Maternal A
A nurse is reviewing the medical record of a client who is one day postpartum. The
client had a vaginal birth with a fourth-degree perineal laceration. The nurse should
contact the provider regarding which of the following prescriptions? - answer The nurse
should not administer a rectal suppository or enema to a client who has a fourth-degree
perineal laceration. These can cause separation of the suture line, bleeding, or
infection.
A nurse is preparing to administer hepatitis B immune globulin to a newborn. The
prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10
mcg/mL. How many mL should the nurse administer? (Round the answer to the nearest
tenth. Use a leading zero if it applies. Do not use a trailing zero.) - answer STEP 8:
Reassess to determine whether the amount to administer makes sense. If there are 10
mcg/mL and the prescription reads 5 mcg, it makes sense to administer 0.5 mL. The
nurse should administer hepatitis B immunoglobulin 0.5 mL IM.
A nurse is teaching a client who is at 8 weeks of gestation about exercise. Which of the
following instructions should the nurse include in the teaching? - answer The nurse
should instruct the client to engage in 30 min of moderate exercise every day to improve
muscle tone throughout her pregnancy.
A nurse is assessing a client who is in labor and notes early decelerations on the fetal
monitor. Which of the following findings should the nurse identify as a possible cause of
the early decelerations? - answer The nurse should identify fetal head compression as a
likely cause of the early decelerations on the fetal monitor. Early decelerations are an
expected fetal pattern caused by fetal head compression due to uterine contractions,
fundal pressure, and vaginal examinations.
A nurse is caring for a client and her partner who have experienced a fetal death. Which
of the following actions should the nurse take? - answer Take photos of the newborn to
give to the parents.
The nurse should create a memory box that includes mementos of the newborn (for
example, photos, the newborn's ID bands, the newborn's hat, and the newborn's
blanket).
A nurse is observing a new mother caring for her crying newborn who is bottle feeding.
Which of the following actions by the mother should the nurse recognize as a positive
parenting behavior? - answer Lays the newborn across her lap and gently sways.
This is a correct technique for quieting a newborn. This tactile stimulation promotes a
sense of security for the newborn.
A nurse on an antepartum unit is caring for four clients. Which of the following clients
should the nurse identify as the priority? - answer Epigastric pain is a clinical
manifestation of preeclampsia and indicates hepatic involvement, which is an urgent
finding. Therefore, the nurse should identify this client as the priority.
, Maternal A
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the
following findings is an indication for the administration of the medication? (Select all
that apply.) - answer Flaccid uterus is correct. Oxytocin increases the contractility of the
uterus.
Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues
even when the uterus is contracted and firm. It will require repair by the provider.
Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing
vaginal bleeding.
Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than
decrease, afterbirth cramping.
Increased maternal temperature is incorrect. The use of oxytocin will have no effect on
maternal temperature.
A nurse is teaching a new mother about newborn safety. Which of the following
instructions should the nurse include in the teaching? - answer Room-sharing is
recommended during the first few weeks. This allows the parents to be readily available
to the newborn and learn the newborn's cues. However, the nurse should instruct the
parents to avoid placing the newborn in their bed as it increases the risk for sudden
infant death syndrome.
A nurse is calculating a client's expected date of birth using Naegele's rule. The client
tells the nurse that her last menstrual cycle started on November 27th. Which of the
following dates is the client's expected date of birth? - answer When using Naegele's
rule to calculate the estimated date of birth for a client, the nurse should subtract 3
months from the first day of the client's last menstrual cycle and then add 7 days.
November 27th minus 3 months equals August 27th. August 27th plus 7 days equals
September 3rd.
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to
perform Leopold maneuvers. Which of the following images indicates the first step of
Leopold maneuvers? - answer Evidence-based practice indicates the nurse should
perform this step first when performing Leopold maneuvers. During this step, the nurse
palpates the client's abdomen with her palms to determine which fetal part is in the
uterine fundus. This step also identifies the lie (transverse or longitudinal) and
presentation (cephalic or breech) of the fetus.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal
monitoring? - answer The nurse should perform Leopold maneuvers to assess the
A nurse is reviewing the medical record of a client who is one day postpartum. The
client had a vaginal birth with a fourth-degree perineal laceration. The nurse should
contact the provider regarding which of the following prescriptions? - answer The nurse
should not administer a rectal suppository or enema to a client who has a fourth-degree
perineal laceration. These can cause separation of the suture line, bleeding, or
infection.
A nurse is preparing to administer hepatitis B immune globulin to a newborn. The
prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10
mcg/mL. How many mL should the nurse administer? (Round the answer to the nearest
tenth. Use a leading zero if it applies. Do not use a trailing zero.) - answer STEP 8:
Reassess to determine whether the amount to administer makes sense. If there are 10
mcg/mL and the prescription reads 5 mcg, it makes sense to administer 0.5 mL. The
nurse should administer hepatitis B immunoglobulin 0.5 mL IM.
A nurse is teaching a client who is at 8 weeks of gestation about exercise. Which of the
following instructions should the nurse include in the teaching? - answer The nurse
should instruct the client to engage in 30 min of moderate exercise every day to improve
muscle tone throughout her pregnancy.
A nurse is assessing a client who is in labor and notes early decelerations on the fetal
monitor. Which of the following findings should the nurse identify as a possible cause of
the early decelerations? - answer The nurse should identify fetal head compression as a
likely cause of the early decelerations on the fetal monitor. Early decelerations are an
expected fetal pattern caused by fetal head compression due to uterine contractions,
fundal pressure, and vaginal examinations.
A nurse is caring for a client and her partner who have experienced a fetal death. Which
of the following actions should the nurse take? - answer Take photos of the newborn to
give to the parents.
The nurse should create a memory box that includes mementos of the newborn (for
example, photos, the newborn's ID bands, the newborn's hat, and the newborn's
blanket).
A nurse is observing a new mother caring for her crying newborn who is bottle feeding.
Which of the following actions by the mother should the nurse recognize as a positive
parenting behavior? - answer Lays the newborn across her lap and gently sways.
This is a correct technique for quieting a newborn. This tactile stimulation promotes a
sense of security for the newborn.
A nurse on an antepartum unit is caring for four clients. Which of the following clients
should the nurse identify as the priority? - answer Epigastric pain is a clinical
manifestation of preeclampsia and indicates hepatic involvement, which is an urgent
finding. Therefore, the nurse should identify this client as the priority.
, Maternal A
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the
following findings is an indication for the administration of the medication? (Select all
that apply.) - answer Flaccid uterus is correct. Oxytocin increases the contractility of the
uterus.
Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues
even when the uterus is contracted and firm. It will require repair by the provider.
Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing
vaginal bleeding.
Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than
decrease, afterbirth cramping.
Increased maternal temperature is incorrect. The use of oxytocin will have no effect on
maternal temperature.
A nurse is teaching a new mother about newborn safety. Which of the following
instructions should the nurse include in the teaching? - answer Room-sharing is
recommended during the first few weeks. This allows the parents to be readily available
to the newborn and learn the newborn's cues. However, the nurse should instruct the
parents to avoid placing the newborn in their bed as it increases the risk for sudden
infant death syndrome.
A nurse is calculating a client's expected date of birth using Naegele's rule. The client
tells the nurse that her last menstrual cycle started on November 27th. Which of the
following dates is the client's expected date of birth? - answer When using Naegele's
rule to calculate the estimated date of birth for a client, the nurse should subtract 3
months from the first day of the client's last menstrual cycle and then add 7 days.
November 27th minus 3 months equals August 27th. August 27th plus 7 days equals
September 3rd.
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to
perform Leopold maneuvers. Which of the following images indicates the first step of
Leopold maneuvers? - answer Evidence-based practice indicates the nurse should
perform this step first when performing Leopold maneuvers. During this step, the nurse
palpates the client's abdomen with her palms to determine which fetal part is in the
uterine fundus. This step also identifies the lie (transverse or longitudinal) and
presentation (cephalic or breech) of the fetus.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take prior to applying an external transducer for fetal
monitoring? - answer The nurse should perform Leopold maneuvers to assess the
