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A nurse is caring for a newborn. The nurse should obtain informed consent before
taking which of the following actions?
a) administering erythromycin ophthalmic ointment
b) conducting a newborn hearing screening
c) giving the hepatitis B vaccine
d) screening for critical congenital heart disease - Correct answer-c) giving the
hepatitis B vaccine
A nurse is caring for an adolescent who is in the second trimester of pregnancy.
The client states, "I've gotten used to the idea of this pregnancy. It will be fun to
have a little baby around the house." Which of the following is the appropriate
response by the nurse?
a) "Babies are not fun. They're a lot of work"
b) "I'm so glad to see you're happy about the baby"
c) "How are your parents reacting to the pregnancy?"
d) "Tell me how you think your life will be after the baby is born" - Correct
answer-d) "Tell me how you think your life will be after the baby is born"
A nurse is assessing a pregnant client at 26 weeks of gestation who reports an
episode of dizziness after lying on her back on the couch. Which of the following
actions should the nurse take?
a) request a prescription for preeclampsia laboratory studies
b) advise the client to lie on her side
c) request an ultrasound to evaluate fetal wellbeing
d) advise the client to add a calcium supplement to her diet - Correct answer-b)
advise the client to lie on her side
A nurse is caring for a client who is in labor and is receiving an infusion of
oxytocin. The nurse should monitor the client for which of the following potential
adverse effects?
a) diarrhea
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b) thromboembolism
c) fetal asphyxia
d) oliguria - Correct answer-c) fetal asphyxia
A nurse is providing education to a client who is 4 weeks postpartum and is
breastfeeding. The client asks about expected weight loss. Which of the following
responses should the nurse make?
a) "Losing 2.2 pounds each month would be acceptable"
b) "Losing 4.4 pounds each month would be acceptable"
c) "Losing 5.5 pounds each month would be acceptable"
d) "Losing 6.6 pounds each month would be acceptable" - Correct answer-a)
"Losing 2.2 pounds each month would be acceptable"
A nurse is talking with a client at 20 weeks of gestation who is scheduled for a
sonogram. The client states, "I am here to have my regular prenatal checkup, but I
do not want any pictures taken of my baby." Which of the following responses
should the nurse make?
a) "Do not worry. We can do the sonogram without showing you the sex of the
baby"
b) "I would like to hear more about why you do not want the sonogram, including
any cultural reasons"
c) "I think you should reconsider because the sonogram is an important part of the
baby's checkup"
d) "You have the right to tell the doctor that you do not want the sonogram" -
Correct answer-b) "I would like to hear more about why you do not want the
sonogram, including any cultural reasons"
A nurse is assessing a pregnant client who is at 38 weeks gestation. The client
reports that her breathing has become easier but notes an increased frequency of
urination. The nurse should document this occurrence as which of the following?
a) effacement
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b) dilation
c) lightening
d) quickening - Correct answer-c) lightening
A nurse is teaching a client who is postpartum about keeping the newborn safe.
Which of the following statements should the nurse identify as an indication that
the client understands the instructions?
a) "I will put bumper pads in the crib"
b) "I will warm my baby's formula in the microwave on a low setting"
c) "I will place my baby on his stomach to sleep"
d) "I will purchase a firm mattress for the crib" - Correct answer-d) "I will
purchase a firm mattress for the crib"
A nurse is caring for a client who reports intestinal gas pain following a cesarean
section. Which of the following actions should the nurse take?
a) assist the client to ambulate in the hallway
b) instruct the client to splint the incision with a pillow
c) have the client drink fluids through a straw
d) encourage the client to drink carbonated beverages - Correct answer-a) assist the
client to ambulate in the hallway
A nurse is assessing a client who is in the fourth stage of labor. Which of the
following findings should the nurse expect?
a) breast engorgement
b) hypothermia
c) urinary retention
d) rupture of membranes - Correct answer-c) urinary retention
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A nurse is teaching a client who is at 30 weeks gestation about warning signs of
complications that she should report to her provider. Which of the following
findings should the nurse include in the teaching?
a) mild constipation
b) nasal congestion
c) vaginal bleeding
d) 10 fetal movements per hour - Correct answer-c) vaginal bleeding
The guardian of a 3-day-old female newborn tells the nurse that he noticed a small
amount of blood-tinged mucus discharge on the newborn's labia. Which of the
following responses should the nurse make?
a) "The blood-tinged mucus is a result of pseudo menstruation"
b) "The blood-tinged mucus indicates a urinary tract infection"
c) "The blood-tinged mucus is due to uric acid crystals"
d) "The blood-tinged mucus is a result of the initial genital examination" - Correct
answer-a) "The blood-tinged mucus is a result of pseudo menstruation"
A nurse is caring for a client who is at 26 weeks gestation and reports constipation.
Which of the following responses by the nurse is appropriate?
a) "You should drink 1 oz of mineral oil every morning"
b) "You should walk for at least 30 minutes every day"
c) "You should eat at least 3 oz of red meat per day"
d) "You should stop taking your prenatal vitamin" - Correct answer-b) "You
should walk for at least 30 minutes every day"
A nurse is assessing a newborn that is 2 hr. old. Which of the following findings
should the nurse report to the provider?
a) overlapping suture lines
b) generalized petechiae
c) acrocyanosis
d) transient strabismus - Correct answer-b) generalized petechiae