Deck 4: Maternity

Question 1

The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" The best response by the nurse should be:

A) "Testosterone stimulates the secretion of milk, which is called lactogenesis."
B) "Oxytocin stimulates the secretion of milk, which is called lactogenesis."
C) "Prolactin stimulates the secretion of milk, which is called lactogenesis."
D) "Progesterone stimulates the secretion of milk, which is called lactogenesis."

Answer 1

"Prolactin stimulates the secretion of milk, which is called lactogenesis."

Question 2

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement, if made by the client, indicates a need for further education?

A) "I need to stay on the diabetic diet."
B) "I will perform glucose monitoring at home."
C) "I need to avoid exercise because of the negative effects on insulin production."
D) "I need to be aware of any infections and report signs of infection immediately to my health care provider."

Answer 2

"I need to avoid exercise because of the negative effects on insulin production."

Question 3

A client has been seen in the clinic and has been diagnosed with endometriosis. The client asks the nurse to describe this condition. The best response by the nurse should be:

A) "It causes the cessation of menstruation."
B) "It is also known as primary dysmenorrhea."
C) "It is pain that occurs during ovulation."
D) "It is the presence of tissue outside the uterus that resembles the endometrium."

Answer 3

"It is the presence of tissue outside the uterus that resembles the endometrium."

Question 4

A client calls the physician's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which of the following in the urine?

A) Estrogen
B) Progesterone
C) Human chorionic gonadotropin (hCG)
D) Follicle-stimulating hormone (FSH)

Question 5

The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the purpose of estrogen. The nurse bases the response on which of the following purposes of estrogen?

A) It maintains the uterine lining for implantation.
B) It stimulates metabolism of glucose and converts the glucose to fat.
C) It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.
D) It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

Question 6

A client is seen in the health care clinic with a diagnosis of mild anemia. The anemia is believed to be a result of her menstrual period. The client asks the nurse how much blood is lost during a menstrual period. The nurse bases the response on which of the following amounts of blood lost during this time?

A) 40 mL
B) 60 mL
C) 80 mL
D) 100 mL

Question 7

The rubella vaccine has been prescribed for a new mother. Which of the following statements should the postpartum nurse make when providing information about the vaccine to the client?

A) "You will need a second vaccination at your 6-week postpartum visit."
B) "You should avoid sexual intercourse for 2 weeks after the administration of the vaccine."
C) "You should not become pregnant for 1 to 3 months after the administration of the vaccine."
D) "You should avoid heat and extreme temperature changes for a week after the administration of the vaccine."

Question 8

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds to the client by telling her that the gender of the fetus can be determined by weeks:

A) 6 to 8
B) 8 to 10
C) 13 to 16
D) 20 to 22

Question 9

The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was and the client reports February 9, 2012. Using Nägele's rule, the nurse determines that the estimated date of confinement (delivery) is:

A) October 16, 2012
B) November 16, 2012
C) October 7, 2012
D) November 7, 2012

Question 10

A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which of the following is the appropriate nursing action?

A) Instruct the client to avoid walking.
B) Assess for signs of venous thrombosis.
C) Tell the client that this is normal during pregnancy.
D) Instruct the client to elevate her legs consistently throughout the day.

Question 11

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/min. Which of the following nursing actions is appropriate?

A) Document the findings.
B) Notify the physician.
C) Inform the client that everything is normal and fine.
D) Instruct the client to return to the clinic in 1 week for reevaluation of the fetal heart rate.

Question 12

The nurse is caring for a pregnant client who has herpes genitalis. The nurse provides instructions to the client about treatment modalities that may be necessary for treatment of this condition. Which of the following statements, if made by the client, indicates an understanding of these treatment measures?

A) "I do not need to abstain from sexual intercourse."
B) "I need to use vaginal creams after I douche every day."
C) "I need to douche and perform a sitz bath three times a day."
D) "It may be necessary to have a cesarean section for delivery."

Question 13

A pregnant client tests positive for the hepatitis B virus (HBV). The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which of the following responses by the nurse is most appropriate?

A) "Breast-feeding is allowed after the baby has been vaccinated with immune globulin."
B) "Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby."
C) "You will not be able to breast-feed the baby until 6 months after delivery."
D) "Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery."

Question 14

The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be which of the following?

A) 22 cm
B) 28 cm
C) 32 cm
D) 40 cm

Question 15

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate?

A) Contact the physician.
B) Instruct the client to maintain bed rest for the remainder of the pregnancy.
C) Instruct the client that these are common and may occur throughout the pregnancy.
D) Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

Question 16

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The physician has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of:

A) A softening of the cervix
B) The presence of fetal movement
C) The presence of human chorionic gonadotropin (hCG) in the urine
D) A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus

Question 17

The nursing instructor asks a nursing student to describe the process of quickening. Which of the following statements, if made by the student, indicates an understanding of this term?

A) "It is the thinning of the lower uterine segment."
B) "It is the fetal movement that is felt by the mother."
C) "It is irregular painless contractions that occur throughout pregnancy."
D) "It is the soft blowing sound that can be heard when the uterus is auscultated."

Question 18

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the client that fetal movements will be noted between weeks' gestation.

A) 6 and 8
B) 8 and 10
C) 12 and 14
D) 16 and 20

Question 19

A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which of the following would the nurse anticipate to be prescribed for this client?

A) Immunization with rubella
B) Retesting rubella titer during pregnancy
C) Counseling the mother regarding therapeutic abortion
D) Antibiotics, to be taken throughout the pregnancy

Question 20

The nursing instructor is reviewing a plan of care formulated by a nursing student who is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of the Kegel exercises. Which of the following responses, made by the student, indicates an understanding of the purpose of these types of exercises?

A) "The exercises will help reduce backaches."
B) "The exercises will help prevent ankle edema."
C) "The exercises will help prevent urinary tract infections."
D) "The exercises will help strengthen the pelvic floor in preparation for delivery."

Question 21

The nurse in a health care clinic is instructing a client how to perform kick counts. Which of the following statements, if made by the client, indicates a need for further education?

A) "I should lie on my back to perform the procedure."
B) "I will use a clock or a timer and record the number of movements or kicks."
C) "I should count the fetal movements for 30 to 60 minutes three times a day."
D) "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

Question 22

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following information will the nurse provide to the client?

A) "The fetus is challenged by uterine contractions to obtain the necessary information."
B) "The test is an invasive procedure and requires that you sign an informed consent."
C) "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed."
D) "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

Question 23

A client in the second trimester of pregnancy is seen in the health care clinic. The client tells the nurse that she is a hostess at a local restaurant and is on her feet most of the day. She states that she has frequent low back pains and ankle edema by the end of the day. The nurse provides instructions to the woman about measures to relieve the discomfort. Which of the following statements, made by the client, indicates an understanding of how to relieve these discomforts?

A) "When I get home I should lie on my left side, with my feet in a dorsiflexed position."
B) "I should soak in a tub bath of hot water when I get home and then perform pelvic tilt exercises."
C) "When I get home I should lie on my right side, with my feet elevated on a pillow, and put a heating pad on my back."
D) "When I get home I should lie on the floor, with my legs elevated onto a couch, and turn my hips and knees at right angles."

Question 24

A pregnant client calls the nurse at the physician's office and reports that she has noti ced a thin, colorless, vaginal drainage. Which of the following information would be most appropriate for the nurse to provide to the client?

A) Come to the clinic immediately.
B) Report to the emergency department at the maternity center immediately.
C) The vaginal discharge may be bothersome but is a normal occurrence.
D) Use tampons if the discharge is bothersome but be sure to change the tampons every 2 hours.

Question 25

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the physician has documented the test results as reactive. The nurse interprets that this result indicates:

A) Normal findings
B) Abnormal findings
C) The need for further evaluation
D) That the findings on the monitor were difficult to interpret

Question 26

The pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. The nurse would tell the client to the knee when the cramps occur.

A) Dorsiflex the foot while extending
B) Dorsiflex the foot while flexing
C) Plantar flex the foot while flexing
D) Plantar flex the foot while extending

Question 27

The nurse is providing instructions about treatment for hemorrhoids to the client who is in the second trimester of pregnancy. Which of the following statements, if made by the client, indicates a need for further instruction?

A) "I should perform Kegel exercises as you have instructed."
B) "Cool sitz baths will help in relieving the discomfort."
C) "I should apply heat packs to the hemorrhoids to help them shrink."
D) "I can apply ice packs to the hemorrhoids to assist in relieving discomfort."

Question 28

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse would instruct the client to supplement the dietary source of calcium by eating which of the following foods?

A) Dried fruits
B) Creamed spinach
C) Hard cheese
D) Fresh squeezed orange juice

Question 29

The nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. The nurse would encourage the client to increase intake of which of the following foods that are highest in folic acid?

A) Cheese
B) Chicken
C) Rice
D) Green leafy vegetables

Question 30

The pregnant client asks the nurse about the type of exercises that are allowable during her pregnancy. The nurse would instruct the client that the safest exercise to engage in is which of the following?

A) Swimming
B) Water skiing
C) Aerobic exercising
D) Downhill skiing

Question 31

A pregnant client reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following assessment, tuberculosis is suspected. A sputum culture is obtained, and Mycobacterium tuberculosis is identified in the sputum. The nurse provides instructions to the client regarding therapeutic management of tuberculosis. Which of the following instructions does the nurse provide to the client?

A) The need for therapeutic abortion is required.
B) Medication will not be started until after delivery of the fetus.
C) Isoniazid (INH) plus rifampin (Rifadin) will be required for a total of 9 months.
D) The newborn must receive medication therapy immediately following birth.

Question 32

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which of the following statements, if made by the client, indicates a need for further education?

A) "It is best that I rest on my left side to promote blood return to the heart."
B) "I need to avoid excessive weight gain to prevent increased demands on my heart."
C) "I need to try to avoid stressful situations because stress increases the workload on the heart."
D) "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

Question 33

A nurse is collecting data on a pregnant client in the first trimester of pregnancy whose medical record indicates the presence of iron deficiency anemia. The nurse would monitor the cli ent to detect which of the following signs indicating that this problem has not yet resolved?

A) Increased vaginal secretions
B) Pink mucous membranes
C) Complaints of increased frequency of voiding
D) Complaints of daily headaches and fatigue

Question 34

A nurse has just received the intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which of the following clients is most at risk for developing postdelivery endometritis?

A) A primigravida with a normal spontaneous vaginal delivery
B) A gravida II who delivered vaginally following an 18-hour labor
C) A client experiencing an elective cesarean delivery at 38 weeks' gestation
D) An adolescent experiencing an emergency cesarean delivery for fetal distress

Question 35

A nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. The nurse would ask the client about which of the following items to determine this risk?

A) Number of sexual partners during pregnancy
B) Presence in the home of cats who use a kitty litter box for elimination
C) Exposure to children with rashes or gastrointestinal symptoms
D) History of high fevers or unusual rashes during the first 6 weeks of pregnancy

Question 36

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which of the following is the priority nursing action?

A) Monitoring daily weight
B) Assessing for edema
C) Monitoring the temperature
D) Monitoring the apical pulse

Question 37

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which of the following data, if noted on the client's record, would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?

A) The client's previous deliveries were by cesarean section.
B) The client's last baby weighed 10 lb at birth.
C) The client has a family history of type 1 diabetes.
D) The client is 5 feet, 3 inches tall and weighs 165 lb.

Question 38

The nurse is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require:

A) Increased insulin
B) Decreased insulin
C) Increased caloric intake
D) Decreased caloric intake

Question 39

The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which of the following?

A) Milk
B) Tea
C) Coffee
D) Orange juice

Question 40

The nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of the following is documented in the client's record?

A) The contractions are regular.
B) The membranes have ruptured.
C) The cervix is completely dilated.
D) The client begins to expel clear vaginal fluid.

Question 41

The nurse is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which most appropriate nursing actions?

A) Placing the mother in a supine position
B) Administering oxygen via face mask
C) Increasing the rate of the intravenous (IV) oxytocin infusion
D) Documenting the findings and continuing to monitor the fetal patterns

Question 42

The nurse is assisting the nurse midwife in preparing to perform Leopold's maneuver on a pregnant client. The nurse instructs the client about the procedure and then:

A) Asks the client to urinate
B) Asks the client to drink 8 oz of water
C) Locates the fetal heart tones with a fetoscope
D) Warms the sonogram gel before placing it on the client's abdomen

Question 43

A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which of the following findings indicates that the rate of the infusion needs to be decreased?

A) Increased urinary output
B) A fetal heart rate of 180 beats/min
C) Three contractions occurring in a 10-minute period
D) Adequate resting tone of the uterus palpated between contractions

Question 44

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. The initial nursing action is to:

A) Take the client's blood pressure.
B) Provide peripads to the client.
C) Determine the fetal heart rate.
D) Note the amount, color, and odor of the amniotic fluid.

Question 45

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of:

A) Hematoma
B) Placenta previa
C) Uterine atony
D) Placental separation

Question 46

The nurse is preparing to care for a client in labor. The physician has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which of the following is implemented prior to the beginning of the infusion?

A) Placing the client on complete bed rest
B) Continuous electronic fetal monitoring
C) An IV infusion of antibiotics
D) Placing a code cart at the client's bedside

Question 47

The nurse provides a list of discharge instructions to the client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further instructions?

A) Begin abdominal exercises immediately.
B) Notify the physician if I develop a fever.
C) Lift nothing heavier than the newborn for at least 2 weeks.
D) Turn on my side and push up with my arms to get out of bed.

Question 48

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse assesses that the amniotic fluid is normal if it has which of the following characteristics?

A) Clear and dark amber color
B) Light green color with no odor
C) Thick white color with no odor
D) Straw-colored, with flecks of vernix

Question 49

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which of the following nursing interventions as the highest priority?

A) Monitoring fetal status
B) Providing comfort measures
C) Changing the client's position frequently
D) Keeping the significant other informed of the progress of the labor

Question 50

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which of the following findings would alert the nurse to a compromise?

A) Maternal fatigue
B) Coordinated uterine contractions
C) The passage of meconium
D) Progressive changes in the cervix

Question 51

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to:

A) Provide pain relief measures.
B) Promote ambulation every 30 minutes.
C) Prepare the client for an amniotomy.
D) Monitor the oxytocin (Pitocin) infusion closely.

Question 52

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?

A) Place the client in Trendelenburg's position.
B) Gently push the cord into the vagina.
C) Find the closest telephone, and page the physician stat.
D) Call the delivery room to notify the staff that the client will be transported immediately.

Question 53

The nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

A) Hemorrhage
B) Infection
C) Chronic hypertension
D) Disseminated intravascular coagulation

Question 54

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. The initial nursing action would be which of the following?

A) Turn the client on her back, and administer oxygen by nasal cannula at 2 to 4 L/min.
B) Turn the client on her side, and administer oxygen by face mask at 8 to 10 L/min.
C) Turn the client on her back, and administer oxygen by face mask at 8 to 10 L/min.
D) Turn the client on her side, and administer oxygen by nasal cannula at 2 to 4 L/min.

Question 55

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. The nurse would prepare the client for:

A) Delivery of the fetus
B) Strict monitoring of intake and output
C) Complete bed rest for the remainder of the pregnancy
D) The need for weekly monitoring of coagulation studies until the time of delivery

Question 56

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia?

A) Hypotonic
B) Precipitate
C) Hypertonic
D) Preterm labor

Question 57

The nurse has collected the following data on a client in labor: the fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, the nurse should take which most appropriate action?

A) Prepare for imminent delivery.
B) Continue to monitor the client.
C) Report the findings to the obstetrician.
D) Report the FHR to the anesthesiologist on call.

Question 58

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client states that her "water broke" before coming to the hospital. The most appropriate nursing action would be to:

A) Sit the client in a high Fowler's position.
B) Call the pharmacy for a tocolytic medication.
C) Get intravenous (IV) therapy equipment and solution from the storage area.
D) Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

Question 59

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the following?

A) Ask the client to turn on her side.
B) Ask the client to urinate and empty her bladder.
C) Ask the client to lie flat on her back, with her knees and legs flat and straight.
D) Massage the fundus gently prior to determining the level of the fundus.

Question 60

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the client's vital signs every:

A) Hour for the first 2 hours and then every 4 hours
B) 15 minutes during the first hour and then every 30 minutes for the next 2 hours
C) 30 minutes during the first hour and then every hour for the next 2 hours
D) 5 minutes for the first 30 minutes and then every hour for the next 4 hours

Question 61

The nurse is providing nutritional counseling to a new client who is breast-feeding her newborn. The nurse instructs the client that her calorie needs need to increase by approximately how many calories a day?

A) 100
B) 300
C) 500
D) 1000

Question 62

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable:

A) When ambulating
B) During breast-feeding
C) While taking sitz baths
D) When the client arrives home and activities are increased

Question 63

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration. The student is asked about client behaviors that are most likely to occur during this phase. Which of the following responses, made by the student, indicates an understanding of this phase?

A) "The client would be independent."
B) "The client initiates activities on her own."
C) "The client participates in mothering tasks."
D) "The client is self-focused and talks to others about labor."

Question 64

The nurse is assisting a new client with learning how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's firstchild. Which of the following nursing interventions will least likely assist in promoting mother-infantinteraction and bonding?

A) Accepting the client's feelings
B) Acknowledging the client's apprehension
C) Leaving the infant with the client so that she will be required to provide the care
D) Assisting the client with giving the baths to allow her to become more at ease

Question 65

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse will plan to instruct the client to:

A) Apply a heating pad to breasts for comfort.
B) Wear a breast shield to correct nipple inversion.
C) Wear a supportive brassiere continuously for 72 hours.
D) Use the manual breast pump provided to express milk.

Question 66

The postpartum client who had a vaginal delivery of a healthy newborn has a prescription for a sitz bath. The nurse who is assisting the client tells the client that the sitz bath will:

A) Numb the tissue.
B) Stimulate a bowel movement.
C) Reduce the edema and swelling.
D) Promote healing and provide comfort.

Question 67

The nurse is monitoring a new client in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss?

A) A temperature of 100.4º F
B) An increased pulse rate of 88 to 102 beats/min
C) A blood pressure change from 130/88 to 124/80 mm Hg
D) An increase in the respiratory rate from 18 to 22 breaths/min

Question 68

The nurse is providing instructions to the client who has been diagnosed with mastitis. Which of the following statements, if made by the client, indicates a need for further education?

A) "I need to wear a supportive bra to relieve the discomfort."
B) "I need to stop breast-feeding until this condition resolves."
C) "I can use analgesics to assist in alleviating some of the discomfort."
D) "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

Question 69

The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which of the following clients would be least likely at risk for the development of thrombophlebitis in the postpartum period?

A) A 35-year-old client who reports that she smokes
B) A 26-year-old client with a family history of thrombophlebitis
C) A 37-year-old client in her fourth pregnancy who is overweight
D) A 22-year-old client in her first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

Question 70

The nurse is monitoring the client for signs of postpartum depression. Which of the following, if noted in the client, would indicate the need for further assessment related to this form of depression?

A) The client demonstrates an interest in the surroundings.
B) The client is caring for the infant in a loving manner.
C) The client constantly complains of tiredness and fatigue.
D) The client looks forward to visits from the father of the newborn.

Question 71

The nurse caring for a client with a diagnosis of subinvolution understands that which of the following is a primary cause of this diagnosis?

A) Afterpains
B) Retained placental fragments from delivery
C) Increased progesterone levels
D) Increased estrogen levels

Question 72

The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse plans to take which action first?

A) Massage the uterus until firm.
B) Take the client's blood pressure.
C) Ask the client about the presence of pain.
D) Recheck the amount of drainage on the peripad.

Question 73

When participating in the planning of care of a postpartum client who plans to breast-feed her infant, the nurse realizes the importance of including which of the following in the teaching plan to prevent the development of mastitis?

A) Offer only one breast at each feeding.
B) Massage distended areas as the infant nurses.
C) Cleanse nipples with a mild antibacterial soap before and after infant feedings.
D) Express and discard milk from the affected breast at the first signs of mastitis.

Question 74

The nurse is preparing to listen to the apical heart rate of a newborn. The nurse performs the procedure and notes that the heart rate is normal if which of the following is noted?

A) A heart rate of 100 beats/min
B) A heart rate of 140 beats/min
C) A heart rate of 180 beats/min
D) A heart rate of 190 beats/min

Question 75

The nurse is preparing to check the respirations of a newborn who was just delivered. The nurse performs the procedure and determines that the respiratory rate is normal if which of the following is noted?

A) A respiratory rate of 20 breaths/min
B) A respiratory rate of 40 breaths/min
C) A respiratory rate of 70 breaths/min
D) A respiratory rate of 80 breaths/min

Question 76

The nurse is performing an assessment on a neonate. The nurse is preparing to measure the head circumference of the neonate. The nurse would:

A) Wrap the paper tape around the newborn's head, and measure just above the eyebrows.
B) Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes.
C) Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn's mouth.
D) Place the paper tape under the newborn's head at the base of the skull, and wrap around to the front, just above the eyes.

Question 77

The nurse is checking the reflexes of a neonate. In eliciting the Moro reflex, the nurse would do which of the following?

A) Stimulate the perioral cavity with a finger.
B) Clap hands, or slap the mattress.
C) Stimulate the ball of the infant's foot with firm pressure.
D) Stimulate the pads of the infant's hands with firm pressure.

Question 78

The nurse is planning to administer an injection of vitamin K to a newborn. In preparing to administer the injection, the nurse would select which of the following injection sites?

A) The gluteal muscle
B) The lower aspect of the rectus femoris muscle
C) The medial aspect of the upper third of the vastus lateralis muscle
D) The lateral aspect of the middle third of the vastus lateralis muscle

Question 79

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, is gasping, and has a heart rate below 100 beats/min. The nurse understands that the number of ventilations per minute that will be delivered to this neonate is breaths/min.

A) 20 to 40
B) 40 to 60
C) 70 to 80
D) 80 to 100

Question 80

The nurse is performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low-set. Which of the following nursing actions would be most appropriate initially?

A) Notify the physician.
B) Document the findings.
C) Arrange for hearing testing.
D) Cover the ears with gauze pads.