Question: What intervention(s) would the nurse initiate for a primigravida at 28 weeks with BP 168/108, 4+ DTRs with clonus, and 3+ edema?
Answer Choices:
A Administer IV bolus of 5 grams of magnesium sulfate
B Place peripheral IV and administer IV lactated Ringers at 125 mL/hour
C Initiate seizure precautions, limit visitors
D Administer oxygen 2 L/minute via nasal cannula
E Obtain consult for a cesarean delivery
F Initiate IV oxytocin at 6 milliunits/minute
Answer: A, B, C, D, E
Question: A client reports fluid leakage on her way to the hospital. What is the best action by the nurse?
Answer Choices:
A Scan the bladder for urinary retention.
B Palpate suprapubic area for fetal head position.
C Test the fluid with a nitrazine strip.
D Insert straight urinary catheter to drain bladder.
Answer: C Test the fluid with a nitrazine strip.
Question: The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
Answer Choices:
A Determine reactivity of neonatal reflexes.
B Perform gestational age assessment.
C Obtain a drug screen for cocaine.
D Weigh and measure the newborn.
Answer: C Obtain a drug screen for cocaine.
Question: Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
Answer Choices:
A Saturating two perineal pads per hour.
B Pulse rate of 56 beats/minute.
C Unilateral lower leg pain.
D Soft, spongy fundus.
Answer: B Pulse rate of 56 beats/minute.
Question: After placing a 36-week-gestation newborn in an isolette and drying the infant with several blankets, which action should the nurse implement next?
Answer Choices:
A Remove the wet blankets and linens from the isolette.
B Place erythromycin ophthalmic ointment in both eyes.
C Administer the vitamin K injection.
D Open the isolette door to assess the infant’s vital signs.
Answer: A Remove the wet blankets and linens from the isolette.
Question: A primigravida client at 32-weeks gestation presents to the clinic with a report of a pounding headache. The client demonstrates hyperreflexia. The nurse should recognize the client’s symptoms may be caused by which condition?
Answer Choices:
A Retinal arteriolar spasms.
B Intravascular coagulation.
C Severe anxiety.
D Cerebral edema.
Answer: D Cerebral edema.
Question: A client who is 3-weeks postpartum tells the nurse, “I am so tired all of the time. I didn’t know having a baby would be so hard.” Which response should the nurse provide?
Answer Choices:
A It is normal to feel tired for the first couple of weeks. Be patient with yourself and rest more.
B Adjusting to a new baby can be difficult. Tell me more about any help you are receiving.
C It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps.
D You should not be doing any housework. Are any of your family members helping you?
Answer: B Adjusting to a new baby can be difficult. Tell me more about any help you are receiving.
Question: At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
Answer Choices:
A Start prescribed intravenous (IV) with Lactated Ringer’s.
B Ensure preoperative lab results are available.
C Inform the anesthesia care provider.
D Contact the client’s obstetrician.
Answer: C Inform the anesthesia care provider.
Question: A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?
Answer Choices:
A Membranes are intact.
B Cervical dilatation is 1 cm.
C 2+ pitting edema in lower extremities.
D Contractions decrease with walking.
Answer: D Contractions decrease with walking.
Question: A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
Answer Choices:
A Tetracaine eye drops.
B Erythromycin ointment.
C Latanoprost eye drops.
D Neomycin ointment.
Answer: B Erythromycin ointment.
Question: A primipara presents to the perinatal unit describing rupture of the membranes (ROM) occurring 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client’s contractions are irregular and mild. Based on this data, the nurse plans to monitor which sign more frequently than for the average laboring client?
Answer Choices:
A Maternal blood pressure.
B Maternal temperature.
C Deep tendon reflexes.
D Color of amniotic fluid.
Answer: B Maternal temperature.
Question: A mother asks the nurse what to use when changing her newborn’s diaper. Which substance is best for the nurse to recommend to this mother?
Answer Choices:
A Talcum powder.
B Baby lotion.
C Clear water.
D Corn starch powder.
Answer: C Clear water.