The client will need to be catheterized before the epidural can be
administered. A client who is HIV+ is receiving zidovudine during
labor. Which information should the nurse provide to the client?
Correct Answer: This treatment helps prevent transmission of the
virus to the fetus.
Vaginal examinations reveal that a laboring client cervix is dilated
2cm, 70% effaced, with presenting part at -2 station. The client
tells the nurse " I need my epidural now! This hurts!" The nurse
response to the client should be based on which information.
Correct Answer: Administering an epidural at this point would
slow the labor process.
A newborn's head circumference is 12 inches (30.5cm), and his
chest measurement is 13 inches (33cm). The nurse notes that
this infant has no molding, and was at breech presentation
delivery by c section. What action should the nurse take based on
these data?
,Correct Answer: Record the finding on the chart. They are within
normal limits.
A three hour old newborn of a gestational diabetic mother who is
asymptomatic and successful breastfed after birth, heel stick
glucose level is 36 mg/dL. Which intervention should the nurse do
first?
Correct Answer: Assist the mother to breastfeed the infant
The nurse is caring for a female client, a primigravida with
preeclampsia. Finding include +2 proteinuria, BP 172/112 mmHg,
Facial and hand sweating, complaints of blurry vision, and a
severe frontal headache. Which medication should the nurse
anticipate for this client?
Correct Answer: Magnesium sulfate
When planning care for a laboring client, the nurse identifies the
need to withhold solid foods while the client is in labor. What is
the most important reason for this nursing intervention?
Correct Answer: An increase risk for aspiration can occur if
general analgesic is needed.
,Which action should the nurse take if an infant, who was born
yesterday weighing 7.5 lbs
Correct Answer: Inform and assure the mother that this is normal
weight loss.
A client at 20 week gestation comes to the antepartum clinic
complaining of vaginal warts. HPV. What information should the
nurse provide?
Correct Answer: The client should be treated with acyclovir.
At 34 weeks gestation, a primigravida is assessing at her
bimonthly clinic visit. Which assessment finding is important for
the nurse to report to the HCP.
Correct Answer: Weight gain of 7 lbs
A client in preterm labor has had an infusion of magnesium
sulfate running 8 hrs. Current assessment finding are: RR 14
bpm, UOP 24
Correct Answer: The finding indicate potential toxicity to
magnesium sulfate and close follow up is indicated.
, the nurse notes that a newborn at 24hrs of age has a large
cephalhematoma. Which intervention has the highest priority?
Correct Answer: Assess the infant for jaundice every 8 hours
The charge nurse working on a postpartum unit is making
assignments for a staff consisting of a nurse, practical nurse and
2 unlicensed assistive personnel. Which client should the charge
nurse assign to the practical nurse?
Correct Answer: A multagraida who delivered during c section 20
min ago and needs her vital signs taken.
The nurse is providing anticipatory guidance for an African-
American client who is at 24-weeks gestation. Which prenatal lab
assessment, prescribed at 28-weeks, should the nurse includes
Correct Answer: One-hour glucose screen
A new mother asks the nurse why her infant son has a needle
mark on his leg. Which response is best for the nurse to provide
the mother?