Antepartum
A 32-week pregnant client reports headache, visual disturbances, and swelling of hands. BP is 160/110. What is the nurse's first action?
What is- Place the client in the Left lateral position?
Oxtyocin is being infused. Contractions occur every 1 minute and last 90 seconds. FHR shows minimal variability and tachycardia. What is the nurse's first action?
What is- Stop the oxytocin infusion?
Patient is 39 weeks gestation being assessed for decreased fetal movement. FHRs 140bpm baseline, moderate variability, positive accelerations, no decelerations.
How does the nurse interpret this?
What is- normal/reassuring tracing?
A postpartum client has a boggy uterus and heavy lochia rubra.
What is the nurse's first action?
What is- Massage the uterus?
Which medication is routinely given to prevent hemorrhagic disease of the newborn?
What is- Vitamin K?
A) persistent vomiting past the 1st trimester
B) sudden gush of fluid at 30 weeks gestation
C) mild dependent edema at the end of the day
D) decreased fetal movement
E) Braxton Hicks contractions
What is- A, B, D?
What are the 5 P's of labor?
G1P0 at term in active labor. FHRs 130s baseline, moderate variability, neg accels, abrupt decels to 90 bpm with contractions with variable timing.
What is the nurse's interpretation?
What is- variable decels?
Which is the most common cause of postpartum hemorrhage?
What is- uterine atony?
Which glucose value in a newborn requires intervention?
A) 60 mg/dL
B) 55 mg/dL
C) 38 mg/dL
What is- C?
A client at 28 weeks has a positive indirect Coombs test and is Rh-negative. The fetus is Rh-positive. Which medication does the nurse expect to administer?
What is- Rho(D) immune globulin (RhoGAM)?
The nurse is facilitating the third stage of labor. Which action is expected?
moderate variable decels to 90 bpm are observed in a laboring patient at term. What is the nurse's first action?
What is- Reposition the client?
Risk factors for postpartum infection include: Select all that apply.
A) Prolonged labor
B) Cesarean birth
C) Frequent vaginal exams
D) Early ambulation
What is- A, B, and C?
Jaundice appearing in the first 12 hours of life suggests-
What is- Pathologic jaundice?
Fundal height at 30 weeks measures 36cm. What should the nurse do next?
What is- Notify the provider for further evaluation?
Which pain management option for labor requires continuous fetal monitoring?
37 week patient in transition phase. FHR's 140s baseline, mod variability, positive accels, gradual decelerations that mirror the contractions are observed. What is the nurse's response?
What is- Continue to monitor?
A client expresses tearfulness and mood swings 3 days postpartum. How does the nurse interpret this?
What is- Postpartum blues?
Which newborn finding at birth is expected?
A) nasal flaring
B) neonatal erythema toxicum
C) acrocyanosis
What is- C?
Which assessment finding in a pregnant client with hyperemesis gravidarum is the PRIORITY?
What is- Signs of dehydration? (dry mucous membranes, poor skin tugor)
A laboring client develops a uterine rupture risk. What would be the MOST concerning assessment finding?
What is- Sudden fetal bradycardia?
40 week patient in active phase of labor. FHRs 140s baseline, absent variability, neg accels, late decels observed. What is the nurse's first action?
What is- Reposition to the laft lateral position?
Which finding suggest postpartum thrombophlebitis? Select all that apply.
A) Unilateral leg pain
B) localized warmth
C) afebrile
D) edema at the affected site
What is- A, B, D?
Which client is at highest risk for pelvic inflammatory disease (PID)?
A) 18-year-old nulligravida, one sexual partner
B) 28-year-old, G2T2P0A0L2, multiple sexual partners and recent STI
C) 35-year-old, G3T1P1A1L2, multiple sexual partners before current monogamous relationship, neg history of STIs
What is- B?