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A primigravida who is at 40 weeks' gestation arrives at the birthing center with
abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before
arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1
station. After obtaining the fetal heart rate and maternal vital signs, what should the
nurse's priority intervention be? - Answer Provide the client with comfort measures used
for women in labor
As the nurse inspects the perineum of a client who is in active labor, the client suddenly
turns pale and states that she feels as if she is going to faint even though she is lying
flat on her back. What is the nurse's priority intervention - Answer Turn her onto her left
side
During the second stage of labor the nurse discourages the client from holding her
breath longer than 6 seconds while pushing with each contraction. Which complication
does this prevent? - Answer Fetal Hypoxia
At 39 weeks' gestation a client asks the nurse about the difference between true and
false labor. Which information regarding true labor contractions should the nurse include
in a response to the client's question? - Answer Accompanied by progressive cervical
dilation
The nurse is teaching participants in a prenatal class regarding breastfeeding versus
formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which
response is most appropriate - Answer "Breastfed infants have fewer infections."
A pregnant client uses a computer while sitting almost continuously during her working
hours. This has implications for her plan of care during pregnancy. What should the
nurse recommend? - Answer "Try to walk around every few hours during the workday."
A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The
nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It
rises to 160 on two occasions and 157 once during a 20-minute period. Each of the
episodes in which the heart rate is increased lasts 20 seconds. Which action should the
nurse take? - Answer Discontinuing the test because the pattern is within the normal
range
A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal
examination, the nurse determines that the client's cervix is dilated 2 cm and 80%
effaced and that the presenting part is at 0 station. What is the location of the presenting
part? - Answer At the level of the ischial spines
A client tells the nurse that the first day of her last menstrual period was July 22. What is
the estimated date of birth (EDB)? - Answer April 29
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Late decelerations are present on the monitor strip of a client who received epidural
anesthesia 20 minutes ago. What should the nurse do immediately? - Answer
Reposition the client from supine to left lateral
A client is admitted to the birthing unit in active labor. Which physiologic changes should
the nurse anticipate after an amniotomy is performed? - Answer Progressive dilation
and effacement
During labor a client begins to experience dizziness and tingling of her hands. What
should the nurse instruct the client to do? - Answer cupped hands
The nurse is reviewing the documented results of a lecithin/sphingomyelin (L/S) ratio.
Which finding is indicative of fetal lung maturity? - Answer 2:1
On a 6-week postpartum visit a new mother tells the nurse she wants to feed her baby
whole milk after 2 months because she will be returning to work and can no longer
breastfeed. The nurse plans to teach the mother that she should switch to formula
feeding because whole milk does not meet the infant's nutritional requirements for
what? - Answer Correct2
Vitamin C and iron
During a routine second-trimester visit to the prenatal clinic a client expresses concern
regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a
diet." What is the nurse's best response? - Answer "If you add 340 calories a day to
your regular diet, you won't become overweight."
A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse
notes blood oozing from the penis. Which intervention is the priority for the nurse at this
time? - Answer Documenting the amount of bleeding in the infant's chart
Which information concerning the childbearing process should the nurse teach a client
during the first trimester of pregnancy? - Answer Physical and emotional changes
resulting from pregnancy
A client at 42 weeks' gestation has a reactive nonstress test. The nurse determines that
the client understands what she was taught about the results when she is overheard
telling her husband that the test was what? - Answer Normal because of an increase in
fetal heart rate (FHR) with fetal movement
What should a nurse teach a nonbreastfeeding mother to help relieve the discomfort of
engorgement? - Answer Apply cold packs to the breasts frequently
After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking."
How should the nurse respond? - Answer "I'll get you some warm blankets to help make
the chill go away.
A primigravida who is at 40 weeks' gestation arrives at the birthing center with
abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before
arrival. A vaginal examination reveals 1 cm of dilation and the presenting part at -1
station. After obtaining the fetal heart rate and maternal vital signs, what should the
nurse's priority intervention be? - Answer Provide the client with comfort measures used
for women in labor
As the nurse inspects the perineum of a client who is in active labor, the client suddenly
turns pale and states that she feels as if she is going to faint even though she is lying
flat on her back. What is the nurse's priority intervention - Answer Turn her onto her left
side
During the second stage of labor the nurse discourages the client from holding her
breath longer than 6 seconds while pushing with each contraction. Which complication
does this prevent? - Answer Fetal Hypoxia
At 39 weeks' gestation a client asks the nurse about the difference between true and
false labor. Which information regarding true labor contractions should the nurse include
in a response to the client's question? - Answer Accompanied by progressive cervical
dilation
The nurse is teaching participants in a prenatal class regarding breastfeeding versus
formula feeding. A client asks, "What is the primary advantage of breastfeeding?" Which
response is most appropriate - Answer "Breastfed infants have fewer infections."
A pregnant client uses a computer while sitting almost continuously during her working
hours. This has implications for her plan of care during pregnancy. What should the
nurse recommend? - Answer "Try to walk around every few hours during the workday."
A primigravid client who is at 38 weeks' gestation is undergoing a nonstress test. The
nurse determines that the baseline fetal heart rate is 130 to 140 beats per minute. It
rises to 160 on two occasions and 157 once during a 20-minute period. Each of the
episodes in which the heart rate is increased lasts 20 seconds. Which action should the
nurse take? - Answer Discontinuing the test because the pattern is within the normal
range
A 22-year-old primigravida is admitted to the hospital in labor. After performing a vaginal
examination, the nurse determines that the client's cervix is dilated 2 cm and 80%
effaced and that the presenting part is at 0 station. What is the location of the presenting
part? - Answer At the level of the ischial spines
A client tells the nurse that the first day of her last menstrual period was July 22. What is
the estimated date of birth (EDB)? - Answer April 29
, asdf
Late decelerations are present on the monitor strip of a client who received epidural
anesthesia 20 minutes ago. What should the nurse do immediately? - Answer
Reposition the client from supine to left lateral
A client is admitted to the birthing unit in active labor. Which physiologic changes should
the nurse anticipate after an amniotomy is performed? - Answer Progressive dilation
and effacement
During labor a client begins to experience dizziness and tingling of her hands. What
should the nurse instruct the client to do? - Answer cupped hands
The nurse is reviewing the documented results of a lecithin/sphingomyelin (L/S) ratio.
Which finding is indicative of fetal lung maturity? - Answer 2:1
On a 6-week postpartum visit a new mother tells the nurse she wants to feed her baby
whole milk after 2 months because she will be returning to work and can no longer
breastfeed. The nurse plans to teach the mother that she should switch to formula
feeding because whole milk does not meet the infant's nutritional requirements for
what? - Answer Correct2
Vitamin C and iron
During a routine second-trimester visit to the prenatal clinic a client expresses concern
regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a
diet." What is the nurse's best response? - Answer "If you add 340 calories a day to
your regular diet, you won't become overweight."
A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse
notes blood oozing from the penis. Which intervention is the priority for the nurse at this
time? - Answer Documenting the amount of bleeding in the infant's chart
Which information concerning the childbearing process should the nurse teach a client
during the first trimester of pregnancy? - Answer Physical and emotional changes
resulting from pregnancy
A client at 42 weeks' gestation has a reactive nonstress test. The nurse determines that
the client understands what she was taught about the results when she is overheard
telling her husband that the test was what? - Answer Normal because of an increase in
fetal heart rate (FHR) with fetal movement
What should a nurse teach a nonbreastfeeding mother to help relieve the discomfort of
engorgement? - Answer Apply cold packs to the breasts frequently
After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking."
How should the nurse respond? - Answer "I'll get you some warm blankets to help make
the chill go away.
