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    Exam Review

    1. Day 1, 2350: Client admitted to the postpartum unit. Fundus firm at umbilicus. Moderate amount of lochia rubra noted. No concerns voiced by client. Day 2, 0600: Client resting in bed. Reports pain as 5 on a scale of 0 to 10. Declines pain medication. Fundus firm at umbilicus. Moderate amount of lochia rubra noted. Perineal pad changed. Client assisted to the bathroom, voided 50 mL of urine. Client performed incentive spirometer exercises. 0700: Called to bedside by client. Client reports needing help changing perineal pad. Perineal pad saturated. Fundus boggy and 2 finger breaths above the umbilicus deviated to the right side. Client reports pain as 3 on a scale of 0 to 10. Client reports urge to urinate. Ambulated client to the bathroom. Client reports straining to empty bladder. Client voided 50 mL of bloody urine. Perineal pad changed. Provider notified. 0715: Straight catheter inserted per routine prescription. Urinary output 700 mL of pink-tinged urine in catheter returned. Which of the following conditions is the client most likely experiencing?
      A)Postpartum hemorrhage.
      B)Postpartum infection.
      C)Endometritis.
      D)Urinary tract infection.
      E)Uterine inversion.
    2. A nurse is assessing a client who is 6 hours postpartum, tachycardic, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?(SATA)
      A)Elevate the head of the client's bed 30 degrees.
      B)Administer a dose of terbutaline.
      C)Initiate oxygen at 2 L/min via nasal cannula.
      D)Initiate an infusion of oxytocin.
    3. A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of the following nonpharmacological interventions should the nurse provide to manage the client's pain?
      A)Teach the client patterned breathing techniques.
      B)Encourage the support person to perform effleurage.
      C)Encourage the support person to apply sacral counterpressure.
      D)Teach the client to use guided imagery.
    4. A nurse is caring for a newborn immediately following birth. The newborn has meconium-stained amniotic fluid. Which of the following actions should the nurse take first?
      A)Place the newborn under a radiant warmer.
      B)Provide tactile stimulation for the newborn.
      C)Determine if the newborn's mouth and nose require bulb suctioning.
      D)Initiate skin-to-skin contact between parent and newborn.
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    Exam Review

    1. A client who is in active labor is admitted to a labor and delivery unit reporting, "My water just broke and my baby is breech.”. Which of the following actions should the nurse take first?
      A)Check fetal heart tones.
      B)Prepare for a cesarean birth.
      C)Check the color, amount, and odor of the fluid.
      D)Perform a Nitrazine test to assess for rupture of membranes.
    2. A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?
      A)A client who has an indwelling urinary catheter.
      B)A client who has a second-degree perineal laceration.
      C)A client who is saturating a perineal pad every 5 to 6 hours.
      D)A client who is experiencing breast engorgement.
    3. A nurse is teaching a client about iron supplementation during pregnancy. Which of the following client statements indicates an understanding of the teaching?
      A)"I will take this supplement with 8 ounces of milk.”.
      B)"I will double my dose if I forget to take my supplement.”.
      C)"I will be certain to consume 28 grams of fiber daily.”.
      D)"I will take 100 milligrams of vitamin K per day while taking this supplement.”.
    4. A nurse is assessing a client who is in labor. Which of the following findings should the nurse expect?
      A)Decrease in white blood cell count.
      B)Decrease in blood glucose level.
      C)Decrease in respiratory rate.
      D)Decrease in temperature.
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    Exam Review

    1. A nurse is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (Select all that apply.)(SATA)
      A)Tachycardia.
      B)Dry mucous membranes.
      C)Poor skin turgor.
      D)Polyuria.
      E)Hypertension.
    2. A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take?
      A)Monitor blood pressure every 30 minutes following epidural placement.
      B)Administer lactated Ringer's 500 mL bolus via intermittent intravenous infusion prior to epidural placement.
      C)Administer oxygen via nasal cannula at 2 L/min prior to epidural placement.
      D)Reposition the client every 2 hours following epidural placement.
    3. A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain?
      A)Encourage the client to listen to music.
      B)Instruct the client how to use biofeedback.
      C)Administer fentanyl 100 mcg every hour via intermittent intravenous bolus.
      D)Request the provider administer a pudendal nerve block.
    4. A nurse is teaching a prenatal class to a group of parents and is discussing facilitation of sibling acceptance of the newborn. Which of the following instructions should the nurse include in the teaching?
      A)The parent should hold the newborn during the initial visit with the older sibling.
      B)The parent should plan to spend individual time with the older sibling.
      C)The parent should have the older sibling purchase a gift for the newborn.
      D)The parent should postpone introducing the older sibling to the newborn until discharge.
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    Exam Review

    1. A nurse is reviewing the results of a nonstress test for a client who is at 37 weeks of gestation. Which of the following findings indicates a reactive nonstress test?
      A)Fetal heart rate (FHR) accelerations occur with fetal movement.
      B)Late decelerations of the FHR occur with contractions.
      C)Variable decelerations of the FHR with uterine contractions.
      D)FHR pattern with minimal variability.
    2. A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?
      A)Epigastric pain.
      B)Leukorrhea.
      C)Excessive salivation.
      D)Darkening of the skin on the face.
    3. A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor. Which of the following findings should the nurse expect?
      A)Uterine contractions every 15 minutes.
      B)FHR baseline 166/min with minimal variability.
      C)Late decelerations in FHR.
      D)Contraction duration of 75 seconds.
    4. A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?
      A)Heart rate 132/min.
      B)Report of headache.
      C)Nasal congestion.
      D)Tremors.
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    Exam Review

    1. A nurse is planning care for a newborn who was exposed to active genital herpes simplex virus (HSV) during birth. Which of the following nursing actions should the nurse anticipate?
      A)Institute droplet precautions.
      B)Administer ceftriaxone sodium.
      C)Inform the client they should bottlefeed the newborn.
      D)Obtain surface cultures from the newborn.
    2. A charge nurse is preparing to discuss actions to take for clients who require an amniotomy during labor with a newly licensed nurse. Which of the following statements should the charge nurse include during the discussion?
      A)"Check the client's temperature frequently following the procedure.”.
      B)"Insert misoprostol rectally every 2 hours following the procedure.”.
      C)"Obtain a biophysical profile during the procedure.”.
      D)"Perform effleurage to the client's abdomen during the procedure.”.
    3. A nurse is teaching a new parent how to correctly use a car seat. Which of the following statements by the parent indicates an understanding of the teaching?
      A)"I should keep my baby in a rear-facing car seat until they are 2 years old.”.
      B)"I should strap my baby in the seat with a four-point harness.”.
      C)"I should place the shoulder harness in the slots above my baby's shoulders.”.
      D)"I should position my baby's car seat at a 30-degree angle.”.
    4. A nurse is caring for a postpartum client who is breastfeeding their newborn and reports that their nipples have become sore and cracked. Which of the following statements should the nurse make?
      A)"Begin each feeding with the breast that is most sore, so the newborn spends less time on it.”.
      B)"Use breast pads with a moisture-proof lining to keep the nipples moist.”.
      C)"Breastfeed the baby less frequently to give the nipples time to heal.”.
      D)"Apply colostrum to the nipples after feeding to help them heal.”.
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    Exam Review

    1. A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility. Which of the following instructions should the nurse include in the teaching?
      A)"Give your newborn only to staff members you recognize.”.
      B)"Remove your newborn's microchip identification band after you have arrived home.”.
      C)"Personally carry your newborn to the nursery if you need assistance.”.
      D)"Bring your newborn in the bassinet into the bathroom with you.”.
    2. A nurse is teaching a class to clients who are pregnant. Which of the following topics should the nurse include in the discussion about cesarean birth? (Select all that apply.)(SATA)
      A)Routine use of intubation equipment during birth.
      B)Delay in initiating breastfeeding.
      C)Advantage of early ambulation post-surgical procedure.
      D)Management of postpartum pain.
      E)The need for an indwelling urinary catheter.
    3. A nurse is providing teaching about nifedipine for a client who is at 34 weeks of gestation and has gestational hypertension. For which of the following adverse effects should the nurse instruct the client to notify the provider?
      A)Tinnitus.
      B)Irregular heartbeat.
      C)Hair loss.
      D)Increased salivation.
    4. A nurse is assessing a 1-hour-old newborn. Which of the following findings should the nurse report to the provider?
      A)Transient circumoral cyanosis.
      B)Transient strabismus.
      C)Caput succedaneum.
      D)Generalized petechiae.
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