VATI ATI Maternal Test
1.
A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?
Epigastric pain
MY ANSWER
The nurse should notify the provider of the client's report of epigastric pain because this is a manifestation of preeclampsia. Other findings the nurse should report include severe headache, blurred vision, confusion, nausea and vomiting, and decreased urinary output.
Leukorrhea
Leukorrhea, or vaginal discharge, is an expected finding throughout pregnancy. Leukorrhea increases during pregnancy due to hypertrophy of the cervix, which increases the amount of mucus secreted from the vagina.
Excessive salivation
Ptyalism, or excessive salivation, is an expected finding in pregnancy. Increased levels of estrogen cause an increase in the production of saliva.
Darkening of the skin on the face
Hyperpigmentation on the face, or melasma, is an expected finding during pregnancy. The anterior pituitary gland increases the production of melanocyte-stimulating hormone, causing an increase in pigmentation of the skin.
2.
A nurse is assessing a newborn following a circumcision 48 hr ago. The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?
Wound infection
Infected circumcision wounds appear swollen with a purulent discharge.
Ulceration
Yellow exudate following a circumcision is not a manifestation of an ulceration.
Exposure to urine
Yellow exudate is not a manifestation resulting from the wound being exposed to urine.
Healing
MY ANSWER
After 24 hr, yellow exudate usually forms over the glans penis and remains for the next 2 to 3 days. It sometimes forms a crust, which is expected. The nurse should explain that the yellow film the guardians will see is granulation tissue as the circumcision heals. The guardians should not remove this tissue.
3.
A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain?
Encourage the client to listen to music.
During the latent phase of labor, the nurse should implement nonpharmacological strategies to encourage relaxation and provide pain relief. There are a wide variety of cutaneous and sensory measures that are simple to implement during this stage of labor, such as music, rocking, breathing techniques, walking and application of hot or cold packs.
Instruct the client how to use biofeedback.
MY ANSWER
Biofeedback can be an effective method to reduce the discomfort of labor by promoting self-awareness and relaxation. However, the client must have received instruction and practiced this technique prior to labor for it to be effective.
Administer fentanyl 100 mcg every hour via intermittent IV bolus.
Fentanyl is an opioid agonist analgesic that enhances a client's ability to rest between contractions. However, opioids can also inhibit uterine contractions and prolong labor. Therefore, avoid administration of opioid analgesia until a client reaches the active phase of labor or cervical dilation of at least 4 cm.
Request the provider administer a pudendal nerve block.
A pudendal nerve block relieves pain in the lower vagina and perineum during the second or third stage of labor. It provides anesthesia for episiotomy or repair of lacerations following birth.
- A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor?
WBC count
The nurse should monitor the WBC count for clients who have conditions such as chorioamnionitis. However, it is not necessary for the nurse to monitor this level for a client who is receiving warfarin therapy.
International normalized ratio (INR)
MY ANSWER
The nurse should monitor the INR of a client who is taking warfarin. Prothrombin time (PT) is also measured to regulate warfarin therapy. However, PT values are more difficult to interpret. INR is determined by multiplying the PT by a correction factor based on the specific thromboplastin preparation used for the test, as a way of equalizing laboratory-to-laboratory variations.
Plasminogen levels
Plasminogen is fibrinolytic and is usually elevated during pregnancy. However, it is not necessary for the nurse to monitor this level for a client who is receiving warfarin therapy.
Activated partial thromboplastin time (aPTT)
The nurse should review the aPTT if the client is receiving heparin.
5.
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?
Uric acid 7.5 mg/dL
The nurse should identify that a uric acid level of 7.5 mg/dL is above the expected reference range of 2.7 to 7.3 mg/dL for a client who is pregnant. Elevated uric acid is a manifestation of preeclampsia and is caused by decreased renal perfusion. However, an elevated uric acid level is not a contraindication for the administration of labetalol, an antihypertensive medication.
Heart rate 54/min
The nurse should identify that a heart rate of 54/min is below the expected reference range of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased blood volume and increased tissue demands for oxygen. Bradycardia is a contraindication for the administration of labetalol, an antihypertensive medication. Therefore, the nurse should withhold the medication and notify the provider.
FHR 112/min
The nurse should identify that an FHR of 112/min is within the expected reference range of 110 to 160/min. Preeclampsia can cause a decrease in placental perfusion, leading to fetal hypoxia. The nurse should closely monitor the FHR for manifestations of fetal distress. However, the nurse should not withhold labetalol, an antihypertensive medication, for this finding.
BUN 23 mg/dL
MY ANSWER
The nurse should identify that a BUN of 23 mg/dL is above the expected reference range of 10 to 20 mg/dL for a client who is pregnant. An elevated BUN is a manifestation of preeclampsia and is caused by decreased renal perfusion. However, an elevated BUN is not a contraindication for the administration of labetalol, an antihypertensive medication.
A nurse is assessing a client who is in labor. Which of the following findings should the nurse expect?
Decrease in WBC count
Physical and emotional stress can lead to an increased WBC count.
Decrease in blood glucose level
MY ANSWER
Maternal metabolism, physical exertion, and delivery of the placenta can lead to a decreased blood glucose level.
Decrease in respiratory rate
Anxiety and increased oxygen consumption from physical exertion during labor can lead to an increased respiratory rate.
Decrease in temperature
Vascular changes during labor can lead to an elevated temperature, flushed cheeks, and warm skin.
7.
A nurse is caring for a newborn immediately following birth who has meconium-stained amniotic fluid and exhibits good muscle tone and respiratory efforts. Which of the following actions should the nurse take first?
Dry the newborn.
The nurse should dry the newborn to reduce evaporative heat loss; however, another action is the priority.
Provide tactile stimulation for the newborn.
Tactile stimulation might be required to elicit crying efforts by the newborn; however, another action is the priority. Tactile stimulation prior to suctioning of the mouth and pharynx can cause meconium to enter the airways of the newborn.
Begin suctioning of mouth and nose.
MY ANSWER
The greatest risk to the newborn is injury from meconium aspiration syndrome and respiratory distress; therefore, the priority action the nurse should take is to suction the mouth and nose. The nurse should assess the newborn's condition at birth and suction the newborn's mouth and nose with a bulb syringe based on the assessment findings. If the newborn's respiratory status is depressed, endotracheal suctioning must be done as well to remove any meconium that has entered the newborn's airways.
Initiate skin-to-skin contact.
Thermoregulation is important for all newborns, especially newborns whose respiratory status might be compromised; however, another action is the priority.
8.
A nurse is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (Select all that apply.)
Hypertension
Tachycardia
Dry mucous membranes
Poor skin turgor
Polyuria
MY ANSWER
Hypertension is incorrect. Hypotension is a finding associated with hyperemesis gravidarum.
Tachycardia is correct. Hyperemesis gravidarum typically occurs during the first trimester and results in electrolyte imbalance, excessive weight loss, ketonuria, and nutritional deficiencies. Tachycardia is a finding of severe dehydration.
Dry mucous membranes is correct. Hyperemesis gravidarum typically occurs during the first trimester and results in electrolyte imbalance, excessive weight loss, ketonuria, and nutritional deficiencies. Dry mucous membranes are a finding of severe dehydration.
Poor skin turgor is correct. Hyperemesis gravidarum typically occurs during the first trimester and results in electrolyte imbalance, excessive weight loss, ketonuria, and nutritional deficiencies. Poor skin turgor is a finding of severe dehydration.
Polyuria is incorrect. Polyuria is not a finding associated with hyperemesis gravidarum.
9.
A nurse is caring for a newborn who was delivered by cesarean birth 1 min ago and displays some flexion of the extremities, is not crying, has irregular respiratory effort, and has a heart rate of 92/min. The nurse notes grimacing but no crying when rubbing the soles of the newborn's feet. The newborn's skin color is pink with blue extremities. What is the correct Apgar score?
5
MY ANSWER
Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. For respiratory effort, 0 means absent, 1 means slow or irregular, and 2 reflects a good cry. This newborn scores 1 for a weak, intermittent respiratory effort. For heart rate, 0 means absent, 1 is slow (below 100/min), and 2 means above 100/min. This newborn scores 1 for a heart rate of 92/min. For muscle tone, 0 is flaccid, 1 indicates some flexion of the extremities, and 2 is active motion. This newborn scores 1 for having some flexion of the extremities. For reflex irritability, 0 means none, 1 is a grimace, and 2 is a vigorous cry. This newborn scores 1 for grimacing with stimulation. For color, 0 is pale or blue, 1 reflects a pink body with blue extremities, and 2 means completely pink. This newborn scores 1 for being pink with blue extremities. Adding the newborn's scores of 1, 1, 1, 1, and 1, this newborn's Apgar score at 1 min is 5.
10.
A nurse is planning to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take?
Cool the newborn's heel prior to the procedure.
The nurse should warm the newborn's heel for 5 to 10 min to dilate the blood vessels before obtaining the blood sample.
Puncture the center of the newborn's heel.
The nurse should puncture either side of the outer aspect of the newborn's heel. Puncturing the center of the heel can lead to complications, such as fibrosis, or bone infection.
Cleanse the puncture site with alcohol gauze prior to the procedure.
MY ANSWER
The nurse should clean the chosen puncture site with alcohol or a facility-approved skin cleanser prior to the procedure to minimize the risk of infection.
Administer vitamin K 30 min prior to each blood draw.
Vitamin K is administered as a single intramuscular dose within 1 hr of birth to decrease the risk of newborn bleeding disorders that might occur during the first week following birth.
11.
A nurse is teaching a className to clients who are pregnant. Which of the following topics should the nurse include in the discussion about cesarean birth? (Select all that apply.)
Delay in initiating breastfeeding
Management of postpartum pain
Routine use of intubation equipment during birth
Advantage of early ambulation post-surgical procedure
The need for an indwelling urinary catheter
MY ANSWER
Delay in initiating breastfeeding is incorrect. A client who undergoes a cesarean birth with regional anesthesia can begin breastfeeding without delay, unless a problem with the newborn requires waiting. Skin-to-skin contact can be initiated during the cesarean birth if the newborn is stable.
Management of postpartum pain is correct. The nurse should discuss with clients that they will have incisional pain and also pain associated with uterine involution.
Routine use of intubation equipment during birth is incorrect. Because most cesarean births are performed after the client receives regional anesthesia, intubation is not necessary.
Advantage of early ambulation post-surgical procedure is correct. Early ambulation following a cesarean birth facilitates circulation in the lower extremities, preventing stasis, and assists with relieving gas pains.
The need for an indwelling urinary catheter during delivery is correct. The nurse should place an indwelling urinary catheter prior to the cesarean birth to keep the client's bladder empty and to avoid interference with the surgical procedure.
12.
A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report to the provider?
Transient circumoral cyanosis
Transient circumoral cyanosis is bluish discoloration around the mouth of the newborn and is an expected finding that does not require reporting to the provider.
Transient strabismus
Transient strabismus is a disorder in which the two eyes do not look in the same direction. This is an expected finding during the newborn period until 3 to 4 months of age and does not require reporting to the provider.
Caput succedaneum
Caput succedaneum is swelling of the scalp of the newborn and is an expected finding following a vaginal birth. While it is important to assess and document, it does not require reporting to the provider.
Generalized petechiae
MY ANSWER
Generalized petechiae are pinpoint round spots that appear on the skin, which can indicate a clotting factor deficiency or infection. The nurse should report this finding to the provider immediately.
13
A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?
Shrill cry
MY ANSWER
A shrill cry can be indicative of neonatal abstinence syndrome and hypocalcemia. Additional findings of neonatal abstinence syndrome include tachypnea, irritability, tremors, incessant crying, frequent sneezing, frequent yawning, excessive sweating, exaggerated Moro reflex, mottling of skin, uncoordinated sucking, incessant hunger, vomiting, and diarrhea.
Weak peripheral pulses
Weak peripheral pulses are not a finding associated with hypoglycemia.
Yellowish skin
Yellowish skin is a finding associated with hyperbilirubinemia. The nurse should assess for hyperbilirubinemia every 8 to 12 hr by pressing the sternum or forehead with a finger for several seconds and then releasing the pressure. The area will blanch and appear yellow if jaundice is present. Other areas to assess in newborns who have darker skin tones include the conjunctival sacs and the oral mucosa.
Hypotonia
CNS findings of hypoglycemia include lethargy and hypotonia, as well as jitteriness, twitching, poor feeding, temperature instability, apnea, respiratory distress, and seizures.
14.
A nurse is caring for a client who had a vaginal delivery 2 hr ago and is reporting increasing perineal pain and pressure. The nurse examines the client's perineum and sees a 4 cm (1.6 in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following?
A hematoma
MY ANSWER
A hematoma is a collection of blood in the connective tissue while the overlying skin or mucous membranes remain intact. Hematomas develop from injury to soft tissue in spontaneous deliveries, as well as forceps- and vacuum-assisted deliveries. Small hematomas usually reabsorb on their own, but large ones might require incision and ligation of bleeding vessels.
Retained placental fragments
Placental retention is trapping of part of or the entire placenta inside the uterus. The placenta is generally retrieved manually if it did not deliver intact during the third stage of labor.
A laceration
A laceration is a tear in the perineal skin or mucous membranes of the vulva or vagina. Cervical lacerations are also a possibility, but the nurse would not be able to see them on an inspection of the perineum. Lacerations generally bleed bright red blood, rather than the darker red color of lochia, and must be repaired.
Ecchymosis
Ecchymosis is a bruised area caused by bleeding from small blood vessels under the skin. A bruise will be tender to the touch, but it will not cause the increasing pain and pressure this client is reporting.
- A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of the following nonpharmacological interventions should the nurse provide to manage the client's pain?
Encourage the support person to apply sacral counterpressure.
MY ANSWER
Consistent pressure applied by the support person using the heel of the hand or fist against the client's sacral area will lift the fetal head off the spinal nerves and provide relief of the pain in the lower back.
Encourage the support person to perform effleurage.
Effleurage is the light, gentle, circular stroking of the client's abdomen with the fingertips in rhythm with breathing during contractions. This can be an effective nonpharmacological pain management intervention for the client in early labor. However, this technique will not relieve the back labor discomfort caused by the fetal head pressing on the spinal nerves.
Teach the client patterned breathing techniques.
Patterned breathing can provide distraction from the discomfort associated with labor pain and promote abdominal relaxation. However, it will not reduce back pain caused by the fetal head pressing against the spinal nerves.
16.
A nurse is performing an initial assessment during a client's first prenatal visit. The client states that her last menstrual period began April 22. Use Nägele's rule to calculate the expected date of birth (EDB). (Use the MMDD format to enter exactly four numerals, with no spaces or punctuation between the numbers.)
MMDD. 0129
MY ANSWER
The most common method of determining the estimated date of birth is to apply Nägele's rule. Begin with the first day of the client's last menstrual period, subtract 3 months, and add 7 days. For this client, subtracting 3 months from April would be January, and adding 7 days to the 22nd would be the 29th. Using the MMDD format, the EDB is 0129.
17.
A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
EXHIBIT
Instruct the client to stop breastfeeding.
Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are manifestations of endometritis, an infection of the lining of the uterus. The nurse should assist the client with bonding, including breastfeeding, during this time as the client might experience fatigue.
Obtain a vaginal culture.
MY ANSWER
Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are manifestations of endometritis, an infection of the lining of the uterus. The nurse should obtain a vaginal culture using a sterile swab to collect the fluid from the client's vaginal cavity to identify the organism.
Initiate airborne isolation precautions.
Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are manifestations of endometritis, an infection of the lining of the uterus. Airborne isolation precautions are not indicated. The nurse should use gloves when assisting the client with perineal care.
Place the client on strict bed rest.
Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are manifestations of endometritis, an infection of the lining of the uterus. The nurse should assist the client to ambulate frequently to promote drainage of the infected lochia and prevent pooling within the uterus.
- A nurse is teaching a client who has hyperemesis gravidarum about dietary modifications. Which of the following client statements indicates an understanding of the teaching?
"I will avoid eating high-carbohydrate, sugary snacks."
Clients who have hyperemesis gravidarum might find that eating a high-carbohydrate, sweet snack before consuming protein will decrease nausea and vomiting.
"I will drink 16 ounces of water during each meal."
The client should consume liquids and solids separately throughout the day to self-manage hyperemesis.
"I will eat small, frequent meals throughout the day."
MY ANSWER
The client should focus on eating small, frequent meals throughout the day and consuming foods that are appealing.
"I will eliminate dairy products from my diet."
The client should not eliminate dairy products from the diet because dairy foods might be easier to tolerate than other foods.
19.
A nurse is reviewing the results of a nonstress test for a client who is at 37 weeks of gestation. Which of the following findings indicates a reactive nonstress test?
Fetal heart rate (FHR) accelerations occur with fetal movement
MY ANSWER
A nonstress test measures the response of the FHR to fetal movement. Accelerations of the FHR with fetal movement are a reassuring sign of fetal well-being.
Late decelerations of the FHR occur with contractions
Late decelerations of the FHR with contractions are an indication of fetal compromise due to uteroplacental insufficiency. Late decelerations require further evaluation.
Variable decelerations of the FHR with uterine contractions
Variable decelerations of the FHR with uterine contractions might indicate fetal compromise due to a disruption in the oxygen supply to the fetus. Variable decelerations require further evaluation.
FHR pattern with minimal variability
Minimal variability of the FHR can indicate fetal compromise from fetal hypoxemia and metabolic academia, neurologic injury, or CNS depression. Minimal variability of the FHR requires further evaluation.
20.
A nurse is assessing a client who has preeclampsia and received a dose of calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?
Respiratory rate 12/min
The nurse should identify that respiratory depression is a manifestation of magnesium sulfate toxicity. A respiratory rate of 12/min is within the expected reference range of 12 to 20/min. Therefore, this finding is an indication that calcium gluconate was effective.
Absent deep tendon reflexes
MY ANSWER
The nurse should identify that absent deep tendon reflexes is a manifestation of magnesium sulfate toxicity. Therefore, this finding does not indicate that calcium gluconate was effective. Other manifestations of magnesium sulfate toxicity include respiratory depression, blurred vision, decreased consciousness, and cardiac arrest.
Slurred speech
The nurse should identify that slurred speech is a manifestation of magnesium sulfate toxicity. Therefore, this finding does not indicate that calcium gluconate was effective. Other manifestations of magnesium sulfate toxicity include respiratory depression, blurred vision, decreased consciousness, and cardiac arrest.
Urine output 22 mL/hr
The nurse should identify that preeclampsia decreases perfusion to organs and tissues. Decreased renal perfusion reduces the glomerular filtration rate which causes oliguria, or urine output less than 25 mL/hr. Decreased renal perfusion increases the risk for magnesium toxicity. Therefore, the nurse should identify urinary output of 22 mL/hr as a manifestation of preeclampsia that increases the risk of magnesium toxicity.
21.
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?
A client who has an indwelling urinary catheter
MY ANSWER
The nurse should identify that a client who has an indwelling urinary catheter is at an increased risk for a fall. The client's required medical interventions, such as IVs and urinary catheters, increase the risk for falls from tripping over tubing. The nurse should assist the client when getting out of bed and ambulating to prevent an injury from a fall.
A client who has a second-degree perineal laceration
The nurse should identify that a second-degree perineal laceration does not increase the client's risk for a fall. A second-degree laceration extends through the perineal fascia and muscles but does not involve the anal sphincter.
A client who is saturating a perineal pad every 5 to 6 hr
The nurse should identify that a client who is saturating a perineal pad every 5 to 6 hr is not at an increased risk for a fall. A client who saturates a perineal pad in less than 1 hr is experiencing excessive vaginal bleeding and might be experiencing a postpartum hemorrhage. Excessive bleeding can cause dizziness and syncope, which increases the risk for a fall.
A client who is experiencing breast engorgement
The nurse should identify that a client who is experiencing breast engorgement is not at an increased risk for a fall. Breast engorgement occurs 3 to 5 days following birth due to significantly increased volume of breast milk. Engorgement usually lasts approximately 24 hr and can be relieved by breastfeeding or pumping the breasts every 2 hr.
22.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following findings is an indication the medication was effective?
Cervical dilation 4 cm
Terbutaline is a tocolytic medication that is used to halt preterm labor by causing relaxation of smooth muscle. Cervical dilation of 4 cm indicates the client is in active labor. Therefore, the nurse should not identify this finding as an indication that terbutaline was effective.
Heart rate 108/min
Terbutaline is a tocolytic medication that is used to halt preterm labor by causing relaxation of smooth muscle. Tachycardia is an expected adverse effect of terbutaline. Therefore, the nurse should identify a heart rate of 108/min as an adverse effect of the medication.
Lecithin sphingomyelin (L/S) ratio 2:1
Terbutaline is a tocolytic medication that is used to halt preterm labor by causing relaxation of smooth muscle. It has no effect on the production of lecithin or sphingomyelin. Lecithin and sphingomyelin are phospholipids found in fetal lungs. An L/S ratio of 2:1 indicates fetal lung maturity. Therefore, the nurse should identify that an L/S ratio of 2:1 is unrelated to terbutaline.
Decreased frequency of contractions
MY ANSWER
Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline causes relaxation of smooth muscle, which decreases uterine activity. Therefore, the nurse should identify that a decrease in frequency of contractions is an indication that terbutaline was effective.
23.
A nurse is admitting a client who is at 39 weeks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks of gestation. Which of the following actions should the nurse expect to take?
Prepare for a cesarean birth.
A client who is GBS positive does not require a cesarean birth.
Administer IV antibiotic prophylaxis.
MY ANSWER
To decrease the risk of the neonate contracting a GBS infection, it is recommended that pregnant clients who test positive for GBS receive antibiotics during labor.
Obtain a vaginal culture.
There is no indication to obtain a vaginal culture.
Administer metronidazole orally.
Metronidazole 500 mg PO twice daily is the expected treatment for bacterial vaginosis.
- A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?
"Manifestations of shock might not appear until a client loses 20% of their blood volume."
The charge nurse should include that manifestations of shock might not appear until a client has lost 30% to 40% of their blood volume. Compensatory mechanisms inhibit a significant decrease in the client's blood pressure. Manifestations of hemorrhagic shock include tachycardia, tachypnea, cool, clammy skin, and decreasing urinary output.
"Hemorrhagic shock will cause an increase in a client's serum pH level."
The charge nurse should include that hemorrhagic shock will cause acidosis, or a decrease in the client's serum pH level. Cellular hypoxia causes an accumulation of lactic acid, leading to acidosis. Without treatment, cellular death will occur.
"The most accurate indication of organ perfusion is a client's urine output."
MY ANSWER
The charge nurse should include that the most accurate indication of organ perfusion is the client's urine output. Output greater than 30 mL/hr is an indication of adequate perfusion and oxygenation.
"An infusion of 1 mL of lactated Ringer's is given for each 1 mL of blood loss."
The charge nurse should include that 3 mL of a crystalloid solution, such as lactated Ringer's or 0.9% sodium chloride, should be infused for every 1 mL of estimated blood loss.
25.
A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take?
Repeat the CST in 20 min.
Repeating the CST in 20 min is not indicated for a CST that indicates a negative result. A pattern of intermittent late decelerations indicate a positive CST. The test should be repeated when fewer than half of the contractions lead to late decelerations.
Administer an IV fluid bolus.
Administering an IV fluid bolus is not indicated for a CST that indicates a negative result.
Prepare the client for cesarean birth.
Preparing the client for cesarean birth is not indicated for a CST that indicates a negative result.
Allow the labor to progress naturally.
MY ANSWER
The absence of late decelerations (a negative result) indicates that the fetus will probably tolerate labor; therefore, the nurse should allow the labor to progress naturally.
26.
A nurse is monitoring a client who is in the active phase of labor and has an intrauterine pressure catheter and fetal scalp electrode. Which of the following findings should the nurse expect?
Uterine contractions every 15 min
The nurse should expect contractions to occur every 3 to 5 min for a client who is in the active phase of labor. The contractions are moderate to strong in intensity and last approximately 40 to 70 seconds. During the latent phase of labor, contractions occur every 5 to 30 min.
FHR baseline 166/min with minimal variability
The nurse should identify that an FHR of 166/min is above the expected reference range of 110 to 160/min and indicates tachycardia. Fetal tachycardia can indicate fetal hypoxemia, maternal fever or infection, and fetal anemia. Minimal variability is also an indication of fetal hypoxemia and can be caused by congenital abnormalities in the fetus, maternal use of CNS depressant medications, and fetal prematurity. Fetal sleep can also cause a temporary and harmless decrease in variability, which should last no more than 30 min.
Late decelerations in FHR
MY ANSWER
The nurse should identify that late decelerations can indicate uteroplacental insufficiency or a disruption in the oxygen transport to the fetus. Late decelerations can be caused by maternal hypotension, uterine tachysystole, preeclampsia, or maternal diabetes. The nurse should place the client in a lateral position, palpate the uterus for tachysystole, increase the rate of the maintenance IV fluid, administer oxygen at 8 to 10 L/min via nonrebreather face mask, and notify the provider.
Montevideo units (MVU) of 220 mm Hg
The nurse should identify that an MVU of 220 mm Hg is within the expected range during the active phase of labor. MVUs generally range between 100 to 250 mm Hg during the first stage of labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs are calculated by subtracting the baseline uterine pressure from the peak contraction pressure for every contraction that occurs during a 10-min period. The nurse then adds the pressure produced by each contraction during that time to determine the MVUs.
- FLAG
A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL and is to begin phototherapy. Which of the following actions should the nurse take?
Give glucose water after feedings.
Glucose water should not be given to newborns who are prescribed phototherapy, because it delays bilirubin excretion.
Instruct the client to avoid breastfeeding during treatment.
The client can continue breastfeeding while the newborn is prescribed phototherapy and can also be asked to pump the breast following the feeding for supplementary breast milk.
Monitor intake and output.
MY ANSWER
The nurse should monitor intake and output because phototherapy can increase the rate of insensible water loss, which contributes to fluid loss and dehydration. The nurse should also monitor the newborn's fontanels. Hydration is achieved by breastfeeding or formula feeding the newborn.
Apply lotions and ointments throughout the treatment.
The nurse should avoid applying lotions and ointments to newborns who are receiving phototherapy because it can cause burns.
28.
A nurse is monitoring a client who is receiving oxytocin to augment labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following actions is the nurse's priority?
Discontinue oxytocin.
The nurse should discontinue oxytocin because it can impede oxygen transfer to the fetus; however, evidence-based practice indicates that another action is the priority.
Increase IV fluid rate.
The nurse should administer a bolus of IV fluid to treat maternal hypotension; however, evidence-based practice indicates that another action is the priority.
Position the client laterally.
MY ANSWER
Late decelerations occur because of uteroplacental insufficiency. According to evidence-based practice, the priority action the nurse should take is to first position the client in a lateral position to improve oxygenation to the fetus.
Administer oxygen via facemask at 8 L/min.
The nurse should administer oxygen via nonrebreather facemask at 8 to 10 L/min to improve oxygenation and treat uteroplacental insufficiency; however, evidence-based practice indicates that another action is the priority.
29.
A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the nurse should take to clear the airway obstruction. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- Stand posterior to the client.
- Position arms under the client's axilla and across the client's chest.
- Place thumb-side of a clenched fist to the client's mid-sternum area.
- Initiate chest thrusts to the client using a backward motion.
An obstructed airway requires immediate intervention. According to the American Heart Association's guidelines, the nurse should first stand posterior to the client. Next, the nurse should position their arms under the client's axilla and across the client's chest. Then, the nurse should place the thumb-side of a clenched fist to the client's mid-sternum area and place the other hand on top of the first. Lastly, the nurse should initiate chest thrusts to the client using a backward motion. If the client becomes unconscious, the nurse should perform CPR and activate emergency medical services.
30.
A nurse is reviewing the medical record of a client who is at 8 weeks of gestation. Which of the following findings should the nurse identify as a risk factor for developing preeclampsia?
Cholelithiasis
Cholelithiasis, or the presence of gallstones in the gallbladder, does not increase a client's risk for preeclampsia. The incidence of cholelithiasis increases during pregnancy due to the increase in hormones and a decrease in drainage of the gallbladder from pressure of the enlarged uterus.
Singleton pregnancy
A singleton pregnancy does not increase a client's risk for preeclampsia. Multifetal pregnancy does increase a client's risk for development of the disorder.
Rheumatoid arthritis
MY ANSWER
The presence of a connective tissue disease, such as rheumatoid arthritis or systemic lupus erythematosus, increases a client's risk for developing preeclampsia.
Anemia
Anemia does not increase a client's risk for preeclampsia. Anemia affects up to 52% of pregnant women and increases the risk of postpartum complications, including infection.
31.
A nurse is teaching a new guardian how to correctly use a car seat. Which of the following statements by the guardian indicates an understanding of the teaching?
"I should keep my baby in a rear-facing car seat until he is 2 years old."
MY ANSWER
The client should keep the newborn in a rear-facing car seat until age 2 or until the child reaches the maximum height and weight for the seat.
"I should strap my baby in the seat with a four-point harness."
The nurse should teach the client about using a five-point harness. It consists of two shoulder straps, two hip straps, and a crotch strap. This kind of harness helps to prevent the newborn from becoming dislodged during a collision.
"I should place the shoulder harness in the slots above my baby's shoulders."
The client should place the shoulder harness in the slots at or below the level of the newborn's shoulders.
"I should position my baby's car seat at a 30-degree angle."
The client should position the car seat at a 45° angle. This position keeps the newborn from slumping and causing airway obstruction.
32.
A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?
Positive pregnancy test
MY ANSWER
A positive serum or urine pregnancy test is a probable sign of pregnancy. False positive results can occur for many reasons, such as the use of medications, liver disease, substance use, and hormone-producing tumors.
Amenorrhea
A client can present with amenorrhea for a variety of reasons besides pregnancy; therefore, the nurse should consider it a presumptive sign of pregnancy.
Fetal heart sounds
The presence of a fetal heart tone is a positive sign of pregnancy. The nurse should be able to auscultate fetal heart tones by Doppler stethoscope at 8 to 17 weeks of gestation.
Chadwick sign
Chadwick sign, which is the bluish coloration of the cervix and vaginal mucosa, is a probable sign of pregnancy.
33.
A nurse is providing client teaching regarding an intrauterine device (IUD). Which of the following statements should the nurse include in the teaching? (Select all that apply.)
"You might have to have cultures for sexually transmitted infections prior to placement of the device."
"The device will have to be replaced every 2 years."
"You might experience irregular spotting the first few months after placement of the device."
"You will need to avoid using tampons during menstrual cycles."
"You will need to sign informed consent prior to the procedure."
MY ANSWER
"You might have to have cultures for sexually transmitted infections prior to placement of the device" is correct. If the provider determines the client is at risk for sexually transmitted infections they might require the collection of cultures for sexually transmitted infections prior to the placement of an IUD.
"The device will have to be replaced every 2 years" is incorrect. An IUD can be effective against pregnancy for 3 to 10 years, depending on the device the provider uses.
"You might experience irregular spotting the first few months after placement of the device" is correct. The client might experience irregular spotting during the first few months after placement of the IUD.
"You will need to avoid using tampons during menstrual cycles" is incorrect. Clients who have an IUD can continue to use tampons during menstrual cycles.
"You will need to sign informed consent prior to the procedure" is correct. The nurse should obtain informed consent prior to placement of the IUD.
- A nurse is teaching routine prenatal care to a group of clients who are pregnant. Which of the following statements by a client indicates an understanding of the teaching?
"I will be able to hear my baby's heart beat when I am 6 weeks pregnant."
Toward the end of the first trimester, or at about 10 to 12 weeks of gestation, the provider can typically auscultate the fetal heart tones when using a Doppler stethoscope. An ordinary stethoscope can be used to detect the fetal heart rate after 18 to 20 weeks of gestation.
"I will have monthly prenatal visits for the first 28 weeks of pregnancy."
MY ANSWER
For prenatal care, the initial visit should occur in the first trimester with monthly visits through week 28, and every 2 weeks until week 36, and then every week until the birth of the newborn.
"I will have a complete blood count performed at each prenatal visit."
A complete blood count (CBC) is not performed at each prenatal visit; however, the nurse should obtain a CBC from the client during the initial prenatal visit to assess for anemia and infection.
"I will have a blood test to check for neural tube defects when I am 32 weeks pregnant."
A maternal serum alpha-fetoprotein (MSAFP) blood test screening is recommended to be obtained between 15 and 20 weeks of gestation. A low level of MSAFP is associated with the presence of a chromosomal abnormality, such as trisomy 18 or trisomy 21 (Down syndrome) in the fetus. An elevated level is associated with open neural tube defects, such as spina bifida and anencephaly, or the presence of multiple gestations.
A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my baby is breech." Which of the following actions should the nurse take first?
Check fetal heart tones.
MY ANSWER
According to evidence-based practice, the nurse should first assess the fetal heart tone immediately following the rupture of membranes to detect any variation in fetal heart tones. A variation in fetal heart tones can occur due to a prolapsed umbilical cord. The risk of a prolapsed cord is increased with noncephalic presentations when the membranes are ruptured. Prolapse of the cord compromises circulation to the fetus.
Prepare for a cesarean birth.
The nurse should prepare the client for a cesarean birth because the newborn is breech; however, evidence-based practice indicates that the nurse should take a different action first.
Check the color, amount, and odor of the fluid.
The nurse should observe the color, amount, and odor of the fluid present whenever a client's amniotic membranes rupture; however, evidence-based practice indicates that the nurse should take a different action first.
Perform Nitrazine test to assess for rupture of membranes.
The nurse should perform a Nitrazine test to confirm rupture of membranes; however, evidence-based practice indicates that the nurse should take a different action first.
36.
A nurse is assessing a client who delivered a 4.5 kg (10 lb) newborn 2 hr ago. Identify the level in the abdomen a nurse should expect to find the client's uterus when assessing the fundus. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A is incorrect. A fundal height at the diaphragm is too high and is a manifestation of uterine atony and possible postpartum hemorrhage or retained placental fragments. The nurse should massage the client's uterus, and the client might need to receive oxytocin to promote involution, prevent hemorrhage, and assist with the expulsion of uterine contents.
B is incorrect. A fundal height of approximately one hand width above the umbilicus is considered too high 2 hr after birth. The nurse should massage the client's uterus, and the client might need to receive oxytocin to promote involution and to prevent hemorrhage. The nurse must assess the client continually for hemorrhage and document expulsion of any other intrauterine contents such as retained placental fragments.
C is correct. Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2 cm below the level of the umbilicus. At 12 hr postpartum the nurse should palpate the fundus at 1 cm (0.4 in) above the umbilicus. Every 24 hr the fundus should descend approximately 1 to 2 cm (0.4 to 0.8 in). It should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum.
D is incorrect. It takes quite some time for the fundal height to return to the level of the symphysis pubis. Many clients need uterine massage to assist with the process of uterine involution. The client should expect fundal height to return to a prepregnancy level at 9 to 10 days postpartum or longer, at which time it will no longer be externally palpable.
37.
A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take?
Monitor blood pressure every 30 min following epidural placement.
The nurse should monitor the client's blood pressure every 5 to 10 min following epidural placement to monitor for hypotension, a common adverse effect.
Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement.
MY ANSWER
The nurse should administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement to prevent hypotension.
Administer oxygen via nasal cannula at 2 L/min prior to epidural placement.
The nurse should administer oxygen via nonrebreather face mask at 10 L/min for hypotension following epidural placement.
Reposition the client every 2 hr following epidural placement.
The nurse should reposition the client every hour following epidural placement.
38.
A nurse is preparing to administer an opioid analgesic to a client who is in active labor. Which of the following assessments should the nurse perform? (Select all that apply.)
Maternal blood pressure
Pain level
Fetal heart rate
Deep tendon reflexes
Blood glucose
MY ANSWER
Maternal blood pressure is correct. Opioid analgesics can cause hypotension. The nurse should assess the client's blood pressure before and after administering opioids.
Pain level is correct. The nurse should assess the client's baseline pain level prior to administering pain medication and again after administering pain medication to determine the effectiveness of the medication. Opioid analgesics are indicated for the relief of moderate to severe labor pain.
Fetal heart rate is correct. Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is within the expected reference range and to have a baseline for future assessments. The nurse should provide ongoing assessments of fetal heart rate throughout labor according to facility protocol.
Deep tendon reflexes is incorrect. It is not necessary to assess deep tendon reflexes prior to administering opioids. The nurse should assess the client's deep tendon reflexes when administering magnesium sulfate.
Blood glucose is incorrect. The nurse should assess a client's blood glucose level when administering insulin to a client who has diabetes mellitus and is in labor.
39.
A nurse is teaching a prenatal className to a group of parents and is discussing facilitation of sibling acceptance of the newborn. Which of the following instructions should the nurse include in the teaching?
The parent should hold the newborn during the initial visit with the older sibling.
The parent should plan to have someone else hold the newborn during the initial visit with the older sibling.
The parent should plan to spend individual time with the older sibling.
MY ANSWER
The parent should spend individual time with the older sibling to enhance and facilitate sibling acceptance of the newborn.
The parent should have the older sibling purchase a gift for the newborn.
The parent should have a small gift available to give to the older sibling from the newborn during the initial visit.
The parent should postpone introducing the older sibling to the newborn until discharge.
The parent should introduce the older sibling to the newborn as soon as possible after birth.
A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?
Weight gain of 0.7 kg (1.5 lb) in 2 weeks
The nurse should identify that a weight gain of 0.7 kg (1.5 lb) in 2 weeks is within the expected gain of 0.4 kg (0.9 lb) per week during the third trimester. Inadequate weight gain can cause deficiencies in important nutrients and restrict fetal growth. Excessive weight gain increases the risk for complications of pregnancy, such as hypertensive disorders and gestational diabetes.
Leg cramps when sleeping
The nurse should identify that leg cramps are a common discomfort of pregnancy during the third trimester. Leg cramps, or spasms of the gastrocnemius muscle, are commonly caused by the compression of the nerves in the pelvis by the enlarging uterus. The nurse should instruct the client to use massage and heat on the affected muscle and dorsiflex the foot until the cramp dissipates.
Varicose veins on labia
The nurse should identify that varicose veins are a common discomfort of pregnancy during the second and third trimesters. Varicose veins are caused by the relaxation of smooth muscle of the vascular system due to influence of pregnancy hormones. Vasocongestion also occurs due to the weight of the enlarging uterus.
Episodes of blurred vision
MY ANSWER
The nurse should identify that episodes of blurred vision are not an expected finding during pregnancy. Blurred vision is a manifestation of preeclampsia. Arterial vasospasms and decreased perfusion to the retina cause visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. The nurse should report this finding to the provider.
41.
A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility. Which of the following instructions should the nurse include in the teaching?
"Give your newborn only to staff members you recognize."
The nurse should instruct the postpartum client never to give the newborn to anyone who does not have proper identification, even if the client recognizes the person. All health care staff should wear a facility-provided photo identification badge.
"Remove your newborn's microchip identification band after you have arrived home."
Microchip identification bands contain a sensor that that will alarm if the newborn leaves the facility unit. The band should be removed immediately prior to facility discharge.
"Personally carry your newborn to the nursery if you need assistance."
The nurse should instruct the client to transport the newborn in a bassinet. This protects the newborn from injury if the client feels dizzy or trips while carrying the newborn, and it also is a safety precaution against abduction. It conditions the entire staff, as well as clients and visitors, to notice any newborn who is being carried by a possible abductor instead of lying in a bassinet and to alert security and law enforcement immediately.
"Bring your newborn in the bassinet into the bathroom with you."
MY ANSWER
The client should wheel the newborn in the bassinet into the bathroom with her rather than leave the newborn unattended. The nurse should instruct the client never to leave the newborn unattended.
42
A nurse is assessing a newborn who is breastfed and has a weight loss of 11% at 48 hr after birth. Which of the following findings should the nurse report to the provider?
Meconium stools
Meconium stools are an expected finding in a newborn who is 48 hr old and are not associated with hydration status.
Depressed fontanels
MY ANSWER
Sunken or depressed fontanels are a finding associated with dehydration of the newborn. Additionally, dry oral mucosa, weight loss greater than 10%, and decreased urine output are findings associated with dehydration.
Rust-stained urine
Rust-stained urine is due to the presence of uric acid crystals in the urine and is an expected finding in a newborn who is 48 hr old.
Overlapping suture lines
Overlapping suture lines are associated with molding of the head, which occurs during the birthing process. This finding is not associated with dehydration.
43.
A nurse is monitoring a client who is in active labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following findings should the nurse recognize as the potential cause of the deceleration?
Umbilical cord compression
Umbilical cord compression can cause variable decelerations. Variable decelerations are typically transient and correctable.
Fetal hypoxia
MY ANSWER
Late decelerations are caused by uteroplacental insufficiency or a decreased blood flow from the uterus to the placenta during contractions. This results in a decreased supply of oxygen to the fetus during the contraction. This pattern can be caused by a wide variety of reasons including increased uterine tone, maternal hypotension, and disorders that affect the placenta such as maternal diabetes, preeclampsia and post maturity.
Fetal movement
Fetal movement should elicit an accelerated fetal heart rate, which is a sign of fetal well-being.
Fetal head compression
Fetal head compression can create an early deceleration pattern. During a contraction, as the uterus presses on the fetal head, nerve receptors are stimulated and the fetal heart rate decreases. The fetal heart rate then returns to baseline as fetal head compression subsides.
44.
A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy. Which of the following actions should the nurse take?
Inform the client to expect to have dark-colored stools.
The client should not expect to have dark-colored stools after receiving methotrexate. Methotrexate can cause gastrointestinal bleeding, a serious adverse effect that requires immediate notification of the provider.
Wear two pairs of gloves when handling the medication.
MY ANSWER
Methotrexate is an antineoplastic agent that a pharmacist must prepare in a syringe under a biologic safety cabinet and place in a sealed plastic bag. The nurse should wear two pairs of gloves when removing the syringe from the bag, administering the medication, and disposing of the syringe.
Administer the medication subcutaneously.
The nurse should administer methotrexate intramuscularly to treat ectopic pregnancy.
Instruct the client to use a condom during interAssignment for the next 7 days.
The client should avoid interAssignment until human chorionic gonadotropin (hCG) is no longer detectable, which can take up to 2 to 8 weeks. The client should then use a more reliable form of contraception than a condom.
45.
A nurse is preparing to administer methotrexate 1 mg/kg IM to a client who weighs 110 lb and is receiving care for an ectopic pregnancy. Available is methotrexate 25 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
2 mL
MY ANSWER
46.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching regarding situations requiring an amniotomy?
Placing a fetal scalp electrode
MY ANSWER
A fetal scalp electrode is attached to the presenting part of the fetus in order to provide accurate continuous monitoring of the fetal heart rate. If the client's membranes are intact, the amniotic sac must be artificially ruptured prior to attaching the electrode to enable access to the presenting part.
Inserting misoprostol
Misoprostol is used as a cervical ripening agent causing uterine contractions, which result in dilation and effacement. An amniotomy is not required for this medication.
Conducting a biophysical profile
A biophysical profile is a noninvasive ultrasound evaluation with a nonstress test and is intended to determine fetal well-being during the third trimester. An amniotomy is not required for this diagnostic test.
Performing effleurage
Effleurage is performed by lightly stroking the abdomen during a contraction and is a technique used for pain management during labor. An amniotomy is not required to perform effleurage.
47.
A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?
Elevate the head of the client's bed 30°.
The nurse should identify that the client is exhibiting manifestations of hypovolemic shock, which is a medical emergency. The nurse should place the client in a lateral position and elevate the client's legs to at least a 30° angle. This position will increase perfusion to the brain and major organs.
Administer a dose of terbutaline.
The nurse should identify that the client is exhibiting manifestations of hypovolemic shock, which is a medical emergency. The nurse should not administer terbutaline, a tocolytic medication, as this will relax the uterine muscle and increase uterine bleeding. The nurse should administer an oxytocic medication, such as oxytocin, to decrease bleeding.
Initiate oxygen at 2 L/min via nasal cannula.
The nurse should identify that the client is exhibiting manifestations of hypovolemic shock, which is a medical emergency. The nurse should initiate oxygen at 10 L/min via a nonrebreather mask to increase oxygen delivery to the cells.
Initiate an infusion of oxytocin.
MY ANSWER
The nurse should identify that the client is exhibiting manifestations of hypovolemic shock, which can be caused by uterine atony and is a medical emergency. The nurse should initiate an infusion of 10 to 20 units of oxytocin, which is an oxytocic medication. This will cause the uterus to contract and decrease bleeding.
48.
A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation. Which of the following results should the nurse identify as an indication of a prenatal complication?
BUN 30 mg/dL
MY ANSWER
The nurse should identify that a BUN of 30 mg/dL is above the expected reference range of 10 to 20 mg/dL for a client who is pregnant. The BUN typically decreases during pregnancy due to the increase in the glomerular filtration rate. The nurse should also identify that an elevated BUN is a manifestation of preeclampsia or HELLP syndrome, potentially serious complications of pregnancy. Therefore, the nurse should report this finding to the provider.
Hgb 11.3 mg/dL
The nurse should identify that a hemoglobin of 11.3 mg/dL is within the expected reference range of greater than 11 mg/dL for a client who is pregnant. The plasma volume level increases by 45% by 32 weeks of gestation. The plasma increase is greater than the increase in red blood cell production, which causes hemodilution. This phenomenon is known as physiologic anemia. The nurse should report a hemoglobin level less than 11 mg/dL to the provider as this is an indication of anemia.
Platelets 360,000/mm3
The nurse should identify that a platelet count of 360,000/mm3 is within the expected reference range of 150,000 to 400,000/mm3 during pregnancy. A decreased platelet count is an indication of HELLP syndrome, a serious complication of pregnancy. Therefore, the nurse should monitor the client's platelet count and notify the provider if it is outside of the expected reference range.
Hct 34%
The nurse should identify that a hematocrit of 34% is within the expected reference range of greater than 33% for a client who is pregnant. The plasma volume level increases by 45% by 32 weeks of gestation. This plasma increase is greater than the increase in red blood cell production, which causes hemodilution. This phenomenon is known as physiologic anemia. The nurse should report a hematocrit level less than 33% to the provider as this is in indication of anemia.
49.
A nurse is providing teaching for a client who is 2 weeks postpartum and has mastitis. Which of the following instructions should the nurse include in the teaching?
"Feed your baby only from the unaffected breast until the infection has resolved."
Continued complete emptying of the breasts is an essential part of first-line management of mastitis. The client should breastfeed the newborn from both breasts to prevent abscess formation. If it is too painful to feed the newborn, the client should pump to empty both breasts.
"Pump your breasts and discard the milk until the infection has resolved."
Unless the provider has prescribed an antibiotic that is contraindicated for lactation, there is no reason why the client cannot breastfeed the newborn. If the affected breast is too sore, the client can use a breast pump on that breast, but there is no need to discard the milk.
"Apply moist heat to the affected breast."
MY ANSWER
The application of warm compresses prior to feeding or pumping promotes the flow of the breast milk and assists to ensure complete emptying of the breast. This is important to prevent the development of further complications such as the formation of a breast abscess or chronic mastitis.
"Ensure you are drinking at least 1,500 milliliters of fluid per day."
Clients who are lactating are encouraged to consume adequate daily fluids and a nutritious diet. However, this action does not prevent or contribute to the resolution of mastitis.
- A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization. Which of the following statements by the client indicates an understanding of the teaching?
"I should see my provider in 2 weeks for a second dose of the immunization."
The client will be checked for immunity if they become pregnant again.
"I will need to prevent getting pregnant for 4 months after I receive the immunization."
The client needs to practice contraception to prevent pregnancy for 4 to 12 weeks after receiving the rubella immunization due to the risk of teratogenic effects on the fetus.
"I will need an additional rubella immunization during the first trimester with my next pregnancy."
The rubella vaccination is a live virus that can potentially have teratogenic effects on the fetus, especially if administered during the first trimester of pregnancy. A pregnant client who is non-immune to rubella must wait until the postpartum period to receive the additional immunization.
"I can breastfeed my baby even though I received this immunization."
MY ANSWER
Clients who receive the rubella immunization can continue to breastfeed. According to the CDC, breastfeeding should not delay a client from receiving the rubella immunization.
51.
A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
"Encourage clients who are prescribed methadone to breastfeed."
MY ANSWER
The nurse should encourage clients who are prescribed methadone during pregnancy to breastfeed their newborns to help with withdrawal symptoms.
"Methamphetamine use during pregnancy is associated with fetal macrosomia."
The nurse should identify that methamphetamine use during pregnancy is associated with intrauterine growth restriction, preterm birth, and placental abruption.
"Environmental stimuli should be increased during the neonatal period."
The nurse should decrease environmental stimuli during the neonatal period to assist with decreasing irritability and hyperactive behaviors.
"Increased head circumference is an expected finding in a newborn who has fetal alcohol syndrome."
The nurse should identify that microcephaly is an expected finding in a newborn who has fetal alcohol syndrome.
A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following clinical findings should the nurse expect?
Variable decelerations
Variable decelerations are the result of umbilical cord compression and are not an expected clinical finding of placenta previa. The nurse might change the client's position to a lateral position and administer oxygen via facemask at 8 to 10 L/min to assist with decreasing umbilical cord compression.
Painless vaginal bleeding
MY ANSWER
Painless vaginal bleeding is an expected clinical finding associated with placenta previa. The placenta implants in the lower uterine segment, partially or completely covering the cervix. With cervical changes, the placental blood vessels can tear, which results in bleeding.
Rigid abdomen
A rigid abdomen is not an expected clinical finding associated with placenta previa. This finding is seen in clients who have abruptio placentae.
Uterine tachysystole
Uterine tachysystole is not an expected clinical finding associated with placenta previa. It typically occurs due to uterine stimulation from oxytocin. The nurse should discontinue the oxytocin if uterine tachysystole occurs.
\
A nurse is receiving report on four newborns born in the past 12 hr. Which of the following newborns should the nurse assess first?
A newborn who has a respiratory rate of 34/min
A newborn who has a respiratory rate of 34/min is within the expected reference range of 30 to 60/min. A respiratory rate of 34/min is nonurgent because it is an expected finding for a newborn; therefore, there is another finding that is the priority.
A newborn who has acrocyanosis
Acrocyanosis is nonurgent because it is an expected finding for a newborn during the first 24 hr after birth; therefore, there is another finding that is the priority.
A newborn who has caput succedaneum
Caput succedaneum is nonurgent because it is an expected finding for a newborn who has a vaginal birth; therefore, there is another finding that is the priority. Caput succedaneum is a generalized edematous area found on the occiput of the scalp that extends across the suture lines, and the swelling should disappear spontaneously within 3 to 4 days after birth.
A newborn who has an axillary temperature of 36° C (96.8° F)
MY ANSWER
When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority assessment is the newborn who has a temperature of 36° C (96.8° F). Cold stress increases the newborn's need for oxygen and can deplete glucose stores. It also can increase the newborn's respiratory rate and cause cyanosis. The expected axillary temperature for the newborn averages 37° C (98.6° F) and ranges from 36.5° C (97.7° F) to 37.2° C (99° F).
54.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for postpartum pain relief 1 hr ago. The nurse notes that the client's respiratory rate is 10/min. Which of the following actions should the nurse take first?
Determine if the client is nauseated.
The nurse should identify if the client is experiencing adverse effects of morphine, such as nausea and vomiting. However, there is another action the nurse should take first.
Auscultate the client's breath sounds.
The nurse should auscultate the client's breath sounds to determine if there is accumulation of pooled secretions in the lungs due to depressed respirations. However, there is another action the nurse should take first.
Check the client's blood pressure.
The nurse should check the client's blood pressure to monitor for adverse effects of analgesia. However, there is another action the nurse should take first.
Administer oxygen by nonrebreather face mask.
MY ANSWER
The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer oxygen by nonrebreather mask to treat manifestations of respiratory depression due to morphine administration.
A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?
Heart rate: 132/min
MY ANSWER
When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority adverse effect to report is a heart rate of 132/min. The nurse should notify the provider of tachycardia greater than 130/min; therefore, this is the priority finding. The client might also report chest discomfort, palpitations and have arrhythmias.
Report of headache
Report of headache is a common adverse effect of terbutaline; however, there is another adverse effect that is the priority for the nurse to report to the provider.
Nasal congestion
Nasal congestion is a common adverse effect of terbutaline; however, there is another adverse effect that is the priority for the nurse to report to the provider.
Tremors
Tremors are a common adverse effect of terbutaline; however, there is another adverse effect that is the priority for the nurse to report to the provider.
- A nurse is caring for a client who is in active labor and receiving epidural anesthesia. The client reports feeling nauseated and experiences a blood pressure drop from 125/70 mm Hg to 90/50 mm Hg. Which of the following actions should the nurse take first?
Turn the client to a lateral position.
MY ANSWER
The greatest risk to this client is injury from maternal hypotension and decreased placental perfusion; therefore, the first action the nurse should take is to place the client in a lateral position to relieve the pressure on the vena cava and restore venous return.
Reassess the client's vital signs.
The nurse should reassess the client's vital signs to detect any further changes in blood pressure; however, this is not the priority action.
Administer ephedrine 5 mg IV.
The nurse might need to administer an IV vasopressor, such as ephedrine, to increase the client's blood pressure; however, this is not the priority action.
Increase the rate of primary IV infusion.
The nurse should increase the rate of the primary IV infusion to raise the client's blood pressure and facilitate placental perfusion; however, this is not the priority action.
A nurse is teaching a client about iron supplementation during pregnancy. Which of the following client statements indicates an understanding of the teaching?
"I will take this supplement with 8 ounces of milk."
The client should avoid taking the supplement with milk because calcium impairs absorption of the supplement. Iron is best absorbed when taken on an empty stomach. Consuming a diet high in vitamin C will increase the absorption of iron supplements.
"I will double my dose if I forget to take my supplement."
The client should take a dose as soon as they realize they missed a dose as long as it is within 12 hr of the missed dose. The client should not double up on the dose.
"I will be certain to consume 28 grams of fiber daily."
MY ANSWER
Constipation often occurs when a client is taking an iron supplement. The client should consume a diet high in fiber and increase fluid intake to help reduce the occurrence of constipation.
"I will take 100 milligrams of vitamin K per day while taking this supplement."
There is no indication the client should take an increased amount of vitamin K while taking iron supplements.
A nurse is assessing a client who is 2 hr postpartum and has saturated a perineal pad in 15 min. The client's skin is cool and clammy to touch. Which of the following actions should the nurse take first?
Administer misoprostol rectally.
The nurse might need to administer misoprostol rectally if fundal massage does not decrease uterine bleeding. However, there is another action the nurse should take first.
Administer oxygen.
The nurse should administer oxygen at 10 L/min via nonrebreather face mask to increase perfusion to the client's organs. However, there is another action the nurse should take first.
Firmly massage the fundus.
The greatest risk for a postpartum client who is experiencing excessive vaginal bleeding is the development of hypovolemic shock, which can lead to coma and death. Uterine atony is a frequent cause of excessive vaginal bleeding. Therefore, the first action the nurse should take is to massage the client's fundus to encourage muscular contractions, which will decrease bleeding.
Place the client in a lateral position.
MY ANSWER
The nurse should place the client in a lateral position and elevate the legs to enhance perfusion to the major organs. However, there is another action the nurse should take first.
59.
A nurse is providing teaching about nifedipine for a client who is at 34 weeks of gestation and has gestational hypertension. For which of the following adverse effects should the nurse instruct the client to notify the provider?
Tinnitus
Tinnitus, which is ringing of the ears, is not an adverse effect of nifedipine.
Irregular heartbeat
MY ANSWER
Cardiac arrhythmia is a potential life-threatening adverse effect of nifedipine. Therefore, the client should report an irregular heartbeat to the provider.
Hair loss
Hair loss is not an adverse effect of nifedipine.
Increased salivation
Dry mouth, not increased salivation, is an expected adverse effect of nifedipine.
60.
A nurse is caring for a postpartum client who is breastfeeding her newborn and reports that her nipples have become sore and cracked. Which of the following statements should the nurse make?
"Begin each feeding with the breast that is most sore, so the newborn spends less time on it."
When starting the letdown reflex, it is best to begin with the breast that is less sore. This makes the breast milk flow more quickly on the second, sorer breast. Warm compresses and massage can also quicken milk flow.
"Use breast pads with a moisture-proof lining to keep the nipples moist."
The nurse should advise that client to avoid plastic lined breast pads because they trap moisture and can contribute to sore nipples. Also, the client should remove the breast pads promptly to avoid further skin irritation.
"Breastfeed the baby less frequently to give the nipples time to heal."
Limiting breastfeeding does not prevent sore nipples. Nipple damage usually results from an improper latch or positioning. The nurse should assess the breastfeeding technique for possible causes.
"Apply colostrum to the nipples after feeding to help them heal."
MY ANSWER
Colostrum and breast milk have healing properties and can help reduce soreness.
