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Yellow-green fluid leaking from the vaginal would indicate
a. Infection
b. Meconium
c. Normal finding
d. Placenta previa
b. Meconium
The nurse is caring for a child born at 32 weeks gestation. After birth the child begins demonstrating nasal flaring, grunting, retractions, and central cyanosis. Which of the following does the nurse anticipate doing next?
A. Assisting with intubation
B. Preparing for an echocardiogram
C. Rubbing the child's foot
D. Applying a non-rebreather mask
A. Assisting with intubation
The nurse is explaining the cardiac catheterization procedure to a 3 year old child. Which of the following learning methods should the nurse implement?
A) Give the child a tour of the cath lab
B) Allow the child to keep an example cardiac stent
C) Explain to the child that they might feel funny when the catheter is inserted
D) Allow the child to play with some of the equipment to be used
D) Allow the child to play with some of the equipment to be used
The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
a. Variability
b. Accelerations
c. Early decelerations
d. Variable decelerations
d. Variable decelerations
A postpartum nurse is caring for a patient who gave birth to a healthy newborn girl 12 hours ago. She notices that the patient has gone to void several times in the last hour and has only produced 25 cc of urine. Which of the following is a priority intervention?
a. Straight catheterize the patient
b. Obtain a bladder scanner
c. Assess the fundus
d. Assess the perineum for signs of trauma
b. Obtain a bladder scanner
A client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains?
A) Bottle-feeding
B) Diabetes
C) Multiple gestation
D) Primiparity
C) Multiple gestation
The nursing student would be correct to identify which of the following patients as suffering from breast engorgement?
A. Swollen, hard breasts; mother says “OUCH!” when breasts are examined
B. Red nipples with a cloudy discharge; mother has a temperature of 103
C. Inverted nipples; difficulty with breastfeeding
D. Cracked, bleeding nipples
A. Swollen, hard breasts; mother says “OUCH!” when breasts are examined
Which of the following lab values would cause you to suspect HELLP syndrome? SATA
a. ALT of 150
b. AST of 32
c. Platelets of 400,000
d. Blood glucose of 153
e. Hematocrit of 6.8
f. Bilirubin of 1.5
a. ALT of 150 (normal is 7-55, would indicate + if elevated)
e. Hematocrit of 6.8 (normal is 12-15 for females, would indicate + if low)
f. Bilirubin of 1.5 (0.3-1, elevation is indicating hemolysis)
A patient has been admitted to the emergency department at 21 weeks gestation. She complains of decreased fetal movements and a trickle of fluid felt between her legs. She asks why you are collecting a sample of the fluid. Which of the following is the correct response from the nurse? SATA
A. “I am going to dip a Nitrazine paper into the fluid to determine if this is amniotic fluid”
B. “We are going to examine the color of the fluid leaking against a special light to determine if this is amniotic fluid”
C. “I am just helping to clean you up”
D. “We are going to assess the fluid under a microscope to determine if this is amniotic fluid”
A. “I am going to dip a Nitrazine paper into the fluid to determine if this is amniotic fluid”
D. “We are going to assess the fluid under a microscope to determine if this is amniotic fluid”
The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a:
A. tonic neck reflex.
B. Moro reflex.
C. cremasteric reflex.
D. Babinski reflex.
B. Moro reflex.
A nurse knows that postpartum women are at an increased risk of venous thromboembolism formation due to meeting all three factors of Virchow’s Triad. Therefore when caring for these patients it is important to assess for: SATA
a. Redness, heat, and swelling of both calves
b. SOB and a stabbing chest pain
c. Flank pain that radiates to the hands
d. Cold and clammy bilateral feet
e. Leg pain with ambulation
a. Redness, heat, and swelling of both calves
b. SOB and a stabbing chest pain
e. Leg pain with ambulation
A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experience a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure?
a. Placing the patient in a supine position
b. Holding down the patient’s head to prevent injury
c. Staying with the patient and activating the emergency response team
d. Timing the seizure
e. Providing 8 to 10 L of oxygen
a. Placing the patient in a supine position (place patient on left side)
b. Holding down the patient’s head to prevent injury (never want to restrain during seizure)
In the fourth stage of labor, a full bladder increases the risk for
a. Hemorrhage
b. Disseminated intravascular coagulation
c. Infection
d. Shock
a. Hemorrhage
A postpartum nurse is assessing the fundal heights of multiple patients. Which of the following patients would the nurse identify as concerning?
A. Delivered 12 hours ago, fundus at the umbilicus
B. Delivered 36 hours ago, fundus one fingerbreadth below the umbilicus
C. Delivered 72 hours ago, fundus two fingerbreadths below the umbilicus
D. Delivered 5 days ago, fundus is about the width of a hand below the umbilicus
C. Delivered 72 hours ago, fundus two fingerbreadths below the umbilicus
The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor?
a. The contractions are regular.
b. The membranes have ruptured.
c. The cervix is dilated completely.
d. The client begins to expel clear vaginal fluid.
c. The cervix is dilated completely.
Multiple gestation increases the risk for developing
a. Prematurity
b. Respiratory distress syndrome
c. IUGR
d. Hyperemesis gravidarum
e. Anemia
f. Preeclampsia
a. Prematurity
b. Respiratory distress syndrome
c. IUGR
d. Hyperemesis gravidarum
e. Anemia
f. Preeclampsia
A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by:
A. Subcutaneous injection
B. Intravenous injection
C. Instillation through an endotracheal tube
D. Intramuscular injection
C. Instillation through an endotracheal tube
To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
A. Monitoring for the passage of meconium each shift
B. Instituting phototherapy for 30 minutes every 6 hours
C. Substituting breastfeeding for formula during the 2nd day after birth
D. Supplementing breastfeeding with glucose water during the first 24 hours
A. Monitoring for the passage of meconium each shift
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider?
a. Hemoglobin of 11 g/dL
b. Fetal heart rate of 180 beats/minute
c. Maternal pulse rate of 85 beats/minute
d. White blood cell count of 12,000 cells/mm3
b. Fetal heart rate of 180 beats/minute
Which of the following are considered danger signs?
a. Saturating a pad w/in 2 hours
b. Temp of 101
c. Clots the size of a nickel
d. Firm uterus
e. Vision changes
f. SOB
b. Temp of 101
e. Vision changes (could develop into seizures)
f. SOB (PE)