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A charge nurse is teaching a newly licensed nurse about substance use disorders
during pregnancy. Which of the following statements by the newly licensed nurse
indicates an understanding of the teaching? - CORRECT ANSWER-Encourage
client who are prescribed methadone to breastfeed.
-The nurse should encourage clients who are prescribed methadone during
pregnancy to breastfeed their newborns to help with withdrawal symptoms.
A nurse is reviewing the laboratory report of a client who is at 31wks of gestation and
has gestation hypertension. Which of the following laboratory results should the
nurse report to the provider? - CORRECT ANSWER-Platelet count 99,000/mm3. -A
platelet count of 99,000/mm3, or thrombocytopenia, is an indication of HELLP
syndrome, a serious complication of gestational HTN.
A nurse is reviewing the laboratory report of a term newborn who is 24hrs old. Which
of the following laboratory results should the nurse report to the provider? - CORRECT
ANSWER-Glucose 35 mg/dL.
-Reference range is 40-45 mg/dL for a newborn who is 24hrs old.
A nurse is assessing a newborn who was born 15mins ago. Which of the following
actions should the nurse take? - CORRECT ANSWER-Count the respiratory rate for
60 seconds.
-Newborn often have an irregular respiratory rate. Short periods of apnea, and shallow
respirations are expected findings for a newborn. The nurse should also assess for
symmetry of chest and abdominal movements during inhalation and exhalation.
A nurse is reviewing the laboratory results for a client who is at 29wks of gestation.
Which of the following results should the nurse identify as an indication of a
prenatal complication? - CORRECT ANSWER-BUN 30 mg/dL
, -Above the expected reference range of 10-20 mg/dL for a client who is pregnant.
The BUN typically decreases during pregnancy due to the increase in the glomerular
filtration rate. The nurse should identify that an elevated BUN is a manifestation of
preeclampsia or HELLP syndrome, potentially serous complications of pregnancy's.
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal pad
in 15min. The clients skin is cool and clammy to touch. Which of the following actions
should the nurse take first? - CORRECT ANSWER-Firmly massage the fundus. -The
greatest risk for a postpartum client who is experiencing excessive vaginal bleeding is
the development of hypovolemic shock, which can lead to coma and death. Uterine
atony is a frequent cause of excessive vaginal bleeding. Therefore, the first action the
nurse should take is to massage the clients fundus to encourage muscular
contractions, which will decrease bleeding.
A nurse is caring for a client who is at 28wks of gestation and has received two doses
of terbutaline subcutaneously. Which of the following adverse effects is the priority for
the nurse to report to the provider? - CORRECT ANSWER-Heart rate: 132/min
-The nurse should notify the provider of tachycardia greater than 130/min; therefore,
this is the priority finding. The client might also report chest discomfort, palpitations and
have arrhythmias.
A nurse is providing teaching for a client who is 2wks postpartum and has mastitis.
Which of the following instructions should the nurse include in the teaching? -
CORRECT ANSWER-Apply moist heat to the affected breast.
-The application of warm compresses prior to feeding or pumping promotes the flow of
the breast milk and assists to ensure complete emptying of the breast. This is
important to prevent the development of further complications such as the formation of
a breast abscess or chronic mastitis.
A nurse is admitting a client who is at 39wks of gestation and in active labor. The
client reports being positive for group B streptococcus (GBS) when screened at 36wks
of gestation. Which of the following actions should the nurse expect to take? -
CORRECT ANSWER-Administer IV antibiotic prophylaxis.
-To decrease the risk of the neonate contracting a GBS infection, it is recommended
that pregnant clients who test positive for GBS receive antibiotics during labor.
A nurse is reviewing the results of a nonstress test for a client who is at 37wks of
gestation. Which of the following findings indicates a reactive nonstress test? -
CORRECT ANSWER-Fetal heart rate (FHR) accelerations occur with fetal movement. -
A nonstress test measures the response of the FHR to fetal movement. Accelerations
of the FHR with fetal movement are a reassuring sign of fetal well being.
A nurse is providing teaching about nifedipine for a client who is at 34wks of gestation
and has gestational HTN. For which of the following adverse effects should the nurse
instruct the client to notify the provider? - CORRECT ANSWER-Irregular heartbeat. -