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A nurse is caring for an adolescent client who is gravida 1 and para 0, the client was admitted to the hospital at 38 weeks of gestation, with a diagnosis of preeclampsia. Which of the following finding should the nurse identify as inconsistent with preeclampia?
Deep tendon reflex of +1
A nurse is in a prenatal clinic caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this patient?
Excessive uterine enlargement.
A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neuro tube defect, which of the following information should the nurse include in teaching?
Consume foods fortifed with folic acid.
A nurse is caring for a client who is in the first stage of labor. The nurse observed the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
Insert a gloved hand into the vagina to relieve pressure on the cord.
A nursing is caring for a client who is in post partum and received methylergonovine. Which of the following findings indicates that the medication was effective?
fundus firm to palpation
A nurse is preparing to assist a newborn who is post mature. Which of the following findings should the nurse expect? (Select all that apply)
Cracked peeling skin
Positive Moro reflex
A nurse is caring for a client who is considering several methods of contraceptives. Which of the following methods of contraception should the nurse identify as being the most reliable?
A nurse is in the hospital caring for a client who is 38 weeks of gestations and has a large amount of painless, bright red vaginal bleeding. The patient is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are BP: 98/52, HR 118/min, RR 24, Temp 36.4 ( 97.6F) which of the following is the priority nursing action?
Initiate IV access
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho ( D-immunoglobulin) Which of the following should be included in the teaching?
It prevents the formation of RH antibodies in mothers who are RH negative.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of one minute and frequency of three minutes. The nurse obtains the following vital signs: FHR 130/min, Maternal HR 128/min, Maternal BP 92/54. Which of the following is a priority action for the nurse to take?
Position the client with one hip elevated.
A nurse is caring for new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse?
"This occurs because newborns lack muscle control to regulate eye movement"
A nurse is caring for a client prima gravida, at term, and having contractions but is stating that she is not really sure if she is in labor or not. Which of the following should the nurse recognize as a sign of true labor?
Changes in cervix.
A nurse is caring for a client who is having a non-stress test performed. The FHR is 130 to 150/min, but there has been no fetal movement for 15 minutes. Which of the following actions should the nurse perform?
Offer the client a snack of orange juice and crackers.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?
A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse?
"Ambivalent feelings are quite common for women early in pregnancy.
A nurse is caring for a client who is 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age. Which of the following interventions should be included in the newborn's plan of care?
Observe for meconium in respiratory secretions.
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dialation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
Vaginal intercourse can be resumed after 2 weeks.
A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?
"Daily jogging for up to 30 minutes is fine throughout the pregnancy"
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?
The client requires a rubella immunization following delivery.
A nurse is leading a discussion about contraception with a group of 14 year old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?
"Before I can help you, I need to know more about your sexual activity".
A nurse is caring for a client who is 39 weeks of gestation and is in active labor. The nurse locates the FHR tones above the client's umbilical at midline. The nurse should suspect that the fetus is in which of the following positions?
A nurse is caring for a client who is breastfeeding and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest?
Reduce her intake of iron
A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?
Dry, cracked skin
A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions?
A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote newborn to latch?
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
A client who is experiencing preterm labor at 26 weeks of gestation.
What is the reccomended weight gain for pregnancy
A nurse is providing teaching about Kegel exercise to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?
"These exercises help pelvic muscles to stretch during birth."
A nurse is caring for a client who is 2 days postpartum, is breastfeeding and reports nipple soreness. Which of the following interventions should be taught to the client during breastfeeding?
Apply breast milk to the nipple before each feeding.
Start breastfeeding with the nipple that is less sore.
Change the infant's position on the nipple.
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring and receiving IV fluids. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this findings?
Variable decelerations are due to umbilical cord compression.
A nurse is caring for a client who experience a vaginal delivery 12 hours ago. When palpating the client's abdomen, at which the following positions should the nurse expect to find the uterine fundus?
At the level of the umbilicus.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this critical finding?
The lowermost portion of the fetus is at the level of the ischial spines.
A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be provided in the teaching?
"You will need to double your intake of iron during pregnancy."
A nurse is teaching about breast engorgement. Which of the following client statements means she understands the teachings?
"I will feed my baby every 2 hours"
A nurse is caring for a client who is pregnant. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?
"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."
A nurse is in the emergency department and is admitting a client who is at 40 weeks of gestation,
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