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1. A nurse is providing discharge teaching to a client who had a cesarean birth
3 days ago. Which of the following instructions should the nurse include?
"You can resume sexual activity in 1 week."
"You won't need to do Kegel exercises since you had a cesarean."
"You can still become pregnant if you are breastfeeding."
"You are safe to start adding sit-ups to your exercise routine in 2 weeks.": "You
can still become pregnant if you are breastfeeding."
2. A nurse is caring for a client who is experiencing preeclampsia and has a
new prescription for IV magnesium sulfate. Which of the following medications
should the nurse anticipate administering if the client develops magnesium
toxicity?
Calcium gluconate
Hydralazine
Medroxyprogesterone acetate
Methylergonovine: Calcium gluconate
The nurse should anticipate administering calcium gluconate if the client develops
magnesium toxicity. Calcium gluconate is the antidote.
3. A nurse in an antepartum clinic is providing care for a client who is at 26
weeks of gestation. Upon reviewing the client's medical record, which of the
following findings should the nurse report to the provider?
Exhibit 1:
Blood pressure 130/78 mm HgRespiratory rate 20/minHeart rate 90/min
2:
Hemoglobin 12 g/dL
Hematocrit 34%1-hr glucose tolerance test 120 mg/dL
3:
Fundal height 30 cmGood fetal movementNot experiencing headache, dizzi-
ness, blurred vision, or vaginal bleedingFetal heart rate 110/min
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1-hr glucose tolerance test
Hematocrit
Fundal height measurement
Fetal heart rate (FHR): Fundal height measurement
A fundal height measurement of 30 cm should be reported to the provider. Fundal
height should be measured in centimeters and is the same as the number of
gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore,
the nurse should report this finding to the provider.
4. A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client
who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of
dextrose 5% in water (D5W). The nurse should set the IV infusion pump to
administer how many mL/hr? (Round the answer to the nearest whole number.
Use a leading zero if it applies. Do not use a trailing zero.): 50 mL/hr
5. A nurse is teaching a client who is at 10 weeks of gestation about nutrition
during pregnancy. Which of the following statements by the client indicates
an understanding of the teaching?
"I should increase my protein intake to 60 grams each day."
"I should drink 2 liters of water each day."
"I should increase my overall daily caloric intake by 300 calories."
"I should take 600 micrograms of folic acid each day.": I should take 600 mcg
of folic acid each day
6. A nurse is preparing to collect a blood specimen from a newborn via a heel
stick. Which of the following techniques should the nurse use to help minimize
the pain of the procedure for the newborn?
Apply a cool pack for 10 min to the heel prior to the puncture.
Request a prescription for IM analgesic.
Use a manual lance blade to pierce the skin.
Place the newborn skin to skin on the mother's chest.: Place the newborn skin
to skin on the mothers chest
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Placing the newborn skin to skin on the mother's chest is an effective technique
to significantly decrease the newborn's pain level and anxiety. The nurse should
implement this technique before, during, and after the procedure.
7. A nurse is performing a routine assessment on a client who is at 18 weeks
of gestation. Which of the following findings should the nurse expect?
Deep tendon reflexes 4+
Fundal height 14 cm
Urine protein 2+
FHR 152/min: FHR 152/min
The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier
in gestation with an average of approximately 160/min at 20 weeks of gestation.
Therefore, this is an expected finding by the nurse.
8. A nurse is assessing a newborn 12 hr after birth. Which of the following
manifestations should the nurse report to the provider?
Acrocyanosis
Transient strabismus
Jaundice
Caput succedaneum: Jaundice
Jaundice occurring within the first 24 hr of birth is associated with ABO incompati-
bility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation
to the provider.
9. A charge nurse on a labor and delivery unit is teaching a newly licensed
nurse how to perform Leopold maneuvers. Which of the following images in-
dicates the first step of Leopold maneuvers?: Evidence-based practice indicates
the nurse should perform this step first when performing Leopold maneuvers. During
this step, the nurse palpates the client's abdomen with the palms to determine which
fetal part is in the uterine fundus. This step also identifies the lie (transverse or
longitudinal) and presentation (cephalic or breech) of the fetus.
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10. A nurse is assessing a client who is 1 day postpartum and has a vaginal
hematoma. Which of the following manifestations should the nurse expect?
Lochia serosa vaginal drainage
Vaginal pressure
Intermittent vaginal pain
Yellow exudate vaginal drainage: Vaginal pressure
The nurse should expect a client who has a vaginal hematoma to report pressure
in the vagina due to the blood that leaked into the tissues.
11. A nurse is demonstrating to a client how to bathe their newborn. In which
order should the nurse perform the following actions?
Clean newborns diaper area
wash the newborns neck by lifting the newborns chin
wipe the newborns eyes from the inner canthus outward
cleanse the skin around the newborns umbillical cord stump
wash the newborns legs and feet: The nurse should demonstrate how to bathe
a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse
should first wipe the newborn's eyes from the inner canthus outward using plain
water. The nurse should then wash the newborn's neck by lifting the newborn's chin.
Next, the nurse should cleanse the skin around the umbilical cord stump followed
by washing the newborn's legs and feet. The last step of the bath should be to clean
the newborn's diaper area.
12. A nurse is creating a plan of care for a client who is postpartum and
adheres to traditional Hispanic cultural beliefs. Which of the following cultural
practices should the nurse include in the plan of care?
Protect the client's head and feet from cold air.
Bathe the client within 12 hr following birth.