is providing care to a laboring client with a GTPAL of 75015. The client reports contractions every 2 to 8 minutes, of moderate intensity, for the past 6 hours. Her cervical exam upon admission is 4/0/75%, and membranes are intact. In the next 20 minutes, what supplies will the nurse gather for this client? (Select all that apply.)

Amnihook

1000 mL of D5LR

Oxytocin

The nurse is providing care to a postpartum client with O negative blood who is antibody positive. The newborn is O negative. What is the best nursing action for this client?

Ask the mother if she desires any more children.

The nurse is preparing a newborn for discharge. There is an order for a hepatitis B vaccination prior to discharge. When planning to administer the vaccination, what information must the nurse obtain from the infants chart?

Site of the vitamin K injection

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take next?

Have the client breathe into her cupped hands.

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?

Two weeks before menstruation

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan?

Place petroleum ointment around the glans with each diaper change and cleansing.

The clinic nurse takes a phone call from a client who reports she is at 12 weeks gestation. Which statements indicate to the nurse the client may be having a spontaneous abortion? (Select all that apply.)

"I am having severe abdominal cramping."

"I am passing blood clots from my vagina."

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. What will the nurse document in the client's chart regarding her GTPAL?

20010

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. What is the nurse's best action?

Asking the client and her partner if they would like the nurse to stay in the room

What specific instructions will the nurse include in the pregnancy client's teaching plan who is also human immunodeficiency virus (HIV) positive? (Select all that apply.)

Use condoms when having sex.

Zidovudine prescription helps decrease risk of fetal exposure

Breastfeeding is not recommended.

A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. What is the next nursing action?

Increase the rate of the oxytocin infusion.

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth?

November 22

A client at 39 weeks gestation overhears her health care provider say to the nurse, "Her Bishop score is 10." The client asks the nurse, "What does that mean?" What is the nurse's best response?

"Your cervix is ready for labor."

The clinic nurse is reviewing signs of pre-term labor with a client at 28 weeks gestation. Which client statements indicate to the nurse further teaching is necessary? (Select all that apply.)

"I expect the discharge from my vagina will change from thick to brown over the next two weeks."

"The baby's movements will decrease and be almost still from here on out."

"I should expect low back pain and diarrhea as the baby grows."

When a new mother receives her infant for the first time, which behavior is most reassuring to the nurse?

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

A client presents to the emergency department with complaints of severe lower left abdominal pain and vaginal spotting. Her last menstrual period was 5 weeks ago. What are the nurse's next actions? (Select all that apply.)

Check the results of the HCG test.

Ask the client to describe the color of the vaginal bleeding.

Ask the client if she has ever been diagnosed with pelvic inflammatory disease.

Draw the client's blood for a type and cross match.

The nurse is providing care to a primipara's whose most recent cervical exam at 0700 was 6/+1/100. Assuming an expected progression of labor, approximately what time will the client enter into the second stage of labor?

1100

The nurse is teaching a group of teen girls about their reproductive system and pregnancy. What risk factors for an unplanned pregnancy will the nurse include in the teaching plan for these girls? (Select all that apply.)

Poverty

Family problems

Early onset of menarche

Sexual exploration

Group think

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?

Encourage the mother to stop feeding for a few minutes and comfort the infant.

The nurse is providing care to a laboring client at term. Which client statement indicates to the nurse that the client is entering stage two of labor?

"I feel like I have to push down."

The clinic nurse is reviewing phone messages left from postpartum clients during the lunch break. Which calls will the nurse return before the others? (Select all that apply.)

The mother who reports her vaginal discharge went from brown to bright red.

The mother who reports her vaginal flow smells "like a chicken farm."

The breast-feeding mother who reports redness and a painful right breast.

A newly pregnant client is crying loudly and reports to the clinic nurse over the phone that she took a prescribed narcotic pain medication 4 weeks ago. What is the nurse's next response?

"When did your last period begin?"

During stage two of labor, what assessments must the labor nurse perform? (Select all that apply.)

Fetal heart rate before the contraction

Fetal heart rate during the contraction

Fetal heart rate after the contraction

Frequency of contractions

Duration of contractions

Uterine tone between contractions

A primigravida at term presents to the labor and delivery unit smiling and states to the nurse, "I am in labor." The nurse assesses the client's cervical dilation and finds it is 2/50%/-1. The fetal heart rate is stable at 135 to 145 beats/min, and membranes are intact. Maternal vital signs are stable. What are the nursing actions for this phase/stage of labor? (Select all that apply.)

Encourage the mother to ambulate.

Have the mother use slow, deep breathing with contractions.

Encourage the mother to urinate every 1 to 2 hours.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. The head is really funny looking." Which response by the nurse is best?

"That is normal. The head will return to a round shape within 7 to 10 days."

The nurse is providing care to a 1-hour-old neonate born to mother who took insulin throughout her pregnancy. Which conditions will the nurse include in the infant's assessment throughout its hospitalization? (Select all that apply.)

Hypoglycemia

Respiratory distress syndrome

Congenital anomalies

A mother who is breastfeeding her baby receives instructions from the nurse. Which instructions are most effective in preventing nipple soreness? (Select all that apply.)

Massage a small amount of medical-grade lanolin into the nipple.

Ensure that the baby is positioned correctly for latching on.

The clinic nurse is performing a fundal height assessment on a client in her third trimester. The client states to the nurse, "I am feeling very dizzy when you are pressing on my belly." What are the nurse's best actions to this comment? (Select all that apply.)

Turn the client to her left side.

State, "That is from your baby pressing down on your blood vessels."

The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted client. The order reads, place 30 units of oxytocin in 500 mL of normal saline and start at 1 mL/hour. Increase by 1 mL every 30 minutes until contractions are every 3 to 4 minutes. Oxytoxin is packaged in a glass vial that reads, 1 mL contains 10 units. What supplies will the nurse need to gather to start the infusion? (Select all that apply.)

Three vials of oxytocin

Alcohol wipe

IV start kit

One or three mL syringe

The health care provider states to the nurse, the baby is in a left occiput anterior (LOA) position. The laboring client asks, "What does that mean?" What descriptions will the nurse use when teaching the client about the LOA fetal position? (Select all that apply.)

"The baby's head is in your pelvis."

"That is the ideal fetal birthing position."

"The baby is looking down towards the floor"

The nurse is teaching a prenatal class about the structure of the pelvis and is using a model of a pelvis in the presentation. Which statements will the nurse include in the teaching plan? (Select all that apply.)

"The baby has to pass through the true pelvis."

"The pelvis consists of three distinct features."

"The true pelvis is below the pelvic brim."

"The ischial spines determine how low the baby is located."

The nurse is providing care to a 1-hour-old infant. An assessment of gestational age is performed and the nurse estimates the age at 39 to 40 weeks. What findings will the nurse document in the infant's chart? (Select all that apply.)

Vernix in the creases of the neck

Labia majora covers the labia minora.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?

Take your blood pressure now, and if it is seriously elevated, go to the hospital.

A client in early labor is requesting pain medication. The health care provider prescribes butorphanol 0.5 mg IV × 1 now. The only butorphanol available is in a concentration of 2 mg/mL. How many mL will the nurse deliver to the client?

0.25

A client at term presents to labor and delivery in spontaneous labor; contractions are occurring every 3 to 4 minutes and they are 60 seconds in duration. The client states to the nurse, "I think I have a break out of my genital herpes." What actions will the nurse take next? (Select all that apply.)

Observe the client's perineum.

Contact the health care provider.

Assess ongoing acyclovir treatment.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV infected. Which explanation should the nurse provide?

HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.

The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur?

January 29 to 30

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take next?

Continue to monitor labor progress.

The postpartum client is preparing for discharge. She states to the nurse, "I have not had a bowel movement yet." What are the nurse's recommendations for this client? (Select all that apply.)

"Drink no less than 5, 8-ounce glasses of water or non-caffeine beverages per day."

"Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and pears."

"Since it is nice outside, take a 15-minute walk two to three times a day."

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? (Select all that apply.)

Gonorrhea

Chlamydia

The nurse is teaching the pregnant client about fetal growth and development. Which client statements indicate understanding of the teaching? (Select all that apply.)

My baby gets oxygen through the placenta.

The amniotic fluid helps with muscle development.

My baby will gain about a half a pound per week after 36 weeks.

The nurse is providing care for a laboring client with a GTPAL of 65005 at term. Which assessments will the nurse include in this client's plan of care for after delivery? (Select all that apply.)

Fundal assessment should be made every 5 minutes for 30 minutes after delivery of the placenta.

Assess for lochia every 5 minutes for 30 minutes after delivery of the placenta.

Place the infant to breast immediately after delivery

The clinic nurse is providing care to a client at 28 weeks gestation. The client asks, "What does my baby look like now?" How will the nurse respond? (Select all that apply.)

"Your baby weighs about 2.5 pounds."

"The baby's arms are bent at the elbows."

"Your baby can open and close its eyes now."

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation?

Vernix is a white cheesy substance, predominantly located in the skin folds.

The nurse is providing care to a client who just delivered her sixth term infant. In addition to routine postpartum care, what additional priority nursing action will the nurse include in this client's plan of care?

Weigh the peri pads before and after placement to the peri area.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?

Skin color that is slightly jaundiced