MAKE
A client who wants to use the vaginal sponge method of contraception shows that she understands the appropriate usage when she makes which statement?
I need to moisten it with water prior to use
Which of the following is a sign of dehydration in the newborn?
Sunken Fontanelles
A woman has been in labor for 16 hours. Her cervix is dilated to 3 cm and is 80% effaced. The fetal presenting part is not engaged. The nurse would suspect which of the following?
Cephalopelvic disproportion (CPD)
The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority?
Gas Exchange, Impaired
A woman is 16 weeks pregnant. She has had cramping, backache, and mild bleeding for the past 3 days. Her physician determines that her cervix is dilated to 2 centimeters, with 10% effacement, but membranes are still intact. She is crying, and says to the nurse, “Is my baby going to be okay?” In addition to acknowledging the client’s fear, what should the nurse also say?
“Your cervix is beginning to dilate. That is a serious sign. We will continue to monitor you and the baby for now.”
The client calls the clinic and tells the nurse that she can’t feel her IUD string after her last menstrual period. What should the nurse tell her ?
Come to the clinic immediately
The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation?
1. "Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function."
What is one of the most common initial signs of nonreassuring fetal status?
Meconium-stained amniotic fluid
The Client at 16 weeks’ gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which statement by the nurse best explains this change?
“Because your blood volume has increased, your hematocrit count is lower.”
A woman at 7 weeks’ gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority?
Fluid Volume: Deficient
The nurse is caring for a premature infant in the NICU, and is going to attempt a bottle feeding with thawed breast milk. How long can thawed breast milk be stored in the refrigerator before the nurse must discard it?
24 hours
The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn?
Offer early feedings with formula or breast milk
Two hours ago, a client at 39 weeks’ gestation was 3 cm dilated, 40% effaced, and +1 station. Frequency of contractions was every 5 minutes with duration 40 seconds and intensity 50 mmHg. The current assessment is 4 cm dilated, 40% effaced, and +1 station. Frequency of contractions is now every 3 minutes with 40-50 seconds’ duration and intensity of 40 mmHg. What would the priority intervention be?
1. Begin oxytocin after assessing for CPD.
The Client at 16 weeks’ gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which statement by the nurse best explains this change?
“Because your blood volume has increased, your hematocrit count is lower.”
A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity?
Patellar reflexes weak or absent
What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn?
Lactose
The client is at 42 weeks’ gestation. Which order should the nurse question?
Have the client return to the clinic in 1 week.
What is one of the most common initial signs of nonreassuring fetal status?
Meconium-stained amniotic fluid
The partner of a client at 16 weeks’ gestation accompanies her to the clinic. The partner tells the nurse that the baby just doesn’t seem real to him, and he is having a hard time relating to his partner’s fatigue and food aversions. Which statement would be best for the nurse to make?
“Many men feel this way. Feeling the baby move in a few weeks will help make it real to you.”
A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse’s best response?
“This medication is effective in stimulating lung development in the preterm infant.”
The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding?
A mother who is HIV positive
The nurse examines the client’s placenta and finds that the umbilical cord is inserted at the placental margin. The client comments that the placenta and cord look different than they did for her first two births. The nurse should explain that this variation in placenta and cord is called what?
Battledore Placenta
The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity?
Strong sucking reflex
The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician?
Platelet count of less than 100,000/mm3
A clinic nurse is planning when to administer Rh immune globulin (RhoGAM) to an Rh-negative pregnant client. When should the first dose of RhoGAM be administered?
At 28 weeks’ gestation