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A client who delivered an infant an hour ago tells the nurse that she feels
wet underneath her buttock. The nurse notes that both perineal pads are
completely saturated and the cline is lying in a 6 in diameter pool of blood.
Which action should the nurse implement next?
a. obtain a blood pressure
b. inspect the perineum for lacerations
c. cleanse the perineum
d. palpate the firmness of the fundus ---------CORRECT ANSWER-------------
----d. palpate the firmness of the fundus
A 38 week primigravida who works as a secretary and sits at a computer 8
hrs each day tells the nurse that her feet have begun to swell. Which
instruction would be most effective in preventing pooling blood in the lower
extremities?
a. avoid constrictive clothing
b. move every hour
c. wear support stockings
d. reduce salt in her diet ---------CORRECT ANSWER-----------------b. move
every hour
The total bilirubin level of a 36 hour breastfeeding newborn is 14 mg/dl.
Based on this finding which intervention should the nurse implement?
a. feed the newborn sterile water hourly
b. assess the newborn's blood glucose level
c. provide phototherapy for 30 mins q8h
d. encourage the mother to breastfeed frequently ---------CORRECT
ANSWER-----------------c. encourage the mother to breastfeed frequently
,A newborn infant is brought to the nursery from the birthing suite. The
nurse notices that the infant is breathing satisfactorily but appears dusky.
What action should the nurse take first?
a. notify the pediatrician immediately
b. position the infant on the right side
c. suction the infant's nares then the oral cavity
d. check the infant's oxygen saturation rate ---------CORRECT ANSWER----
-------------d. check the infant's oxygen saturation rate
28 year old client in active labor complains of cramps in her leg.What
intervention should the nurse implement.
A. massage the calf and foot
B. extend the leg and dorsiflex the foot
C. lower the leg off the side of the bed
D. elevate the leg above the heart. ---------CORRECT ANSWER---------------
--B. Extend the leg and dorsiflex the foot.
The nurse instructs a laboring client to use accelerated blow breathing. The
client begins to complain of tingling finger and dizziness. What action
should the nurse take?
a. administer o2 by face mask
b. notify the HCP for the client's syndrome
c. have the client breathe into her cupped hands
d. check the client's BP and fetal HR/ ---------CORRECT ANSWER------------
-----c. have the client breathe into her cupped hands.
When assessing a client who is at 12 week gestation, the nurse
recommends that she and her husband consider attending childbirth
preparation classes. When is the best time for the couple to attend these
classes?
A. at 16 weeks gestation
B.at 20 weeks gestation
C. at 24 weeks gestation
,D. at 30 weeks gestation ---------CORRECT ANSWER-----------------D. At 30
weeks gestation.
In developing a teaching plan for expectant parents the nurse plans to
include formation about when the parents can expect the infants fontanels
to close. The nurse bases the explanation on knowledge that for the normal
newborn, the
A. anterior fontanel closes at 2 to 4 months and the posterior by the end of
the first week.
B. anterior fontanel closes at 5 to 7 months and the posterior by the end of
the second week.
C. anterior fontanel closes at 8 to 11 months and the posterior by the end
of the first month.
D. anterior fontanel closes at 12 to 18 months and the posterior by the end
of the second month ---------CORRECT ANSWER-----------------D. anterior
fontanel closes at 12 to 18 months and the posterior by the end of the
second month
A 42 week gestational client is receiving an intravenous infusion of
oxytocin(Pitocin) to augment early labor. The nurse should discontinue the
oxytocin infusion for with pattern of contractions?
A. transition labor with contractions every 2 mins, lasting 90 seconds each.
B. early labor with contractions every 5 min, lasting 40 seconds each.
C. Active labor with contractions every 31 mins, lasting 60 seconds each.
D. Active labor with contraction every 2 to 3 mins, lasting 70 to 80 seconds
each. ---------CORRECT ANSWER-----------------A. transition labor with
contractions every 2 mins, lasting 90 seconds each.
What action should the nurse implement to decrease the client's risk for
hemorrhage after c-section.
A. Monitor urinary output via an indwelling catheter.
B. assess the abdominal dressings for drainage.
C. Give the Ringer's lactated infusion at 125ml
, D. Check the firmness of the uterus every 15mins. ---------CORRECT
ANSWER-----------------D. Check the firmness of the uterus every 15mins.
Which assessment finding should the nursery nurse report to the pediatric
healthcare provider?
A. blood glucose level of 45mg/dl
B. blood pressure of 82/45 mmHG
C. Non bulging anterior fontanel
D. central cyanosis when crying ---------CORRECT ANSWER-----------------
D. central cyanosis when crying
The nurse is assessing a 3 day old infant with a cephalohematoma in the
newborn nursery. Which assessment finding should the nurse report to the
healthcare provider?
A. yellowish tinge to the skin
B. babinski reflex present bilaterally
C. pink papular rash on the face
D. moro reflex noted after a loud noise ---------CORRECT ANSWER----------
-------A. yellowish tinge to the skin
A client who delivered an infant an hour ago tells the nurse that she feels
wet underneath her buttock. The nurse notes that both perineal pads are
completely saturated a
nd the client is lying in a 6inch diameter pool of blood.
A. Cleanse the perineum
B. obtain a BP
C. palpate the firmness of the fundus
D; inspect the perineum for lacerations ---------CORRECT ANSWER----------
-------C. palpate the firmness of the fundus