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Thenurseperformsaroutineassessmentona12-hour-oldinfant. Whichfindingrequires
A. Novoidingor stoolingsincebirth
B. Cryingfor morethan 10 minutes
C. Respiratory rate of 73 breaths/minute
D. Acrocyanosis withhands & feetcool totouch
Thenursereceiveschange-of-shift report for fournewborns. Thenurseshould monitor
closely which newborn for an increased risk for developing neonatal sepsis
A. Birth weightof2.75 kg
B. Reported prolonged rupture of membranes
C. Deliveredbyscheduled Cesareansection
D. Ballardscoreof 36-weeks-gestation
A client whois 37 weeksgestationcomes tothe woman'shealthclinicreportingan
excruciating headache. On examination, the nurse determines the client has an elevated
blood pressure which action should the nurse implement next?
A. Askaboutahistoryofdeliveringlargebabies
B. Collect urine sample to screen for protein
C. Examinetheclient forpedal edema
D. Establishthefrequencyofheadaches
Followingaprecipitouslabor,apostpartum clienthasacontinuous tricklingofbright red
blood from her vagina. Her uterus is firm, and her vital signs are within normal limits. The
nurse determines at that sign may indicate which condition?
A. Expectedcourseinfourthstageof labor
B. Laceration on the cervix
C. Earlypostpartum hemorrhage
D. A full urinarybladder
A client whosuspects sheispregnant tells thenurseshehas apeptic ulcer andis being
treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond?
A. “this medication willhavenoeffectonyourunbornchild”
B. “you mayhaveanincreasedchanceofhavingpreeclampsia”
C. You mayexperiencepostpartum hemorrhagingafterdelivery
D. You may be at higher riskfor having aspontaneous miscarriage”
Thenurseisassessinga 38-weekgestationnewborninfant immediatelyfollowingavagina
birth. Which assessment finding indicates that the infant is transitioning well too
extrauterine life?
A. A positive Babinski reflex
B. flexionofall four extremities
C. heart rateof220 beats per minute
D. Criesvigorously when stimulated
A clientat40-weeks’gestationisadmittedtolaboranddelivery. Herobstetricalhistory
includes three life births at 39, 38, and 35-weeks’ gestation, 2 miscarriages at 6 & 8-weeks’
gestation, and a fetal demise at 33-weeks gestation. Which is an accurate summary of this
client’s obstetrical history?
A. Gravida7Term 2 Preterm 2 Abortion2Living 3
B. Gravida 6 Term 3 Preterm 1 Abortion 2 Living 3
C. Gravida 6 Term 2 Preterm 2 Abortion2Living4
D. Gravida7Term 1 Preterm 3 Abortion2Living4
A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain
medication. Review of theclient’srecordindicates thatshe was medicated 30 minutesago
with butorphanol tartare 2 mg & promethazine25 mg IV push.Vaginal examination reveals
that the client’s cervical dilation is 3 cm, 70% effaced, and at a 0 station. Which action
should the nurse implement?
A. Instruct the client to use deep breathing during acontraction
B. Notify thehealthcareprovider
C. Discontinuetheoxytocininfusion
D. Medicatetheclient withan additional 1 mgofbutorphanol tartrateIVpush
Whenpreparingtoassist thehealthcareprovider withavaginal examinationtoassessa
client’s cervical dilation during labor, which equipment should the nurse assemble?
A. Sterileglove & sterilespeculum
B. Sterileglove & speculum
C. Sterile glove & lubricant
D. Sterilespeculum & lubricant
Following avaginal delivery, thenurseplaces theneonate under theradiant warmer,
provides naso-oropharyneal suction,anddries theneonate’sskintoelicitspontaneous
respirations. The newborn’s heart rate is 100 beats/minute & remains apneic when the
nurse flicks the soles of the feet. Which action should the nurse implement next?
A. Assistneonatologist withintubation
B. Provide positive pressure ventilation
C. Start IVinfusionin ascalp vein
D. Giveblow-byoxygenviacannula
Duringaroutineprenatal healthassessment foraclient inher thirdtrimester, theclient
reports that she had fluid leakage on her way to the appointment. Which technique should the
nurse implement to evaluate the leakage?
A. Scan thebladder forurinary retention
B. Test the fluid with a nitrazine strip
C. Palpatethesuprapubicareafor fetalheadposition
D. Insertstraighturinarycatheter todrainbladder
A client whodelivered ahealthynewborn anhour agoasks thenurse whenshe cangohome.
Which information is most important for the nurse to provide the client?
A. When there is no significant vagina bleeding
B. After thebabynolongerdemonstratesacrocyanosis
C. Whenambulating toavoiddoes notcausedizziness
D. After thevitamin Kinjectionisgiven tothebaby
Whenplanningcarefor thenewbornofaninsulin-dependentdiabetic mother, thenurse
should be alert for which condition that should be reported immediately to the health care
A. hyperglycemia2hoursafterbirth
B. hypoglycemia2hoursafterbirth
C. hypoglycemiaat birth
D. hyperglycemiaatbirth
A three-houroldinfant'shands and feetarecyanotic,andhehasanaxillary temperatureof
96.5 F, a respiratory rate of 40 bpm, and the heart rate of 165 beats per minute. Which
nursing intervention is best for the nurse to implement?
A. Gradually warm the infant under aradiant heat source
B. notify thepediatricianof theinfant's unstablevital signs
C. Perform aheel-stick to monitorbloodglucoselevel
D. Administeroxygenby maskat2L/minute
The newborn nursery protocol includes a prescription for ophthalmic erythromycin 5%
ointment tobotheyesuponanewborn’sadmission. Whatactionshouldthenursetaketo
ensure adequate instillation of the ophthalmic ointment?
A. Mummy wraptheinfantbeforeinstillingtheointment
B. Stabilizetheinstillinghandontheneonate’shead
C. Occludetheinnercanthusafter retractingtheeyelids
D. Instillathin ribbon into each lowerconjunctival sac

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