Exam Review

A nurse is caring for a client with the nursing diagnosis of acute pain related to breast engorgement.Which interventions should the nurse include in the plan of care?
A)Apply warm compresses to the breasts before breastfeeding.
B)Advise the client to limit fluid intake to reduce milk production.
C)Apply cold compresses to the breasts after breastfeeding.
D)Instruct the client to breastfeed frequently or pump milk regularly.
E)Encourage the client to wear a tight-fitting bra throughout the day.
A nurse is reviewing the differences between placenta previa and abruptio placentae with a group of nursing students.Which of the following statements accurately differentiates placenta previa from abruptio placentae?
A)Placenta previa is characterized by sudden onset of severe abdominal pain and uterine tenderness, while abruptio placentae is associated with painless bleeding.
B)Placenta previa typically presents with severe pain and contractions, whereas abruptio placentae involves painless bleeding without contractions.
C)Placenta previa involves the placenta partially or completely covering the cervix, whereas abruptio placentae involves the premature separation of the placenta from the uterine wall.
D)Placenta previa usually results in a higher risk of maternal hypertension, while abruptio placentae is commonly associated with a low-risk pregnancy.
A G1P1 patient at 37 weeks' gestation is scheduled for a nonstress test (NST). The nurse's greatest concern is the client's risk of developing related to ▾ preeclampsia and ▾ primigravida and 37 weeks' gestation.
Dropdown 1:
Option 1: gestational diabetes
Option 2: preeclampsia
Option 3: placenta previa
Option 4: fetal growth restriction
Dropdown 2:
Option 1: advanced maternal age and gestational hypertension
Option 2: history of cesarean section and twin pregnancy
Option 3: primigravida and 37 weeks' gestation
Option 4: obesity and polyhydramnios
The client arrives at the emergency room following a sexual trafficking incident. She is experiencing significant pain but has difficulty swallowing pills. The provider prescribes 15 mL of Codeine with acetaminophen oral elixir to be taken by mouth once. Pharmacy Formulary Codeine with acetaminophen oral elixir available: 2 mg/mL of codeine 24 mg/mL of acetaminophen. The client is prescribed elixir. She will receive of ______ acetaminophen based on the formulary concentration.

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Exam Review

The nurse is reviewing fetal and maternal circulation with a group of nursing students.Which statement by a student demonstrates a need for further clarification?
A)"The fetal heart pumps blood to both the placenta and the developing organs.”.
B)"Maternal and fetal blood mix to allow for nutrient and oxygen exchange.”.
C)"The placenta is the site of gas exchange for the fetus.”.
D)"The umbilical arteries carry deoxygenated blood from the fetus to the placenta.”.
A 19-year-old client comes to the clinic seeking information about the use of the morning-after pill (levonorgestrel) for emergency contraception.Which of the following statements made by the client indicates a need for further teaching?
A)"I can use the morning-after pill as a regular form of birth control.”.
B)"I should take the morning-after pill as soon as possible after unprotected intercourse.”.
C)"The morning-after pill does not protect against sexually transmitted infections.”.
D)"The morning-after pill can be less effective if I take it more than 72 hours after unprotected sex.”. . . .
A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor.The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication.The nurse should provide which of the following explanations?
A)"It increases the fetal heart rate.”.
B)"It promotes fetal lung maturity.”.
C)"It halts cervical dilation.”.
D)"It is used to stop preterm labor contractions.”.
A nurse is monitoring a client who is receiving magnesium sulfate for severe preeclampsia.The client asks, "How will I know if the medication is working?" Which response by the nurse is most appropriate?
A)"We will check for a reduction in swelling and fluid retention.”.
B)"You should feel less pain and have fewer headaches.”.
C)"We will monitor your blood pressure to see if it decreases.”.
D)"We will assess for a decrease in seizure activity and improved reflexes.”.

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Exam Review

Which interventions should be immediately initiated when caring for a patient at 32 weeks' gestation who presents with a moderate amount of painless bright red vaginal bleeding?(SATA)
A)Monitor vital signs.
B)Administer oxygen at 10L via non-rebreather face mask.
C)Perform a digital vaginal examination to assess cervical dilation.
D)Initiate intravenous (IV) Lactated Ringers for fluid replacement.
E)Assess client for incidence of domestic violence.
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?
A)Observe an area of redness on the breast of a client who is 1 day postpartum.
B)Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum.
C)Monitor vital signs during admission of a client who has gestational hypertension.
D)Change the initial perineal pad of a client who just transferred from labor and delivery.
A nurse is reviewing urinalysis and symptom findings to determine which support a suspected genitourinary or reproductive tract infection. Which of the following findings support the nurse’s suspicion? (Select all that apply.)(SATA)
A)A. The client's urinalysis reveals a specific gravity within the expected range.
B)The client's urinalysis indicates the presence of ketones and bacteria.
C)The client's reported symptoms include pain and foul-smelling vaginal discharge.
D)The client denies any unprotected sexual activity according to the provided cues.
E)The client's urinalysis shows a cloudy appearance and a pH that is not provided.

For each medication below, click to select the appropriate nursing action. (Each category can have zero or more response options selected)

	Oxytocin (Pitocin)	Carboprost (Hemabate)	Misoprostol (Cytotec)	Methylergonovine (Methergine)
Administer intravaginally for cervical ripening.			✓
Monitor the length, strength, and duration of contractions.	✓
Ensure the client has a full bladder before administration.
Administer orally for preeclampsia.
Monitor for nausea, vomiting, and diarrhea.		✓
Keep client in supine position with lateral tilt for 30 minutes after administration.			✓
Avoid use in clients with a history of liver disease.		✓
Administer IM for postpartum hemorrhage.		✓
Encourage oral intake of grapefruit juice.
Monitor for manifestations of hypertensive crisis.				✓
Administer IV before passage of placenta to stimulate uterine contractions	✓

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Exam Review

A nurse is caring for a client in the first trimester of pregnancy and discovers that the client lacks immunity to rubella based on her blood work.When is the recommended time for administering rubella immunization?
A)Immediately after delivery.
B)During the first trimester of pregnancy.
C)During the third trimester of pregnancy.
D)During the next attempt to get pregnant.
Based on the client's assessment on 2/11 at 1200, indicate if the client's condition is improving, worsening or not related based on the condition.
Improvement Worsening Unrelated
Blood pressure ✓
Deep tendon reflexes (DTR) ✓
Vaginal exam (client denies pain) ✓
Decreased sensation in legs ✓
Creatinine ✓
A first-time mother presents for a labor check.She is informed that her vaginal exam shows dilated (3 cm), effaced (100%), and fetal station (-2). What explanation is the most appropriate response by the nurse?
A)Your cervix is open a little and the baby is very low.
B)Your cervix is all thinned out and the baby is very low.
C)Your cervix is open a little, but the baby is still high in the pelvis.
D)Your cervix is open a little, but still needs to thin out.
A nurse is monitoring a client in active labor who has an epidural in place.Which of the following findings should be reported to the anesthesiologist immediately?(SATA)
A)Decreased sensation in the lower extremities.
B)Respiratory depression.
C)Blood pressure 108/62.
D)Sustained fetal heart rate of 150 bpm.
E)Slurred speech.

	Worsening	Unrelated
Blood pressure	✓
Deep tendon reflexes (DTR)	✓
Vaginal exam (client denies pain)		✓
Decreased sensation in legs	✓
Creatinine	✓

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Exam Review

A female client reports green-yellow vaginal discharge, vaginal itching, and foul-smelling genitals.She has been sexually active for six months in a monogamous relationship with her boyfriend.Both were tested for sexually transmitted diseases when she received a hormonal implant five months ago.The couple broke up a month ago, and since then, she has had unprotected sex with two partners.The client's symptoms are most consistent with which of the following conditions?
A)Urinary tract infection.
B)Trichomoniasis.
C)Herpes simplex.
D)Human papillomavirus.
A 35-year-old postpartum client has the following assessment findings: Temperature 99.8 F (37.7 C), Heart Rate 80, Respiratory Rate 16, Blood Pressure 150/86, SpO2 100% on room air.Based on these findings and the client's history of prolonged labor and being a primipara, which condition is the client most likely experiencing?
A)Placenta previa.
B)Placental abruption.
C)Postpartum hemorrhage.
D)Preeclampsia.
A 37 weeks' gestation patient with a scheduled nonstress test (NST) has the following vital signs recorded over two days: 2/10 1535: BP 162/100, HR 78, SpO2 100%; 2/10 1600: BP 168/100, HR 76, SpO2 100%; 2/11 1200: BP 166/100, HR 84, SpO2 99%; 2/11 1818: BP 152/86, HR 78, SpO2 99%. The nurse anticipates needing to administer Magnesium Sulfate to prevent which of the following complications?
A)Preterm labor.
B)Gestational diabetes.
C)Seizures.
D)Fetal growth restriction.
A nurse is caring for a postpartum client who reports feeling anxious, irritable, and unable to sleep despite extreme fatigue.The client also expresses feelings of inadequacy as a mother.Which of the following nursing interventions is the most appropriate initial action?
A)Advise the client to seek help from family members to reduce stress and manage the baby's care.
B)Encourage the client to rest whenever the baby is sleeping to alleviate fatigue.
C)Assess the client for further signs of postpartum mood disorders.
D)Reassure the client that these feelings are normal and will subside in a few days.

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Exam Review

A nurse is caring for a client at the first prenatal visit who has a BMI of 23.5. The client asks how much weight she should gain during pregnancy.Which of the following responses should the nurse make?
A)"A gain of about 25 to 35 pounds is recommended for you.”.
B)"A gain of about 1 pound per week is the best pattern for you.”.
C)"The recommendation for you is about 15 to 25 pounds.”.
D)"It would be best if you gained about 11 to 20 pounds.”.
Which interventions should the nurse include in the plan of care for a client with the nursing diagnosis of acute pain related to breast engorgement?(SATA)
A)Suggest massaging the breasts in a circular motion before and during breastfeeding.
B)Apply warm compresses to the breasts before breastfeeding.
C)Instruct the client to breastfeed frequently or pump milk regularly.
D)Apply cold compresses to the breasts after breastfeeding.
E)Encourage the client to wear a tight-fitting bra throughout the day.
F)Advise the client to limit fluid intake to reduce milk production.
A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor.Which of the following is the priority nursing assessment for this client?
A)Fetal heart rate (FHR).
B)Respiratory rate.
C)Temperature.
D)Bowel sounds.
While caring for a client in labor, which assessment finding best indicates fetal well-being to the nurse?
A)Fetal heart rate of 160 beats per minute with moderate variability.
B)Fetal heart rate consistently below 120 beats per minute with no accelerations.
C)Presence of late decelerations with each contraction during monitoring.
D)Increased fetal movement between contractions.

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