TEST BANK INTRODUCTION TO GESTATION
9TH EDITION LEIFER EXAM WITH CORRECT
DETAILED ANSWERS 2023-2024
26-week gestational primigravida who is carrying twins is seen in the clinic today. Her
fundal height in measured at 29cm. Based on these findings what actions the nurse
implement.
a. Notify the healthcare provider of the finding
b. Document the finding in the medical record
c. Schedule the client for a biophysical profile
d. Request another nurse measure the fundus - ANSWERS -b. Document the finding in
the medical record
A 3-hour old male infant's hands are feet are cyanotic, and he has an axillary
temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165
beats/min. Which nursing intervention is best for the nurse to implement?
A. Perform a heel- stick to monitor blood glucose level
B. Gradually warm the infant under a radiant heat source
C. Administer oxygen by mask at 2L/minute
D. Notify the pediatrician of the infant's unstable vital signs - ANSWERS -B. Gradually
warm the infant under a radiant heat source
A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the
hospital. Which instruction should the nurse include in the discharge teaching plan?
a. breastfeed infant every 4 hours
b. monitor skin and eyes for yellow tinge
c. reposition the infant every 2 hours
d. change diapers every hour - ANSWERS -b. monitor skin and eyes for yellow tinge
A 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?
a. immediately, at six weeks gestation to protect this fetus
b. early postpartum within 72 hours of delivery
c. after the client stops breastfeeding
d. after the client reaches 20-weeks' gestation - ANSWERS -b. early postpartum within
72 hours of delivery
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the
thorax, back, and abdomen. What action should the nurse implement? documented the
,findings in the infant's record - ANSWERS -Erythema toxicum (or erythema
neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a
normal finding that is documented in the infant's record.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal
birth of twins is transferred to the postpartum unit. The nurse knows that assessment for
what complication has the highest priority for this client?
a. postpartum psychosis
b. hard, painful uterine afterpains
c. placenta accreta
d. disseminated intravascular coagulation* - ANSWERS -d. disseminated intravascular
coagulation*
A 26-week gestation primigravida who is carrying twins is seen in the clinic today. Her
final height is measured at 29 cm. Based on these findings, what action should the
nurse implement?
a. notify the HCP of the finding
b. schedule the client for a biophysical profile
c. document the finding in the medical record
d. request another nurse measure the fundus - ANSWERS -c. document the finding in
the medical record
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her
fundal height in measured at 29cm. Based on these findings what actions the nurse
implement.
A) Notify the healthcare provider of the finding
B) Document the finding in the medical record
C) Schedule the client for a biophysical profile
D) Request another nurse measure the fundus - ANSWERS -B) Document the finding in
the medical record
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate? - ANSWERS -Tachycardia and a feeling of
nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
A 28-year-old client in active labor complains of cramps in her leg. What intervention
should the nurse implement? - ANSWERS -Extend the leg and dorsiflex the foot
,Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client
is capable) and putting the heel of the foot on the floor is the best means of relieving leg
cramps
A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor.
What is the priority nursing action for this client?
A. Observe for signs of uterine hemorrhage
B. Encourage direct contact with the infant
C. Assess the blood pressure for hypertension
D. Gently massage fundus every four hours - ANSWERS -A. Observe for signs of
uterine hemorrhage
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation
in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg
subcutaneous. Which assessment is the highest priority for the nurse to monitor during
the administration of this drug? - ANSWERS -Monitoring maternal and fetal heart rates
is most important when terbutaline is being administered.
Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors
(causing tachycardia, a side effect of the drug) and stimulation of beta 2 receptors
(causing uterine relaxation, a desired effect of the drug).
A 32- week primigravida who is in preterm labor receives a prescription for an infusion
of D5W 500 ml with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hours
should the nurse program the infusion pump? - ANSWERS -ANS: 25
A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action should
the nurse take first?
a. assess the urine for proteinuria
b. record the finding on a flowsheet
c. obtain blood pressure reading
d. notify the healthcare provider - ANSWERS -d. notify the healthcare provider
A 33-year-old client at 9 weeks gestation tells the nurse that while she has "cut down,"
she still has at least one alcoholic drink every evening before bedtime. What
intervention should the nurse implement?
a) Notify child protective services of the client's illicit drug use and probable child
endangerment
b) Praise the client for her actions and offer to discuss ways to decrease consumption
even more
c) Insist that the client stop all alcohol use and draw a blood alcohol level at each
prenatal visit - ANSWERS -c) Insist that the client stop all alcohol use and draw a blood
alcohol level at each prenatal visit
, A 33-year-old client at 9 weeks gestation tells the nurse that while she has "cut down,"
she still has at least one alcoholic drink every evening before bedtime. What
intervention should the nurse implement?
a. Notify child protective services of the client's illicit drug use and probable child
endangerment
b. Praise the client for her actions and offer to discuss ways to decrease consumption
even more
c. Insist that the client stop all alcohol use and draw a blood alcohol level at each
prenatal visit - ANSWERS -c. Insist that the client stop all alcohol use and draw a blood
alcohol level at each prenatal visit
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium
sulfate via continuous IV infusion. Which assessment data indicates to the nurse that
the client is experiencing magnesium sulfate toxicity?
a. Deep tendon reflexes 2+
b. Blood pressure 140/90
c. Respiratory rate 18/minute
d. Urine output 90 ml/4 hours - ANSWERS -d. Urine output 90 ml/4 hours
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of
less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity
A 38-week primigravida client who is positive for group A beta streptococcus receives a
prescription for cefazolin 2grams IV to be infused over 30mins. The medications
available in 2 grams/100ml of normal saline. The nurse should program the infusion
pump to deliver how many ml/hours? - ANSWERS -1.6ml/hr
A 38-week primigravida client who is positive for group A beta streptococcus receives a
prescription for cefazolin 2grams IV to be infused over 30mins. The medications
available in 2 grams/100ml of normal saline. The nurse should program the infusion
pump to deliver how many ml/hours? - ANSWERS -200 ml/hr.
A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would be
most effective in preventing pooling of blood in the lower extremities? - ANSWERS -
Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic
veins and increase venous return.
A 39-week gestational multigravida is admitted to labor and delivery spontaneous
rupture of membranes and contraction occurring 2 to 3 minutes. A vaginal exam
indicates that the cervix is dilated 6cm, 90% effaced and the fetus is at a +2 station.
9TH EDITION LEIFER EXAM WITH CORRECT
DETAILED ANSWERS 2023-2024
26-week gestational primigravida who is carrying twins is seen in the clinic today. Her
fundal height in measured at 29cm. Based on these findings what actions the nurse
implement.
a. Notify the healthcare provider of the finding
b. Document the finding in the medical record
c. Schedule the client for a biophysical profile
d. Request another nurse measure the fundus - ANSWERS -b. Document the finding in
the medical record
A 3-hour old male infant's hands are feet are cyanotic, and he has an axillary
temperature of 96.5 F, a respiratory rate of 40 breaths/min, and a heart rate of 165
beats/min. Which nursing intervention is best for the nurse to implement?
A. Perform a heel- stick to monitor blood glucose level
B. Gradually warm the infant under a radiant heat source
C. Administer oxygen by mask at 2L/minute
D. Notify the pediatrician of the infant's unstable vital signs - ANSWERS -B. Gradually
warm the infant under a radiant heat source
A 5-day old infant with a serum bilirubin of 19 mg/dl is being discharged from the
hospital. Which instruction should the nurse include in the discharge teaching plan?
a. breastfeed infant every 4 hours
b. monitor skin and eyes for yellow tinge
c. reposition the infant every 2 hours
d. change diapers every hour - ANSWERS -b. monitor skin and eyes for yellow tinge
A 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?
a. immediately, at six weeks gestation to protect this fetus
b. early postpartum within 72 hours of delivery
c. after the client stops breastfeeding
d. after the client reaches 20-weeks' gestation - ANSWERS -b. early postpartum within
72 hours of delivery
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the
thorax, back, and abdomen. What action should the nurse implement? documented the
,findings in the infant's record - ANSWERS -Erythema toxicum (or erythema
neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a
normal finding that is documented in the infant's record.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal
birth of twins is transferred to the postpartum unit. The nurse knows that assessment for
what complication has the highest priority for this client?
a. postpartum psychosis
b. hard, painful uterine afterpains
c. placenta accreta
d. disseminated intravascular coagulation* - ANSWERS -d. disseminated intravascular
coagulation*
A 26-week gestation primigravida who is carrying twins is seen in the clinic today. Her
final height is measured at 29 cm. Based on these findings, what action should the
nurse implement?
a. notify the HCP of the finding
b. schedule the client for a biophysical profile
c. document the finding in the medical record
d. request another nurse measure the fundus - ANSWERS -c. document the finding in
the medical record
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her
fundal height in measured at 29cm. Based on these findings what actions the nurse
implement.
A) Notify the healthcare provider of the finding
B) Document the finding in the medical record
C) Schedule the client for a biophysical profile
D) Request another nurse measure the fundus - ANSWERS -B) Document the finding in
the medical record
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate? - ANSWERS -Tachycardia and a feeling of
nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
A 28-year-old client in active labor complains of cramps in her leg. What intervention
should the nurse implement? - ANSWERS -Extend the leg and dorsiflex the foot
,Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client
is capable) and putting the heel of the foot on the floor is the best means of relieving leg
cramps
A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor.
What is the priority nursing action for this client?
A. Observe for signs of uterine hemorrhage
B. Encourage direct contact with the infant
C. Assess the blood pressure for hypertension
D. Gently massage fundus every four hours - ANSWERS -A. Observe for signs of
uterine hemorrhage
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation
in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg
subcutaneous. Which assessment is the highest priority for the nurse to monitor during
the administration of this drug? - ANSWERS -Monitoring maternal and fetal heart rates
is most important when terbutaline is being administered.
Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors
(causing tachycardia, a side effect of the drug) and stimulation of beta 2 receptors
(causing uterine relaxation, a desired effect of the drug).
A 32- week primigravida who is in preterm labor receives a prescription for an infusion
of D5W 500 ml with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hours
should the nurse program the infusion pump? - ANSWERS -ANS: 25
A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action should
the nurse take first?
a. assess the urine for proteinuria
b. record the finding on a flowsheet
c. obtain blood pressure reading
d. notify the healthcare provider - ANSWERS -d. notify the healthcare provider
A 33-year-old client at 9 weeks gestation tells the nurse that while she has "cut down,"
she still has at least one alcoholic drink every evening before bedtime. What
intervention should the nurse implement?
a) Notify child protective services of the client's illicit drug use and probable child
endangerment
b) Praise the client for her actions and offer to discuss ways to decrease consumption
even more
c) Insist that the client stop all alcohol use and draw a blood alcohol level at each
prenatal visit - ANSWERS -c) Insist that the client stop all alcohol use and draw a blood
alcohol level at each prenatal visit
, A 33-year-old client at 9 weeks gestation tells the nurse that while she has "cut down,"
she still has at least one alcoholic drink every evening before bedtime. What
intervention should the nurse implement?
a. Notify child protective services of the client's illicit drug use and probable child
endangerment
b. Praise the client for her actions and offer to discuss ways to decrease consumption
even more
c. Insist that the client stop all alcohol use and draw a blood alcohol level at each
prenatal visit - ANSWERS -c. Insist that the client stop all alcohol use and draw a blood
alcohol level at each prenatal visit
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium
sulfate via continuous IV infusion. Which assessment data indicates to the nurse that
the client is experiencing magnesium sulfate toxicity?
a. Deep tendon reflexes 2+
b. Blood pressure 140/90
c. Respiratory rate 18/minute
d. Urine output 90 ml/4 hours - ANSWERS -d. Urine output 90 ml/4 hours
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of
less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity
A 38-week primigravida client who is positive for group A beta streptococcus receives a
prescription for cefazolin 2grams IV to be infused over 30mins. The medications
available in 2 grams/100ml of normal saline. The nurse should program the infusion
pump to deliver how many ml/hours? - ANSWERS -1.6ml/hr
A 38-week primigravida client who is positive for group A beta streptococcus receives a
prescription for cefazolin 2grams IV to be infused over 30mins. The medications
available in 2 grams/100ml of normal saline. The nurse should program the infusion
pump to deliver how many ml/hours? - ANSWERS -200 ml/hr.
A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would be
most effective in preventing pooling of blood in the lower extremities? - ANSWERS -
Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic
veins and increase venous return.
A 39-week gestational multigravida is admitted to labor and delivery spontaneous
rupture of membranes and contraction occurring 2 to 3 minutes. A vaginal exam
indicates that the cervix is dilated 6cm, 90% effaced and the fetus is at a +2 station.
