(OB HESI /RETAKE PRACTICE REVIEW)
The nurse observes a new mother avoiding eye contact with her newborn. Which action should
the nurse take?
Observe the mother for other attachment behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose?
Screen for neural tube defects.
What action should the nurse implement to decrease the client's risk for hemorrhage after a
cesarean section?
Check the firmness of the uterus every 15 minutes
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous
abortion at 8-weeks’ gestation. What type of emotional response should the nurse anticipate?
Grief related to her perceptions about the loss of this child.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider?
Yellowish tinge to the skin.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple to
attend these classes?
At 30-weeks gestation is closest to the time parents would be ready for such classes. Learning is
facilitated by an interested pupil! The couple is most interested in childbirth toward the end of
the pregnancy when they are psychologically ready for the termination of the pregnancy, and the
birth of their child is an immediate concern.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most
indicative of an impending convulsion?
Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign
of an impending convulsion (eclampsia) and requires immediate attention.
A client is admitted with the diagnosis of total placenta previa. Which finding is most important
for the nurse to report to the healthcare provider immediately?
Onset of uterine contractions.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal
therapy. Which response is best for the nurse to provide?
It is important that you want to take part in your care.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare
, (OB HESI /RETAKE PRACTICE REVIEW)
provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure
complaint indicates that the fallopian tubes are patent?
, (OB HESI /RETAKE PRACTICE REVIEW)
If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic
collection of peritoneal dye/gas.
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her
buttock. The nurse notes that both perineal pads are completely saturated and the client is lying
in a 6-inch diameter pool of blood. Which action should the nurse implement next?
Palpate the firmness of the fundus.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small
to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood
pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action
should the nurse take immediately?
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should
contact the healthcare provider and question the prescription (D).
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client?
Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may
develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the
increased blood volume that occurs during pregnancy, so obtaining information about this client's
health history is a priority.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin?
Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the
client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture,
and fetal distress or demise.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is
experiencing magnesium sulfate toxicity?
Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a
respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
The nurse is planning preconception care for a new female client. Which information should the
nurse provide the client?
Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with
healthy lifestyles in the family (D) which is an intervention in preconception care that targets an
overall goal for a client preparing for pregnancy.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-
stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test
should the nurse prepare the client for additional information about fetal status?
, (OB HESI /RETAKE PRACTICE REVIEW)
Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining
5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and
heart rate.
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The
nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75%
effaced. What additional information is most important for the nurse to obtain?
Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes
priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider
may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the
fetus.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she is
not experiencing any uterine contractions or abdominal pain. What instruction should the nurse
provide?
Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a
placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous.
Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is
confirmed by transabdominal ultrasound (A).
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which
explanation should the nurse give to this anxious client?
There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or
comb his/her hair.
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In
which sequence should the nurse implement these nursing actions? (Arrange in order.)
Reposition the client.
Provide oxygen via face mask.
Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her
husband is screaming for someone to help his wife. Which intervention has the highest priority?
Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and
prevent a postpartum hemorrhage--this intervention has the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary
infusion and complains of pain in her lower back. Which intervention should the nurse
implement?
Apply firm pressure to sacral area. The discomfort of back labor can be minimized by the
application of firm pressure to the sacral area
The nurse observes a new mother avoiding eye contact with her newborn. Which action should
the nurse take?
Observe the mother for other attachment behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose?
Screen for neural tube defects.
What action should the nurse implement to decrease the client's risk for hemorrhage after a
cesarean section?
Check the firmness of the uterus every 15 minutes
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous
abortion at 8-weeks’ gestation. What type of emotional response should the nurse anticipate?
Grief related to her perceptions about the loss of this child.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider?
Yellowish tinge to the skin.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple to
attend these classes?
At 30-weeks gestation is closest to the time parents would be ready for such classes. Learning is
facilitated by an interested pupil! The couple is most interested in childbirth toward the end of
the pregnancy when they are psychologically ready for the termination of the pregnancy, and the
birth of their child is an immediate concern.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most
indicative of an impending convulsion?
Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign
of an impending convulsion (eclampsia) and requires immediate attention.
A client is admitted with the diagnosis of total placenta previa. Which finding is most important
for the nurse to report to the healthcare provider immediately?
Onset of uterine contractions.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal
therapy. Which response is best for the nurse to provide?
It is important that you want to take part in your care.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare
, (OB HESI /RETAKE PRACTICE REVIEW)
provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure
complaint indicates that the fallopian tubes are patent?
, (OB HESI /RETAKE PRACTICE REVIEW)
If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic
collection of peritoneal dye/gas.
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her
buttock. The nurse notes that both perineal pads are completely saturated and the client is lying
in a 6-inch diameter pool of blood. Which action should the nurse implement next?
Palpate the firmness of the fundus.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small
to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood
pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action
should the nurse take immediately?
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should
contact the healthcare provider and question the prescription (D).
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client?
Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may
develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the
increased blood volume that occurs during pregnancy, so obtaining information about this client's
health history is a priority.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin?
Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the
client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture,
and fetal distress or demise.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is
experiencing magnesium sulfate toxicity?
Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a
respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
The nurse is planning preconception care for a new female client. Which information should the
nurse provide the client?
Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with
healthy lifestyles in the family (D) which is an intervention in preconception care that targets an
overall goal for a client preparing for pregnancy.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-
stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test
should the nurse prepare the client for additional information about fetal status?
, (OB HESI /RETAKE PRACTICE REVIEW)
Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining
5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and
heart rate.
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The
nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75%
effaced. What additional information is most important for the nurse to obtain?
Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes
priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider
may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the
fetus.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she is
not experiencing any uterine contractions or abdominal pain. What instruction should the nurse
provide?
Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a
placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous.
Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is
confirmed by transabdominal ultrasound (A).
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which
explanation should the nurse give to this anxious client?
There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or
comb his/her hair.
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In
which sequence should the nurse implement these nursing actions? (Arrange in order.)
Reposition the client.
Provide oxygen via face mask.
Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her
husband is screaming for someone to help his wife. Which intervention has the highest priority?
Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and
prevent a postpartum hemorrhage--this intervention has the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary
infusion and complains of pain in her lower back. Which intervention should the nurse
implement?
Apply firm pressure to sacral area. The discomfort of back labor can be minimized by the
application of firm pressure to the sacral area
