The categories in order of most typically missed items are: Reduction of risk potential, Basic care and
comfort, Physiological adaptation, health promotion and maintenance and pharmacological therapies.
See topics under each category below to review. They are in order of statistically most missed by
students so that you can prioritize your studying.
Reduction of risk potential:
A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has
saturated two perineal padas in the past 30 minutes. The nurse caring for her suspect s placenta
previa. Which of the following is an appropriate nursing action? Preparation for cesarean birth.
• Nonstress Test. A nurse is caring for a client at 37 weeks gestation who is undergoing a
nonstress test. The fetal heart rate (FHR) is 130/min without acceleration for the past 10
min. Which of the following actions should the nurse take?
Ans: Use vibroacoustic stimulation on the client’s abdomen for 3 seconds. The nurse will
determine a nonstress test to be nonreactive after 40 minutes of continuous monitoring without
accelerations in the FHR despite vibroacoustic stimulation.
A nurse is providing education to a client who is at 34 weeks of gestation about a non-stress test. Which
of the following pieces of information should the nurse include? You might have to drink orange juice
during the test.
A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and
reports vaginal bleeding. Which of the following additional manifestations should the nurse
expect? The fundal height measures greater than gestational age.
- A nurse is preparing to perform Leopold maneuvers on a client who is n=in labor. Which of
the following actions should the nurse plan to take? Stand at the client’s right side if the
nurse is right-handed
• CST results
• Identifying decelerations: A nurse is caring for a client who is in labor and has fetal heart
tracings of variable decelerations. Which of the following actions should the nurse take?
D. Reposition the client from side to side
• The variable decelerations reflect an umbilical cord prolapse, and nurse should act
immediately to help shift the pressure of the presenting part off the cord by assisting to
position the client in a side-lying position.
• Caring for a newborn whose mother has type 2 diabetes
• Care following chorionic villus sampling
• Lab findings for a woman with Pre-Eclampsia
• A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks
of gestation. For which of the following results should the nurse notify the provider?
A. Hgb 11.3g/dL
, B. Platelet count 135,000/mm^3
C. WBC count 10,500/mm^3
D. Hct 38%
Explanation: The nurse should notify the provider of this result because it indicates
thrombocytopenia. A low platelet count is a manifestation of preeclampsia or
HELLP syndrome and requires further evaluation.
• A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After
turning the client’s head to the side, which of the following actions should the nurse take
next?
A. Administer magnesium sulfate 4g IV bolus
B. Insert and indwelling urinary
catheter C. Give oxygen 10L/min via face
mask
D. Keep the environment quiet and lights dimmed
The first action is ABC approach to client care is to administer O2 to tonic clonic seizure.
• A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium
sulfate via continuous IV infusion about expected adverse effect. Which adverse effect should
the nurse include in the teaching? Feeling of warmth. The nurse should tell the client to expect
the feeling of warmth all over her body while the magnesium sulfate is infusing (BP decreases
b/c of magnesium)
• A nurse is assessing a client who is pregnant for preeclampsia. Which of the following
findings should indicate to the nurse that the client requires further evaluation for this
disorder? Elevated blood pressure
A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal
bleeding. Which of the following actions should the nurse take? Obtain blood samples
for
baseline lab value (hemoglobin and hematocrit)
A nurse is planning care for a client who is postpartum and has cardiac disease. For which of
the following prescriptions should the nurse seek clarification? Monitor the client’s weight weekly
Explanation: Nurse should weigh the client daily to monitor for fluid overload.
• Newborn exstrophy of the bladder
• Newborn neonatal abstinence syndrome (NAS)is expected to have exaggerated reflexes
• A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence
syndrome (NAS). Which of the following actions should the nurse take? Avoid eye contact
during feedings. Explanation: The nurse should avoid eye contact and talking during feedings.
Infant with NAS have difficulty processing multiple forms of stimulation and can quickly become
frustrated.
• Risk factors for postpartum hemorrhage: A weak, irregular and rapid pulse can indicate
postpartum hemorrhagic shock due to decreased oxygenation and perfusion to the heart.
The client will need fluid replacement and medical attention.
• A postpartum nurse is caring for a client who ha developed hemorrhagic shock. Which of
the following manifestations should the nurse expect?
A. Urinary output of 40mL/hr
B. Deep abdominal breathing
C. Weak and irregular pulse
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