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1.    The nurse is reviewing the chart of a 16-year-old gravida 1, para 0. Her basal metabolic index is 20 and her hemoglobin is 14g/dl. The nurse should recognize this client is at increased risk for which complication of pregnancy?
Gestational hypertension
Gestational diabetes
Miscarriage
Multifetal pregnancy
2.    A nurse is caring for a client with preeclampsia and is being tested with magnesium sulfate iv. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent. Which action should the nurse take first?
Assess maternal blood glucose
Place the clients in Trendelenburg position
Prepare for an emergency cesarean birth
Discontinue the medication infusion
3.    When assessing an infant that is 2 hours old, the nurse determines that an infant is small for gestational age (SGA) which intervention would the priority nursing care for this infant?
Evaluate for genetic anomalies
Monitor for increasing abdominal girth
Monitor for signs of jaundice
Monitor blood glucose levels
4.    A nurse in the antepartum unit is caring for a client at 36 weeks of gestation and has pregnancy-induced hypertension suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which complication?
Placenta previa
Abruptio placentae
Prolapsed cord
Incompetent cervix
5.    When completing a head-to-toe assessment on a newborn, which finding would indicate developmental dysplasia of the hip?
Asymmetric gluteal folds
Absent plantar reflexes
Poor muscle tone in lower extremities
Inwardly turned foot on the affected side
6.    A breastfeeding client is 3 days postpartum. The nursing assessment notes the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breast is hard and warm to touch bilaterally, urine output was 2000 ml for the last 24 hours. What is the best nursing action for these findings?
Message the fundus vigorously
Evaluate the client for signs of urinary tract infection
Teach the client techniques for managing engorgement
Notify the primary health care provider regarding early indications of mastitis
7.    Following delivery via cesarean section, a client asks the nurse about vaginal birth after cesarean (VBAC) which factor should the nurse tell the client is a contraindication for VBAC?
History of a classic uterine incision
Breech presentation during a previous pregnancy
Previous cesarean for fetal distress
History of preterm labor
8.    A nurse is caring for a 4-hour-old newborn. Which action should the nurse include in the plan of care to prevent jaundice?
Administer vitamin k immediately after birth
Initiate early feeding
Suction excess mucus with a bulb syringe
Monitor vital signs frequently
9.    A client is admitted to the labor and delivery unit for induction of a know intrauterine demise. What is the most appropriate intervention by the nurse?
Avoid talking about the baby
Reassure the client that she ‘ll get pregnant again soon
Provide privacy and emotional support
Contact the health care facility on-call clergy
10.   The nurse is assessing a 12-week postpartum client. Upon asking how she is feeling the client burst into tears and reports that she cries most of the time, feels like a failure, and can barely get out of bed to dress. The nurse suspects the client is experiencing?
Postpartum neurosis
Postpartum psychosis
Postpartum depression
Postpartum blues
11.   A nurse is admitting a client at 37 weeks of gestation with severe gestational hypertension. Which action should the nurse expect to implement (select all that apply)
Administer magnesium sulphate IV
Ensure that calcium gluconate is readily available
Provide a dark, quiet environment
Evaluate reflexes every 4 hours
Assess respiratory status every 8 hours
12.   A nurse is assessing a neonate born less that 8 hours ago and notes a yellow tint to the sclera and skin. What data would be important for the nurse to assess in relation to this finding?
Maternal hepatitis B status
Maternal glucose testing
Maternal and newborn blood type and Rh factor
Length of time membranes ruptured before delivery
13.   A nurse is caring for a client that is 12 hours postpartum. What finding is of greatest concern to the nurse at this time?
Orthostatic hypotension
Fundus palpable as the umbilicus
Heart rate 110/min
Urine output of 3,000 ml in 12 hours
14.   A nurse is caring for a client 8 hours postpartum who asks the nurse to feed her newborn for her. Which response should the nurse provide?
Oh, this isn’t difficult. You will be fine doing this
You can learn to feed your baby, I wasn’t comfortable the first time I fed a baby either
Feeding an infant can feel a little intimidating at first, but I ‘ll stay and help you
I ll feed the baby today. Maybe tomorrow you can try it
15.   A nurse teaching on newborn nutrition to a new mother. The client asks, “how will I know that my baby is getting enough breast milk? What is the nurses best response?
Your baby should feed at least 6 times a day
Your baby should sleep at least 3 hours between feedings
Your baby should wet 6 to 8 diapers per day
Your baby should have at least 3 bowel movements a day
16.   A nurse is caring for a client that is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The fetal monitor indicates a regular fetal heart rate of 138/min and no uterine contractions. The clients vital signs are blood pressure 98/52 mm hg, heart rate 24/min, and temperature 97.6 what is the priority nursing action?
Witness the signature for informed consent for surgery
Initiate IV access
Prepare the abdominal and perineal areas
Insert an indwelling urinary catheter
17.   A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?
Administer eye prophylaxis
Administer vitamin k
Dry the skin
Place an identification bracelet
18.   A nurse is caring for a client in preterm labor at 32 weeks of gestation. The client repeatedly asks the nurse, will my baby be okay? What response by the nurse would be best to meet the clients needs
Tell the more about your concerns
We have a neonatal unit here that’s equipped to handle emergencies
Your pregnancy is advanced so your baby should be fine
Everyone worries about her baby when she s in labor
19.   A nurse caring for a client in the first stage of labor observes the umbilical cord protruding from the vagina. What is the most appropriate nursing action?
Place the client in knee-chest position
Cover the cord with a sterile, moist saline dressing
Insert a gloved hand into the vagina to relieve pressure on the cord
Prepare the client for an immediate birth
20.   A grandparent of a newborn in the nursery asks to take the baby to the mother’s room..
Have the mother call and I will take the baby to the room
You may carry grandchild to the room as long as
If you show me your photo identification, you may take the infant
You can push the baby to the room in a wheeled bassinet
21.   A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which assessment the nurse priority?
Respiratory rate of 80
Acrocyanosis
Small scalp lacerations
Temperature 97.5
22.   A nurse is instructing a newborn’s parent to care for the umbilical cord stump. What instruction should the nurse include?
Wash the cord daily with mild soap and water
Apply alcohol to the cord stump at each diaper change
Give me a sponge bath until the cord stump fails off
Apply the diaper snugly over the cord
23.   A nurse is planning care for a preterm newborn. Which nursing intervention should be included in the plan of care to promote development?
Avoid over stimulation by avoiding touching the instant
Position the newborn to promote extension of muscles
Keep the newborn in a well-lit nursery
Cluster the newborn’s care activities
24.   A nurse is admitting a client at 35 weeks of gestation. Her blood pressure is 140/90, reflexes are 3+ bilaterally, and she has a severe headache. In reviewing the primary healthcare provider’s orders, which order is not appropriate for this client?
Continuous fetal monitoring
Assess deep tendon reflexes every hour
Obtain a daily weight
Ambulate twice daily
25.   A nurse is caring for a client that is 12 hours postpartum following a vaginal delivery. Which finding should the nurse expect?
Fundus firm, at the level of the umbilicus
Lochia rubra is heavy, soaking one pad an hour
Last void measure 50 ml
Breasts are full, firm and slightly red
26.   A nurse is caring for a client that experienced a vaginal birth 3 hours. Upon palpation, the fundus is displaced to the right of mid-line, is firm, and is two fingerbreadths above the umbilicus. What action should the nurse complete at this time?
Administer an analgesic
Massage the fundus
Have the client urinate
Insert a urinary catheter
27.   A client three weeks postpartum reports to the clinic feeling “down” sad, lethargic, and tearful. What is the priority action by the nurse at this time?
Let her know this is a normal part of transition and she will be fine
Anticipate a need for an antidepressant and refer her for further evaluation
Ask the client if she has had thoughts of harming herself or her newborn
Assist the family to identify prior use of positive coping skills in family crises
28.   A nurse is admitting a client that is laboring at 28 weeks gestation. The nurse would anticipate the possibility of prescriptions for which medications? Select all that apply
Methylergonovine
Corticosteroids
Indomethacin
Magnesium sulphate
Oxytocin
29.   A nurse is planning care for a client with a history of thromboembolic disease following a cesarean birth. Which nursing intervention should be included in the plan of care?
Apply heat to the client’s lower extremities
Place pillows under the client’s knees when resting in bed
Have the client message her legs period
Have the clients ambulate as soon as possible
30.   A nurse is caring for a client in labor at 40 weeks of gestation and reports saturating two perineal pads in the past 30 minutes. What is the priority nursing action at this time?
Prepare for cesarean birth
Perform a vaginal exam to determine labor status
Send the client to ultrasound to confirm placental location
Start a magnesium sulphate infusion to stop contractions
31.   A nurse is reviewing contraception options for four clients. The nurse should identify which client has a contraindication for receiving oral contraceptives?
A 32 year old client with benign breast disease
A 28 year old client with a history of pelvic inflammatory disease
A 26 year old client with migraine headaches at the start of each menstrual cycle
A 38 year old client that reports smoking one pack of cigarettes every day
32.   A nurse is assisting with the care of a newborn immediately following birth. Which medications should the nurse anticipate administering? Select all that apply
Lidocaine gel for the circumcision site
Antibiotic ointment to both eyes
Hemophilus influenza type B immunization
Vitamin k injection
Hepatitis B immunization
33.   A nurse is caring for a group of clients on an intrapartum unit. Which finding should be reported to the primary health care provider immediately?
Experiencing irregular, frequent contractions at 32 weeks of gestation
Receiving terbutaline that reports feeling jittery and has a heart rate of 98 bpm at 28 weeks of gestation
Reporting epigastric pain and unresolved headache with a blood pressure of 160/95
Lab reports 2+ proteinuria and physical assessment of 2+ patellar refelexes
34.   A nurse is reviewing a newborns laboratory results. Which finding is the nurses priority?
Bilirubin 10 mg/dl
Platelets 200,000/mm
Blood glucose 45 mg/dl
Hemoglobin 22 g/dl
35.   A nurse is caring for a newborn and observes signs of jitteriness and lethargy. Which action should the nurse take?
Monitor the newborn’s pulse
Check the newborn’s temperature
Obtain a bilirubin level of heel stick
Obtain blood glucose by heel sick
36.   A client who is 2 hours postpartum reports an urge to void. She is post epidural anesthesia, alert, can move her legs but states her legs feel numb. How should the nurse respond?
I will go get a bedpan and let you try to empty your bladder
I will walk you to the bathroom and stay with you
Because of the numbness, you will need a urinary catheter
Lets wait about an hour so you can walk to the bathroom on your own
37.   A preterm labor client has a prescription for Betamethasone 12mg/IM q 12 hours. The concentration available is 6mg/2ml. what volume will the nurse administer per injection? (if need round to the nearest tenth)———- ml
38.   A nurse is preparing to administer methylergonovine to a client. Which assessment should the nurse perform prior to administering the medication?
Blood pressure
Breath sounds
Last administration of analgesics
Location of the fundus
39.   A nurse in a prenatal clinic is caring for a client with a suspected hydatidiform mole. Which finding should the nurse expect to observe in this client?
Rapid decline in human chorionic gonadotropin levels
Irregular fetal heart rate
Profuse, clear vaginal discharge
Excessive uterine enlargement
40.   A nurse is caring for a client with a suspected ectopic pregnancy at 8 weeks of gestation. Which manifestation should the nurse expect to identify?
Uterine enlargement greater that expected for gestational age
Unilateral cramp like abdominal pain
Severe nausea and vomiting
Large amount of vaginal bleeding
41.   A home health nurse is instructing a client that is breastfeeding about managing breast engorgement which client statement indicates understanding of the information?
I will try drinking an herbal tea to reduce the engorgement
I will apply cold compresses 20 minutes before each feeding
I will feed my baby about every 2 hours
I will my baby drain one breast at each feeding
42.   A nurse is caring for a client that is 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. Which action should the nurse take first?
Assess the bladder for distension
Assess client’s blood pressure
Massage the clients fundus
Prepare to administer a prescribed oxytocic preparation
43.   A nurse is caring for a client that is 16 hours postpartum and states “My baby has been breathing funny, fast and slow, off and on. What is the nurses best response?
Lets sit here together and observe your baby for a while
Most new mothers feel somewhat anxious about things like this
Why do you think there is something wrong with the baby
Don’t worry, newborns often breathe this way
44.   The nurse is assessing a 12 week postpartum client. Upon asking how she is feeling the client bursts into tears and reports that she cries most of the time, feels like a failure, and can barely get out of bed to dress. The nurse suspects?
Postpartum neurosis
Postpartum psychosis
Postpartum depression
Postpartum blues
45.   A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which treatment should the infant receive?
Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine for 6 months
Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen
Hepatitis B vaccine within 12 hours of birth followed by hepatitis B immune globulin every 12 hours for 3 days
Hepatitis B immune globulin and hepatitis B vaccine within 12 hours of birth
46.   Which nursing action is designed to avoid unnecessary heat loss in the newborn?
Maintain a room temperature of 75 degrees Fahrenheit
Bathe the infant within the first 4 hour of life
Place a warm blanket over the scale prior to weighing the infant
Monitor the newborns rectal temperature hourly
47.   A nurse is caring for a client that is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which measures should the nurse suggest to reduce discomfort during breastfeeding (select all that apply)
Apply ice to the nipples between feedings
Begin the breastfeeding with the nipple that is less sore
Make sure the infant latches onto the arreola when feeding
Alternate breastfeeding with bottle feeding
48.   A nurse is caring for a client that experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which finding would support this assessment
Eagerness to take on newborn care skills
Focus on the family unit and its members
Expressions of excitement
Lack of appetite
49.   A nurse is preparing to assess a newborn at 42.5 weeks of gestation. Which findings should the nurse expect? Select all that apply
Absent moro reflex
Creases over the entire plantar surface
Positive Babinski reflex
Cracked peeling skin
Abundant lanugo
50.   A nurse is administering rhogan 1500 units IM x 1 to a Rh negative client following delivery. Available is Rhogam 2500 units/2 ml. how many ml (s) should the nurse administer? (if needed round to the nearest tenth) ——– ml
51.   A nurse on a maternal infant unit is teaching a postpartum client regarding nutrition for breastfeeding. Which instruction is most important to include?
Increase fluid intake to support milk production
Increase intake of saturated fats for rich milk
Caloric needs are less than in pregnancy
Double iron intake for fetal growth needs
52.   A nurse is assessing a client for postpartum infection. Which findings should indicate to the nurse that the client requires further evaluation for endometritis?
Moderate amount of dark red lochia with a bloody odor
A localized area on the perineum
Pelvic pain
Hematuria
53.   A nurse is assessing a newborn whose mother has gestational diabetes. The newborn’s blood glucose level is 33mg/dl. Which findings should the nurse expect? SATA
Low temperature
Vomiting
Jitteriness
Abdominal distension
Irregular respiratory rate
54.   A postpartum nurse is caring for a client that is 4 hours postpartum following a vaginal birth of a newborn weighing 4300g. The nurse recognizes this client is at increased risk for which postpartum complication?
Hypercoagulation
Hemorrhage
Retained placental pieces
Endometritis
55.   A nurse is providing discharge instruction about reducing perineal infection with a client following a vaginal delivery. Which instructions should the nurse include? SATA
Wipe the area vigorously with tissue to dry well
Perform hand hygiene and after voiding
Use a vinegar based douche to clean the vagina daily
Clean the perineal area from front to back
Cleanse the perineal area using warm water after each voiding
56.   A nurse is caring for a preterm labor newborn that has been placed on a warming bed with a temperature probe. The parents of the newborn ask why it is necessary. What is the nurses best response?
The added brown fat layer in a preterm newborn reduces the newborn’s ability to generate heat
The heat in the incubator rapidly dries the sweat of preterm newborns
Preterm newborns lack adequate temperature control mechanisms
Preterm newborns have a similar body surface area than normal newborns
57.   When assessing an infant that is 2 hours old, the nurse determines that the infant is small for gestational age (SGA). Which intervention would be priority nursing care for this infant?
Evaluate for generic anomalies
Monitor for increasing abdominal girth
Monitor for signs of jaundice
Monitor blood glucose levels
SCIENCE
HEALTH SCIENCE
NURSING
