(2023)
A woman is being interviewed by a triage nurse at a medical doctor's office. Which of the
following signs/symptoms by the client would warrant the nurse to suggest that a pregnancy test
be done? (Select all that apply)
1. Amenorrhea
2. Fever
3. Fatigue
4. Nausea
5. Dysuria - ans1,3,4
1.Pregnancy is the most common cause of amenorrhea
3. A common complaint of women in early pregnancy is fatigue
4. A common complaint of women is early pregnancy is nausea
The nurse is caring for a client, 37 weeks gestaton, who was just told that she is group B
strep positive. The client states, "How could that happen? I only have sex with my husband. Will
my baby be OK?" Based on this information, which of the following should the nurse
communicate to the client?
, 1. The client's partner must have acquired the bacteria during a sexual encounter
2. The bacteria do not injure babies, but they could cause the client to have a bad sore
throat
3. The client is high risk for developing pelvic inflammatory disease from the bacteria
4. Antibiotics will be administered during labor to prevent vertical transmission of the
bacteria - ans4.
This statement is accurate. Antibiotics will be administered to the mother during labor
and delivery to prevent verticle transmission.
The nurse is caring for a client in labor and delivery with the following history: G2
P1000, 39 weeks gestation in transition phase, FH 135 with the early decelerations. The client
states, I'm so scared. Please make sure the baby is OK!" Which of the following responses by the
nurse is appropriate?
1. There is absolutely nothing to worry about
2. The fetal heart rate is within normal limits
3. How did your first baby die
4. Was your first baby preterm - ans2.
, This is the best reponse for the nurse to make. The nurse is providing the client with
accurate, reassuring information without guaranteeing that there wil definitely be a positive
outcome
A woman is seeking counseling regarding tubal ligation. Which of the following should
the nurse include in her discussion?
1. The woman wil no longer mensrtuate
2. The surgery shuld be done when the woman is ovulating
3. The surgery is easily reversible
4. The woman will be under anesthesia during the procedure - ans4.
This response is correct. BTL surgery, usually performed laparoscopically, is done under
general anesthesia
A woman is admitted to the labor and delivery unit with active TB. She has not been
under a physician's care and is not on medication. Which of the following actions should the
nursery nurse perform when the neonate is delivered?
1. Isolate the baby from the other babies is a special care nursery
2. Keep the baby in the regular care nursery but separated from the mother
3. Isolate the baby with the mother in the mother's room
, 4. Obtain an order from the doctor for antituberculosis medications for the baby - ans2.
This response is accurate. The baby can be cared for in the well baby nursery, but must
be kept separated from its mother
A client has just recieved syntheric prostaglandins for the induction of labor. The nurse
plans to monitor the client for which of the following side effects?
1. Nausea and uterine tetany
2. Hypertension and vaginal bleeding
3. Urinary retention and severe headache
4. Bradycardia and hypothermia - ans1.
Two side effects of prostaglandin administration are nausea and uterine tetany
The triage nurse in an obstetric clinic received the following forur messages during the
lunch hour. Which of the woman should the nurse telephone first?
1. " My section incision from last week is leaking a whitish yellow discharge and I have a
fever. What should I do?"