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Maternity all 55
Terms in this set (55)
1. Pregnant patient, with contractions that are 5 min apart, goes to the bathroom and you hear a baby crying. What is the best action for the nurse to do?
hit the call light to call for help
2. Post partal patient has a spinal headache 24 hours after delivery. Prior to anesthesiologist's arrival what action is best for the nurse to perform?
have equipment at bedside
3. Patient 20 weeks gestation has HPV. What is the best information for the nurse to provide?
treatment is available but limited due to pregnancy
4. One hour after delivery the nurse is unable to palpate the fundus. Large amount of lochia on pad. Massage umbilicus and get vitals. What intervention does the nurse implement next?
palpate for bladder distention
5. Infant with cephalatoma. What action should the nurse do next?
assess for jaundice q 8 hours
6. Math problem - Pitocin 4 mU/min. 1000 mL/2 mU. mL/hr
7. Patient receiving Pitocin is experiencing tetanic contractions with variable FHR. What action should the nurse implement?
- turn off the Pitocin drip
8. Patient scheduled for cesarean for 0600 tells the nurse that she drank some coffee at 0400 to avoid getting a headache. What action does the nurse take next?
tell the anesthesiologist
9. After delivery of a 10 pound baby 2 hours ago, the fundus is above and to the right of the umbilicus. She voids 250 mL in a bed pan, Action to implement?
palpate suprapubic region for distention
10. 33 weeks gestation. Moderate bleeding. No contractions. What intervention to implement?
11. Primipara 42 weeks gestation. Pitocin started then stopped. O2 applied. Contractions 5 minutes apart for 20 seconds. Intervention to implement?
restart Pitocin per protocol
12. Patient with continuous fetal monitoring notices FHR fall and rise abruptly with "v" shaped pattern. Nurse action to take first?
change position of patient
13. 28 weeks gestation with twins. Fundal height 27 cm. fundal height measured 28 cm 3 weeks ago. What does the nurse conclude from this?
may indicate IUGR
14. Patient received prostaglandin gel vaginally to induce labor. 30 minutes after insertion of gel, patient complains of vaginal warmth. What action should nurse implement first?
turn patient to a side lying position
15. Parents tell nurse that baby is trying to walk. Nurse's response?
explain it is a normal stepping reflex
16. Patient delivered baby 24 hours ago and complains of urinating every hour or so. She asks the nurse "is that ok?" Nurse's action?
measure next voiding
17. Magnesium sulfate infusion begins. Patient develops slurred speech and decreased reflexes. What nurse action to implement?
stop the infusion
18. After breastfeeding for 10 minutes on each breast, baby spits up. Action to implement first?
Turn baby to the side and suction
19. 35 weeks gestation. Breech baby. Contractions 3-5 minutes apart and mom states "I think my water just broke". Inspection reveals umbilical cord protruding. Intervention to implement?
place patient in the knee-chest position
20. Extrauterine transition
cries vigorously when stimulated
21. 3 day old baby. Feeds every 2 hours. Nurse notes white curd patches on oral mucus membranes. Action to implement?
22. 38 weeks gestation with a history of PIH. Pitocin started. 1 hour after Pitocin, patients gets a headache. Contractions are 1-2 minutes apart lasting 60-75 seconds. Intervention most important?
discontinue the Pitocin
23. After delivery patient asks the nurse when she can leave to go home. Information most important to provide? -
when bleeding stops
24. Mother who is lactoovovegetarian plans to breastfeed. Information to provide before discharge?
continue taking prenatal vitamins
Teaching how to perform kick counts. Instruction to include?
- 10 kicks not felt, drink orange juice and count again
26. 40 weeks gestation and spontaneous rupture of membranes that is meconium stained. What additional finding should the nurse report?
- FHR 100-110
27. Patient with gestational diabetes has an amniocentesis. Why is the amniocentesis being performed?
fetal lung maturity
28. Jehovah's Witness patient hemorrhaging is in the ICU. Nurse action to take?
clarify the wishes of the client
29. Patient breastfeeding
decrease need for insulin
30. Newborn receiving positive pressure intubation after delivery. Which assessment finding should nurse initiate chest compressions?
31. 30 year old primigravida delivers 9 pound vaginally after 30 hour labor. Priority nursing action?
observe for signs of hemorrhage
32. Magnesium Sulfate in D5W 500 mL. 20 g Mag Sulfate at 1 g/hr. How many mL/hr?
33. 32 weeks gestations with possible UTI. Action to implement?
collect urine for culture
34. 38 weeks gestation, tachycardia, tremulous, hypertensive. Assessment action most important?
obtain a drug screen
35. Patient requests an epidural for pain control. Action to implement first?
check cervical dilation
36. Patient presents with bright red blood, rigid abdomen and in pain. Nurse suspects possibility?
37. Large for gestational age infant. Action to implement first? -
obtain blood glucose
After delivery patient presents with profuse hemorrhage. Action to implement?
check maternal blood pressure
39. Discussing involution. Patient understands effect of breastfeeding when states?
period may be delayed
40. Baby born with congenital heart defect. Which assessment finding warrants immediate intervention? -
bluish tinge to tongue
41. Mom is Rh- suffers abdominal trauma in a motor vehicle accident. Which assessment finding is most important to report to the healthcare provider?
positive fetal hemoglobin
42. Which hormone is responsible for positive pregnancy test? -
43. Doctor hands baby to nurse immediately after delivery. Which action is most important to implement?
place under warmer
44. Education most important for nurse to implement to teenage pregnant patient?
iron deficiency anemia
45. Nurse identifies localized swelling that does not cross the suture line of parietal bone. Action to implement?
notify pediatrician of cephalhematoma
46. Action to implement before administering Hep B vaccine?
get consent signed
47. Beractant given for RDS in preemie. Assessment finding indicates condition is improving? -
urinary output increased
48. 34 weeks gestation. Bimonthly visit. Assessment finding important to report to health care provider?
weight gain 7 pounds
49. Primigravida asks nurse about exercise during pregnancy. What recommendation?
50. Cyanotic 3 hour old infant temperature 96.5, 40 breaths/min, 165 beats/minute. Intervention best to implement?
gradually warm under heat source
51. Patient comes in stating that she is in labor. Which finding confirms not in labor?
contractions decrease when walks
52. Multigravida asks for more pain meds. Just received pain meds, Stadol 2 mg, 30 minutes ago. Action to implement?
instruct to deep breathe
53. Postpartum patient complains of severe pain and feeling pressure in perineal area. Nurse finds hematoma beginning to form. Which assessment finding should nurse obtain first?
blood pressure and heart rate
54. Patient complains of morning sickness. Nurse recommends?
55. 3 day postpartum patient. Husband calls states wife is crying, irritable. Inform the husband?
contact the clinic in 2 weeks if symptoms become worse
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