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A mother of a 3-year-old boy has just given birth to a new baby girl. The little
boy asks the nurse, "Why is my baby sister eating my mommy's breast?" How
should the nurse respond? (Select all that apply)
A. Explain that newborns get milk from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
D. Suggest that the baby can also drink from a bottle
E. Clarify that breastfeeding is his mother's choice
A. Explain that newborns get milk from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
The nurse is examining an infant for possible cryptorchidism. Which exam
technique should be used?
A. Place the infant in side-lying to facilitate the exam
B. Hold the penis and retract the foreskin gently
C. Cleanse the penis with an antiseptic-soaked pad
D. Place the infant in warm room and use a calm approach
D. Place the infant in warm room and use a calm approach
,The nurse is planning care for a client at 30-weeks gestation who is experiencing
preterm labor. What maternal prescription is most important in preventing this
fetus from developing respiratory distress syndrome?
A. Betamethasone (Celestone) 12 mg deep IM
B. Butorphanol 1 mg IV push q2h PRN pain
C. Ampicillin 1 Gram IV push q8h
D. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x3
A. Betamethasone (Celestone) 12 mg deep IM
A 3-month-old with myelomeningocele and atonic bladder is catheterized every
4 hours to prevent urinary retention. The home health nurse notes that the
child has developed episodes of sneezing, urticaria, watery eyes, and a rash in
the diaper area. What action is most important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change
C. Change to latex-free gloves when handling infant
The nurse is caring for a female client, a primigravida, with preeclampsia. Findings
include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints
of blurry vision and a severe frontal headache. Which medication should the
nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate
D. Magnesium sulfate
,Vaginal prostiglandin gel is used to induce labor women who are 42 weeks of
gestation. Thirty minutes after insertion of the gel , the client complains of
vaginal warmth, and is experiencing 90 second contractions with fetal heart
deceleration. What action should the nurse implement first
A. Assess maternal vital signs
B. Notify the healthcare provider
C. Increase the IV infusion rate
D. Turn to a side lying position
D. Turn to a side lying position
A primigravida at 40 weeks gestation is contraction q2 minutes her cervix is
9cm dilated and 100% effaced. The fetus heart rate is 120 beats per minute. The
client is screaming
and her husband is alarmed. What intervention should the nurse do?A. Notify
rapid response
B. Have delivery table set up
C. Ask husband to step out
D. Administer a PRN narcotic
B. Have delivery table set up
The nurse is assessing a client at 29 weeks gestation. Which assessment
measure would provide the most accurate determination of fetal position?
A. Ultrasound
B. Vaginal examination
C. Leopolds maneuver
D. Doppler
A. Ultrasound
, A client at 28 weeks gestation is admitted to the obstetrical unit following her
involvement in a motor vehicle collision. While stabilizing the patient , the
nurse obtains fetal monitor reading. Which action should the nurse take if the
fetus is tachycardic is on the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask
D. Contact the healthcare provider after initiating oxygen per face mask
On the first postpartum day, the nurse examines the breasts of the new mother.
Which condition is the nurse most likely to.
A. Slightly firm with immediate let down response
B. Filing and secreting colostrum
C. Soft, with no change from before delivery
D. Firm, larger very tender to touch
B. Filling and secreting colostrum
The nurse who is working at a prenatal clinic notes a woman that is at 18 weeks
of gestation has two elevated maternal alpha feto-protein (MSAFP) values.
What action should the nurse implement?
A. Instruct the client to increase intake of folic acid supplements
B. Request a consultation with genetic counselor
C. Schedule a sonogram in the radiology department
D. Send the client to the laboratory for repeat MSAFP
C. schedule a sonogram in the radiology department