Nurse is performing a newborn assessment, which of the following should the nurse identify as
a sign of spina bifida occulta?
Tuft of hair.
A nurse is assessing a client that is 12-hour post-partum, the client’s fundus is 2 fingerbreadths
above the umbilicus, deviated to the right of midline, and less firm than previously noted.
Which action should the nurse take?
Assist the client to the restroom to void.
A nurse is teaching a client who is 36 weeks gestation and has a prescription for a non-stress
test. Which of the following statements should the nurse include in her teaching?
You will be offered orange juice and a snack during your test.
A nurse is admitting a client to the labor and delivery unit, when the client states, “My water
just broke.” What is the nurses first action of priority?
Monitor fetal heart rate.
Nurse is developing an educational program for adolescents about nutrition during the third
trimester of pregnancy. Which of the following statements should the nurse include in the
program?
Consume three to four servings of dairy each day.
Nurse is assessing a client that is 38 weeks gestation during a weekly prenatal visit, which of the
following findings should the nurse report to the doctor?
Weight gain of 2.2 kg (4.8 pounds)
The nurse is providing discharge teaching to the parents of a newborn about using a car seat
properly. Which of the following instructions should the nurse include?
Position the car seat rear facing, in the back seat of the vehicle.
A nurse is preparing to collect a blood specimen from a newborn via heel stick, which of the
following techniques should the nurse use to help minimize the pain?
Place the newborn skin to skin on the mother’s chest.
A nurse is developing a plan for a client who has preeclampsia, and is receiving magnesium
sulfate via continuous IV infusion. Which of the following interventions should the nurse include
in the plan?
Monitor the FHR continuously.
, Nurse is caring for a client in labor who is experiencing increased rectal pressure, She is
experiencing contraction that are 2-3 minutes apart, each lasting 80-90 seconds, and a vaginal
examination reveals that her cervix is dilated to 9cm, the nurse should identify that the client is
in which phase of labor?
Transition
A nurse is performing a vaginal exam on a client that reports severe pressure and pain in the
lower back. The nurse notes that the fetal head is in posterior position, the nurse should
identify that which of the following is the best non-pharmacological to perform to relieve the
client’s discomfort?
Counter-Pressure
A nurse is caring for a client who is at 24 weeks gestation and reports daily, mild headaches.
Which of the following should the nurse include in the instructions for the plan of care?
Recommend that the client perform conscious relaxation techniques daily.
A nurse is teaching a new mom how to bulb syringe to suction her newborn’s secretions, Which
of the following instructions should the nurse include in her teaching?
Stop suctioning when the newborn’s cry sounds clear. (always suction mouth before nose, nose
only if you must)
A nurse is assessing a newborn who is 12 hours old, which of the following clinical
manifestations requires intervention by the nurse?
Substernal chest retractions while sleeping
A nurse is teaching a client about effective breast feeding who is 3 days postpartum, which of
the following information should the nurse include?
Newborn should appear content after each feeding.
Nurse is caring for a client that had uterine hypotonicity and is experiencing post-partum
hemorrhage, which of the following actions is the nurse’s priority?
Massage the client’s fundus.
Nurse is teaching a client who is 24 weeks gestation regarding a 1-hour glucose tolerance test,
which of the following statements should the nurse include in her teaching?
Blood glucose between 130 and 140 is considered a positive screening result.
Nurse is teaching a client who has pre-gestational type 1 diabetes about management during
pregnancy, which of the following statements made by the client, indicates an understanding of
the teaching?
I will continue taking my insulin if I experience nausea and vomiting.
a sign of spina bifida occulta?
Tuft of hair.
A nurse is assessing a client that is 12-hour post-partum, the client’s fundus is 2 fingerbreadths
above the umbilicus, deviated to the right of midline, and less firm than previously noted.
Which action should the nurse take?
Assist the client to the restroom to void.
A nurse is teaching a client who is 36 weeks gestation and has a prescription for a non-stress
test. Which of the following statements should the nurse include in her teaching?
You will be offered orange juice and a snack during your test.
A nurse is admitting a client to the labor and delivery unit, when the client states, “My water
just broke.” What is the nurses first action of priority?
Monitor fetal heart rate.
Nurse is developing an educational program for adolescents about nutrition during the third
trimester of pregnancy. Which of the following statements should the nurse include in the
program?
Consume three to four servings of dairy each day.
Nurse is assessing a client that is 38 weeks gestation during a weekly prenatal visit, which of the
following findings should the nurse report to the doctor?
Weight gain of 2.2 kg (4.8 pounds)
The nurse is providing discharge teaching to the parents of a newborn about using a car seat
properly. Which of the following instructions should the nurse include?
Position the car seat rear facing, in the back seat of the vehicle.
A nurse is preparing to collect a blood specimen from a newborn via heel stick, which of the
following techniques should the nurse use to help minimize the pain?
Place the newborn skin to skin on the mother’s chest.
A nurse is developing a plan for a client who has preeclampsia, and is receiving magnesium
sulfate via continuous IV infusion. Which of the following interventions should the nurse include
in the plan?
Monitor the FHR continuously.
, Nurse is caring for a client in labor who is experiencing increased rectal pressure, She is
experiencing contraction that are 2-3 minutes apart, each lasting 80-90 seconds, and a vaginal
examination reveals that her cervix is dilated to 9cm, the nurse should identify that the client is
in which phase of labor?
Transition
A nurse is performing a vaginal exam on a client that reports severe pressure and pain in the
lower back. The nurse notes that the fetal head is in posterior position, the nurse should
identify that which of the following is the best non-pharmacological to perform to relieve the
client’s discomfort?
Counter-Pressure
A nurse is caring for a client who is at 24 weeks gestation and reports daily, mild headaches.
Which of the following should the nurse include in the instructions for the plan of care?
Recommend that the client perform conscious relaxation techniques daily.
A nurse is teaching a new mom how to bulb syringe to suction her newborn’s secretions, Which
of the following instructions should the nurse include in her teaching?
Stop suctioning when the newborn’s cry sounds clear. (always suction mouth before nose, nose
only if you must)
A nurse is assessing a newborn who is 12 hours old, which of the following clinical
manifestations requires intervention by the nurse?
Substernal chest retractions while sleeping
A nurse is teaching a client about effective breast feeding who is 3 days postpartum, which of
the following information should the nurse include?
Newborn should appear content after each feeding.
Nurse is caring for a client that had uterine hypotonicity and is experiencing post-partum
hemorrhage, which of the following actions is the nurse’s priority?
Massage the client’s fundus.
Nurse is teaching a client who is 24 weeks gestation regarding a 1-hour glucose tolerance test,
which of the following statements should the nurse include in her teaching?
Blood glucose between 130 and 140 is considered a positive screening result.
Nurse is teaching a client who has pre-gestational type 1 diabetes about management during
pregnancy, which of the following statements made by the client, indicates an understanding of
the teaching?
I will continue taking my insulin if I experience nausea and vomiting.
