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100

A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother’s temperature is 100.2°F. Which of the following actions would be most appropriate?

•      A. Retake the temperature in 15 minutes.

•      B. Notify the physician.

•      C. Document the findings.

•      D. Increase hydration by encouraging oral fluids




•      D. Increase hydration by encouraging oral fluids

100

A pregnant client is concerned about the potential teratogenic effects of over-the-counter medications. What should the nurse advise the client regarding the use of medications during pregnancy?

A. Over-the-counter medications are generally safe and can be used without restriction


B. Only prescription medications pose risks, so over-the-counter medications are safe


C. Limit medication use to essential ones and consult with the healthcare provider before taking any


D. Avoid all medications, including over-the-counter options, during pregnancy

C. Limit medication use to essential ones and consult with the healthcare provider before taking any

100

A client who has just delivered a baby is prescribed Methergine to prevent postpartum hemorrhage. What is the nurse's priority assessment before administering Methergine?

A. Verify the client's blood type and Rh factor
B. Assess the client's level of pain and discomfort
C. Measure the client's blood pressure
D. Evaluate the client's emotional well-being

C. Measure the client's blood pressure

100

A pregnant client is scheduled for a cesarean delivery due to a breech presentation. What information should the nurse provide to the client regarding the planned cesarean section?

A. "Cesarean deliveries are only performed in emergency situations."
B. "You will be awake during the procedure, but your lower body will be numb."
C. "Cesarean deliveries are associated with a lower risk of infection compared to vaginal deliveries."
D. "After the cesarean section, you can expect a shorter recovery time than with a vaginal delivery."

B. "You will be awake during the procedure, but your lower body will be numb."

100

A laboring client is undergoing continuous external electronic fetal monitoring (EFM). The nurse observes accelerations on the fetal heart rate (FHR) tracing. What is the appropriate interpretation of accelerations?

A. Indicative of fetal distress
B. Associated with fetal head compression
C. Sign of adequate fetal oxygenation
D. Suggestive of uteroplacental insufficiency

C. Sign of adequate fetal oxygenation

200

A pregnant client at 32 weeks gestation presents with back pain, fever, and cloudy, foul-smelling urine. The nurse suspects a urinary tract infection (UTI). What is the appropriate nursing action?

A. Administer an analgesic for pain relief
B. Encourage increased fluid intake
C. Initiate antibiotic therapy as prescribed
D. Instruct the client to perform Kegel exercises

C. Initiate antibiotic therapy as prescribed

200

A pregnant client at 28 weeks gestation has Rh-negative blood type. What intervention is essential to prevent Rh isoimmunization?

A. Administer Rho(D) immune globulin (RhoGAM)
B. Schedule a glucose tolerance test
C. Recommend a low-sodium diet
D. Initiate anticoagulant therapy

 Administer Rho(D) immune globulin (RhoGAM)

200

A laboring client is receiving oxytocin (Pitocin) to augment contractions. The nurse should monitor the client closely for signs of:

A. Increased blood pressure
B. Water retention and edema
C. Uterine hyperstimulation
D. Elevated maternal heart rate

C. Uterine hyperstimulation

200

A postpartum client who underwent a cesarean section is experiencing severe pain, redness, and warmth at the incision site. The nurse suspects an infection. What is the most appropriate nursing intervention?

A. Administer a prescribed intramuscular antibiotic injection
B. Encourage the client to perform deep-breathing exercises
C. Apply a cold compress to the incision site
D. Assess the client's vital signs and notify the healthcare provider

D. Assess the client's vital signs and notify the healthcare provider

200

A laboring client is being monitored using continuous internal electronic fetal monitoring (IEMF). The nurse observes a baseline fetal heart rate (FHR) of 150 beats per minute. How should the nurse interpret the baseline FHR?

A. Bradycardia
B. Tachycardia
C. Normal baseline FHR
D. Variable decelerations

C. Normal baseline FHR

300

A client reports experiencing amenorrhea, breast tenderness, and urinary frequency. The nurse recognizes these signs as:

A. Positive signs of pregnancy
B. Probable signs of pregnancy
C. Presumptive signs of pregnancy
D. Early signs of labor

C. Presumptive signs of pregnancy

300

A pregnant client at 8 weeks gestation is prescribed a urine culture and sensitivity test. What is the primary reason for conducting this test during pregnancy?

A. Monitor glucose levels
B. Screen for urinary tract infections
C. Assess kidney function
D. Determine proteinuria

B. Screen for urinary tract infections

300

A primigravida in active labor is experiencing severe pain and requests an epidural for pain relief. What information should the nurse provide to the client before the administration of an epidural?

A. "Epidurals are associated with minimal risks and rarely have side effects."


B. "Epidurals may cause a temporary decrease in blood pressure; we will monitor you closely."


C. "Epidurals can only be administered during the early stages of labor."


D. "Epidurals are contraindicated if you have already received any other pain medications."

B. "Epidurals may cause a temporary decrease in blood pressure; we will monitor you closely."

300

A client who had a cesarean delivery develops shortness of breath and chest pain on postoperative day two. What complication should the nurse suspect?

A. Pulmonary embolism
B. Atelectasis
C. Peritonitis
D. Urinary tract infection

A. Pulmonary embolism

300

A laboring client is undergoing intermittent external electronic fetal monitoring (EFM). The nurse notes a variable deceleration on the fetal heart rate (FHR) tracing. What is the appropriate nursing intervention?

A. Change the client's position
B. Administer oxygen to the client
C. Discontinue the fetal monitoring
D. Prepare for an emergency cesarean section

A. Change the client's position

400

A pregnant client at 28 weeks gestation has Rh-negative blood type. What intervention is essential to prevent Rh isoimmunization?

A. Administer Rho(D) immune globulin (RhoGAM)
B. Schedule a glucose tolerance test
C. Recommend a low-sodium diet
D. Initiate anticoagulant therapy

A. Administer Rho(D) immune globulin (RhoGAM)

400

A pregnant client at 28 weeks gestation presents with dependent edema in the lower extremities. What physiological change is responsible for this condition?

A. Increased glomerular filtration rate
B. Enhanced venous return
C. Decreased blood pressure
D. Compression of pelvic vessels by the uterus

D. Compression of pelvic vessels by the uterus

400

A pregnant client at 41 weeks gestation presents to the labor and delivery unit with regular contractions that are increasing in intensity. The nurse assesses the client and notes cervical dilation and effacement. What is the nurse's priority action?

A. Administer analgesics for pain relief
B. Encourage the client to walk to promote labor progress
C. Begin continuous fetal monitoring
D. Prepare for an emergency cesarean section

C. Begin continuous fetal monitoring

400

A client is being discharged after a cesarean section, and the nurse provides instructions about signs of incisional dehiscence. What information should the nurse include in the discharge teaching?

A. "Expect a small amount of serosanguinous drainage from the incision site."
B. "Report any separation or opening of the incision, even if it seems minor."
C. "Apply hydrogen peroxide to the incision daily to prevent infection."
D. "Avoid any movement that involves abdominal muscles for the next 24 hours."

B. "Report any separation or opening of the incision, even if it seems minor.

400

A pregnant client at 39 weeks gestation is undergoing intermittent external electronic fetal monitoring (EFM). The nurse notes variability on the fetal heart rate (FHR) tracing. How should the nurse interpret normal variability?

A. Absence of variability is normal in late pregnancy
B. Variability is an expected finding and indicates a responsive fetal nervous system
C. Variability is concerning and may indicate fetal distress
D. Variability is only present during contractions

B. Variability is an expected finding and indicates a responsive fetal nervous system

500

An antepartal client asks when her baby is due.  Her last menstrual period was August 28.  Using Naegele's rule, calculate the estimated date of delivery.

June 4th

500

A pregnant client at 20 weeks gestation develops mild anemia. What physiological change contributes to the dilutional anemia commonly seen in pregnancy?

A. Increased red blood cell production
B. Expansion of plasma volume
C. Enhanced iron absorption
D. Elevated erythropoietin levels

B. Expansion of plasma volume

500

A pregnant client at 38 weeks gestation calls the clinic and reports the passage of a small amount of blood-tinged mucus. The client is concerned about the significance of this finding. What is the nurse's best response?

A. "This is a sign that you are in active labor, and you should come to the hospital immediately."


B. "Passage of a small amount of blood-tinged mucus, known as the bloody show, is a common sign that labor may begin soon."


C. "Bleeding is abnormal during pregnancy, and you should go to the emergency room right away."


D. "It is a sign of a possible infection, and you should start antibiotics right away."

B. "Passage of a small amount of blood-tinged mucus, known as the bloody show, is a common sign that labor may begin soon."

500

A multiparous client is in the third stage of labor. What is the primary nursing intervention during this stage?

A. Administer oxytocin to enhance uterine contractions
B. Assess the client's pain level and provide pain relief measures
C. Monitor for signs of placental separation and assist with delivery
D. Prepare for immediate neonatal resuscitation

C. Monitor for signs of placental separation and assist with delivery

500

A postpartum client is experiencing uterine atony, and the healthcare provider orders an oxytocin infusion. What is the primary purpose of administering oxytocin in this situation?

A. Pain relief
B. Uterine relaxation
C. Uterine contraction and involution
D. Prevention of infection

C. Uterine contraction and involution

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