HESI RN Maternity V1 – Notes and Questions with answers

HESI RN Maternity V1 – Notes and Questions with answers Maternity and Peds • The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. • Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 • Ampicillin 1 gram IV push q8h. • Betamethasone (Celestone) 12 mg deep IM • Butorphanol (Stadol) 1 mg IV push q2h PRN pain 2. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? • Carrots • Chicken • Yogurt • Cheese 3. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? • Respiratory rate of 22 breaths/min • A large amount of lochia rubra • Blood pressure 149/90 • Positive Homan’s sign 4. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? • Begin a training program lifting weights and running • Splint affected joints during activity • Exercise in a swimming pool • Perform passive range of motion exercises twice daily 5. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? • Pain level • Blood pressure • Infusion site • Contraction pattern 6. One day after vaginal delivery of a full term baby, a postpartum client’s white blood cell count is 15.000/mm. What action should the nurse take first? • Check the differential, since the WBC is normal for this client • Assess the client’s temperature, pulse, and respirations q4h • Assess the client’s perineal area for signs of a perineal hematoma • Notify the healthcare provider, since this finding is indicative of infection 7. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? • Discuss the need for cortisol and aldosterone replacement therapy after discharge • Support the parents in their decision to assign sex of their child according to their preference • Offer information about ultrasonography and genotyping to determine sex assignment • Explain that corrective surgical procedures consistent with sex assignment can be delayed 8. The nurse assessing a 9-year old boy who has been admitted to the hospital with possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? • Back pain for a few days • A history of hypertension • A sore throats last week • Diuresis during the nights Note: Page 1538 MB 9. A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer? 13 10. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? • Alert the neonatal team and prepare for neonatal resuscitation • Notify the healthcare provider from the client’s bedside • Obtain written consent for an emergency cesarean section • Draw a blood sample for stat hemoglobin and hematocrit 11. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? • Turn the client to her left side • Contact the healthcare provider • Assess the fetal heart rate • Check the cervical dilation 12. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? A. Obtain a culture of any sputum or wound drainage. • Obtain a culture of any sputum or wound drainage • Initiate normal saline IV at 50 ml/hr • Administer a loading dose of penicillin IM • Administer the initial dose of folic acid PO 13. A child has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? • Respiratory alkalosis • Respiratory acidosis • Metabolic alkalosis • Metabolic acidosis 14. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? • Respiratory alkalosis • Respiratory acidosis • Metabolic acidosis • Metabolic alkalosis 15. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child? • Reduce cerebral edema and lower intracranial pressure • Avert hypotension and septic shock • Prevent cardiac arrhythmias and heart failure • Promote kidney perfusion and normal blood pressure. 16. A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? • Decrease the oxytocin infusion rate • Determine current cervical dilation • Request placement of the epidural • Give a bolus of intravenous fluids 17. A child who received multiple blood transfusions after correction of a congenital heart defects is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider? • CO combining power • Calcium • Sodium • Chloride 18. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic (sudden aimless movements of the arms and legs). Which information should the nurse to the parents? • Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged • The chorea or movements are temporary and will eventually disappear • Permanent life-style changes need to be made to promote safety in the home • Consistent discipline is needed to help the child control the movements 19. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next? • Measure the infant’s head to heel length • Observe the infant for sunset eyes • Palpate the anterior fontanel for tension and bulging • Plot the measurement on the infant’s growth chart 20. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan? • Keep airway equipment at the bedside. • Allow liberal family visitation • Monitor blood pressure, pulse, and respirations q4h • Assess temperature q1h 21. During a well-child visit for their child, one of the parent who has an autosomal dominant disorder tells the nurse, “We don’t plan on having any more children, since the next child is likely to inherit this disorder”. How should the nurse respond? • Explain that the risk of inhering the disorder decrease by 50% with each child the couple has • Acknowledge that the next that the next child will inherit the disorder since the first child did not • Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked • Confirm that there is a 50% chance of their future children inheriting the disorder 22. The nurse is caring for a one-year-old child following surgical correction of hypospadias. The nursing action has the highest priority? • Monitor urinary output • Auscultate bowel sounds • Observe appearance of stool • Record percent of diet eaten 23. Patient with Duchenne Disease. The nurse has to explain to the mother that: This condition is inherited in an X-linked recessive chromosome pattern 24. Primipara patient. What is the pet to share time a, home that is not recommended? CAT 25. An infant with letralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? • Administer morphine sulphate • Start IV fluids • Place the infant in a knee-chest position • Provide 100% oxygen by face mask 26. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12 year old sibling at the child’s bedside. Which instruction best supports family? • While waiting for the healthcare provider, only one visitor may stay with the child • All of you should leave while the healthcare provider sutures the child’s forehead • It is best if the sibling goes to the waiting room until the suturing is completed • Please decide who will stay when the healthcare provider begins suturing 27. The parents of a 3 year-old boy who has Duchenne muscular dystrophy (DMD) ask “how can our son have this disease? We are wondering if we should have any more children” What information should the nurse provide these parents? • This is an inherited X-linked recessive disorder, which primarly affects male children in the family • The male infant had a viral infection that went unnoticed and iuntreated, so muscle damage was incurred • The XXXX muscle groups of males can be impacted by a lack of the protein dystrophyn in the mother • Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles 28. A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? • Bilateral bronchial breath sounds • Diaphragmatic respiration • A resting respiratory rate of 35 breathe per minute • Flaring of the nares 29. A two year old child with a heart failure(HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement? • Determine the pulse deficit • Administer the schedule dose • Calculate the safe dose range • Review the serum digoxin level 30. Which nursing intervention is most important to include in the plan of care for for a child with acute glomerulonephritis? • Encourage fluid intake • Promote complete bed rest • Weight the child daily • Administer vitamin supplements 31. A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history which finding should the nurse expect to obtain? • High blood cholesterol level on routine screening • Increased thirst and urination • A recent strep throat infection • A recent DPT immunization • A newborn yellow abdomen and chest Assess bilirubin level • Child HIV Respiratory system • Glomerunephritis Strawberry • Percentile 97 Is in normal high level con respect a las caracteristicas del nino • To confirm RDS in a newborn Diagphrama breathing • Cryptorchidism Put baby in a room and calm the baby • Diaper Clean water • ADHD Encourage the parents to help the baby with homework • Watery vaginal white in the first trimester Is normal • Propanol Decrease headache • Palirizumab (synagis) Is given to high risk baby 43. A child with leukemia is admitted for Chemotherapy and the nursing diagnosis " altered nutrion, less those body requirements related to anorexia, nausea and vomiting" is identified. Which intervention the nurse included in this child plan of care? Allow the child to eat any food desired and tolerated. 44. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide? Maternal blood pressure 45. A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother? Ask the mother to stop feeding, confront the infant, and then assist the mother to help the baby latch on. 46. A blind litter girld, 8 year sold was admitted to the hospital ..... Bring familiarly toys from home, such as bear,doll. 47. Apple 48. 9 redondiado 49. Preclancia Zeisures 50. A woman with mastitis Ice pack 51. Belling Change the client position before call the doctor. 52. A pregnant woman with hypermesis gravidarium, what is the best nurse intervention. Administered prescribed IV solution. 2021 HESI RN Maternity V1 – Notes Practice Questions 1. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client’s teaching plan? A. Oral contraceptive use for at least one year. 2. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? C. Betamethasone (Celestone) 12 mg deep IM. 3. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this fiding? B. Both the lower uterine segment and the fundus must be massaged. 4. Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl with a history of frequent urinary tract infections? D. Monitor for changes in urinary odor. 5. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet? B. Chicken. 6. The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer? 0.3 7. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? C. Blood pressure 149/90. 8. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and a 12-year-old sibling are the child bedside. Which instruction best supports this family? A. “ While waiting for the healthcare provider, only one visitor may stay with the child” 9. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? C. Exercise in a swimming pool. 10. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time? D. Contractions decrease with walking. 11. Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest? D. Checkers 12. The nurse has completed a teaching plan for the mother of a child who is taking digitalis and a diuretic for treatment of the heart failure. Choosing which lunch would indicate that the mother understands the best diet for her child? B. Peanut butter and banana sandwich with orange juice. 13. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding? C. The TSH is high because of the low production of T4 by the thyroid. 14. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? D. Stimulate the infant to cry. 15. At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? D. Early postpartum, within 72 hours of delivery. 16. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? D. Contraction pattern. 17. One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? A. Check the differential, since the WBC is normal for this client. 18. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client’s condition, what information is most important for the nurse to provide? A. Maternal blood pressure. 19. While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement? A. Inspect the posterior oropharynx. 20. During a routine clinic visit, the nurse determines that a 5-year-old boy’s blood pressure is 112/70. When calculating the child’s blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next? A. Compare the child’s blood pressure with readings from previous visits. 21. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? C. Offer information about ultrasonography and genotyping to determine sex assignment. 22. A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child’s hair with permethrin (Nix) shampoo and calls his parents. What instruction should the nurse provide to the parents about treatment for head lice? A. Rewash the child’s hair following a 24-hour isolation period. B. Wash the child’s bed linens and clothing in hot soapy water Maybe this C. Take the child to a hair salon for a shampoo and a shorter haircut. D. Dispose of the child’s brusches, combs, and others hair accessories. 23. During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client. D. Elevate the head with two pillows while sleeping. 24. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement? A. Document the vital signs in the record. 25. The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? C. A sore throat last week 26. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? C. Apply hot packs just before each feeding. 27. A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only) 13 28. A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first? A. Place the infant on the abdomen to protect the sac. 29. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take? D. Determine the infant’s blood sugar level. 30. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son’s acne cream, benzoyl peroxide, on the baby’s face. Which answer should the nurse to provide? A. “ Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider” 31. The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity? D. Early ambulation after surgery will be encouraged to reduce complications and promote healing. 32. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? C. obtain written consent for an emergency cesarean section. 33. 33. 34. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? B. Contact the healthcare provider. 35. A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer’s Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only) 75 36. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby’s weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? D. “What food does your baby usually eat in a normal day?” 37. A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? B. Initiate normal saline IV at 50ml/hr. 38. A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? C. Metabolic Alkalosis. 39. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority? D. Have a meconium aspirator available at delivery. 40. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration? C. Metabolic acidosis 41. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child? A. Reduce cerebral edema and lower intracranial pressure. 42. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first? B. Determine current cervical dilation. 43. A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant’s skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)? A. Sweat-chloride test. 44. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a button attached to the fetal monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. Which outcome indicates a reactive NST? C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded. 45. A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform? B. Babinski’s reflex. 46. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse to review before reporting to the healthcare provider? B. Calcium. 47. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea ( sudden aimless movements of the arms and legs). Which information should the nurse tell to the parents? B. The chorea or movements are temporary and will eventually disappear. 48. The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life? C. Cries vigorously when stimulated. 49. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, and notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to the body size. Which action is most important for the nurse to take next? C. Palpate the anterior fontanel for tension and bulding. 50. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis af eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan? C. Monitor Blood pressure, pulse, and respirations q4h. 51. During a well-child visit for their child, one of the parents who has an autosomal dominant disorder tells the nurse, “We don’t plan on having any more children, since the next child is likely to inherit this disorder.” How should the nurse respond? D. Confirm that there is a 50% chance of their future children inheriting the disorder. 52. The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority? A. Monitor urinary output. 53. What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes? A. Restrict carbohydrate intake. 54. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother? B. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby lactch on. 55. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance. Maternity 1. A 3-month-old with myelomeningocele and atonic bladder is catheterized every four hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria,, watery eyes, ad a rash in the diaper area. What action is most important for the nurse to take? 2. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? 3. The 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated? 4. A 6-year old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is most important for the nurse to implement? 5. A 34-week primigravida with preeclampsia is receiving Lactated Ringer's 500 ML with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many mL/hour should be the nurse program into the infusion pump? 6. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? Change to latex - free gloves when handling infant A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? Visible peristaltic wave Assess bilateral lung sounds 75mL/hour Notify healthcare provider at patients' bedside 7. A 39 week gestation, a multigravida is having a non-stress test (NST). The fetal heart rate (FHR) has remained non- reactive during the 30 minutes of evaluation. Based on this finding, which action should the nurse implement? 8. Artificial rupture of the membranes of a laboring client reveals meconium- stained fluid. What intervention has the greatest priority? 9. At 20 weeks gestation, a client who has gained 20 pounds during pregnant states that she is felling fetal movement. Fundal height measurement is 20 cm, and the clients only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? 10. A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2 F, with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? 11. A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. What information is most important foe the nurse to obtain first? 12. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide? 13. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first? Place an acoustic simulator on the abdomen. Have a meconium aspirator available at delivery Gestational weight gain. Chorioamnionitis Color and consistency of fluid Maternal blood pressure Determine current cervical dilation 14. A community health nurse visits a family in which a 16-year old unmarried daughter is pregnant with her first child and is at 32 weeks gestation. The client tells the nurse that she has been intermittent back pain since the night before. What is the priority nursing intervention? 15. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement? 16. A four-year-old boy was recently diagnosis with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during initial teaching? 17. A full-term 24 hour old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? 18. The healthcare provider prescribes amoxicillin 500 mg PO every eight hours for a child who weighs 77 pounds. The available suspension is labeled, amoxicillin suspension 250 mg/5 ml. The recommended maximum does is 50 mg/kg/24 hour. How many mL should the nurse administer in a single dose based on the child's weight? (enter the numerical value only. If rounding is required, round to the whole number.) 19. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take? 20. An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. What action should the nurse implement first? 21. Insulin therapy is initiated for a 12 year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is important for the nurse to include in the child plan of care? ask the client if she has experienced any recent changes in vaginal discharge Document vital signs in record (normal) Lower legs become progressively weaker, causing a wedding, unsteady gait Stimulate the infant to cry 10mL/dose Determine infants blood sugar level Place the infant in a knee -chest position Monitor serum glucose for adjustment in infusion rate of regular insulin (Novolin R). 22. A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? 23. A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. What prescription is most important to implement? 24. A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "why is my baby sister eating my mommy's breast?" How should the nurse responds? (Select all that apply.) 25. A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond? 26. The nurse is assessing a 2 hour-old infant born by cesarean delivery at 39-weeks gestation. Which finding should receive the highest priority when planning the infants care? 27. The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life? 28. The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complains of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client? Assess fetal heart rate Infuse normal saline intravenously Remind him that his mother breastfed him too Reassure the older brother that it does not hurt Explain that newborns get milk mothers this way Advice the mother to wait at least another month before starting any solid foods. Respiratory rate of 76 breaths per min Cries vigorously when stimulated Magnesium Sulfate 29. The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control, which method should the nurse recommend to this client as best for her to use in preventing an unwanted pregnancy? 30. The nurse is examining an infant for possible crytorchildism. Which exam technique should be used? Condoms and contraceptive foam or gel Place the infant in warm room and use a calm approach 37. A one-day-old infant develops a cephalhematoma. The nurse closely assess this neonate for which common complication? 38. A one-day-old neonate develops a cephalhematoma. The nurse should closely assess this neonate for which common complication? 39. The parents of a newborn tell the nurse that their newborn is already trying to walk. How should the nurse respond? Brain Damage Jaundice Explain the newborns normal stepping reflex 31. The nurse is planing care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? 32. The nurse is planning discharge teaching Betamethasone (Celestone) 12 mg deep IM. OCP at least 40. Positive FHR, active fetal movements palpable by examiner, outline of fetus on US for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client's teaching plan? 33. The nurse is reviewing the serum one year Potassium of 41. A postpartum client is Rh-negative refuses to receive Rho(D) immune globulin (RhoGram) after delivery of an infant who is Rh-positive. What information should the nurse provide to this client? RhoGram prevents maternal antibody formation for future Rh- positive babies laboratory finding for a 5 day old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the healthcare provider immediately? 34. The nurse observes a mother giving her 11 month old ferrous sulfate, followed by 2 ounces of orange juice. What should the nurse do next? 35. The nurse places one hand above the symphysis while massaging the fundus of 4.5mEg/L Give positive feedback about way she administered the sulfate Both lower uterine 42. Presumptive amenorrhea, n/v, increase size/tenderness in breasts, pronounced nipples, urinary frequency, quickening (woman thinks she feels movements), fatigue a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this finding? 36. One day after vaginal delivery of a full- time baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first? segment and fundus need to be massaged Check the differential since the WBC is normal for this client. 43. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time? 44. A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the grieving process which intervention is most for the nurse to implement ? Contractions decrease with walking provide a time for the parents to hold their infant in privacy 45. Probable uterine enlargement, Hegar sign (softening of uterus), Chadwicks sign (blueish color cervix), Goodells sign (softening of cervical cap), ballottement (rebound fetus), positive test with hcg 46. What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes? 47. What is the most important assessment for the nurse to conduct the following the administration of epidural anesthesia to a client who is at 40 weeks gestation? 48. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (the) fistula ? 49. While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart patterns that falls and rise abruptly with a "V" shape appearance. What action should the nurse take first? 50. While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a "v" shaped appearance. What action should the nurse take first? Restrict carbohydrate intake Maternal blood pressure Time of first void Change the maternal position Change maternal position (for U shaped too)