A client who is pregnant at 39 weeks gestation spontaneously ruptured her membranes while ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action?A. Assess the color of the amniotic fluidB. Perform a vaginal examination to assess the cervix for dilationC. Inform the client she is now on strict bed rest until further noticeD. Assess the fetal heart tones

The nurse is aware that a client at 40 weeks’ gestation is experiencing true labor if:*1 pointA. cervical dilatation has occurredB. the pains become more noticeableC. her membranes have rupturedD. the fetal heart rate baseline decreases

71.  Nursing care during the second stage of labor include:*1 pointA. coach breathing, encourage to bear down with each contractionB. careful evaluation of prenatal historyC. shave the perineumD. administer enema to the patient72.  The nurse is caring for a client on her 2nd postpartum day. The nurse should expect the client's lochia to be:*1 pointA. red and moderateB. brown and scantyC. continuous with red clotsD. thin and white73.  The nurse is assessing a client who gave birth yesterday. Where should the nurse expect to find the top of the client’s fundus?*1 pointA. 1 fingerbreadth above the umbilicusB. at the level of the umbilicusC. 1 fingerbreadth below the umbilicusD. below the symphysis pubis74. The nurse is helping to prepare a client for discharge following childbirth. During teaching a session, the nurse instructs the client to do Kegel exercise. What is the purpose of this exercise?*1 pointA. to tone the abdominal musclesB. to strengthen the perineal musclesC. to prevent urine retention .D. to relieve lower back pain75. Which of the following characteristics best describes that lochia is normal?*1 pointA. lochia amount increases with strenuous exerciseB. lochia is absent during the first 1-3 weeks after a cesarean birth.C. lochia contains no large clotsD. lochia is white for the first 1-3 days postpartum

11. The nurse is aware that a client at 40 weeks’ gestation is experiencing true labor if:*1 pointA. cervical dilatation has occurredB. the pains become more noticeableC. her membranes have rupturedD. the fetal heart rate baseline decreases12. A postpartum nurse is caring for a client who delivered a viable newborn infant 2 hours ago. The nurse palpates the fundus and notes the character of the lochia. Which characteristic of the lochia would the nurse expect to note at this time?*1 pointA. white-colored lochiaB. serosanguinous lochiaC. pink-colored lochiaD. dark red-colored lochia13. A nurse is monitoring a postpartum client in the fourth stage of labor. Which of the following findings, if noted by the nurse, would indicate a complication related to a laceration of the birth canal?*1 pointA. Presence of dark red lochiaB. Palpation of the fundus at the level of the umbilicusC. Palpation of the uterus as a firm contracted ballD. The saturation of more than one perineal pad per hour14. It has been 12 hours since the client’s delivery of a newborn. The nurse assesses the mother to the process of involution and documents that it is progressing normally when palpation of the client’s fundus is noted:*1 pointA. at the level of the umbilicusB. midway between the umbilicus and the symphysis pubisC. one finger breath below the umbilicusD. two finger breadths below the umbilicus15.  Mr. Young’s wife cervix is dilated 8cm. There is a sudden increase in the amount of bloody show. She vomits and her legs begin to tremble. She then becomes very irritable and cries out, “I can’t take it anymore.” At this time which of the following actions is most appropriate:*1 pointA. give her a dose of PRN of her pain relief medicationB. notify her physician of the possibility of hemorrhageC. review the breathing techniques with her againD. explain that she is progressing normally through labor16. A nurse is assisting in caring for a woman in labor who is receiving oxytoxin by intravenous infusion. The nurse monitors the client, knowing that which of the following indicates an adequate contraction pattern?*1 pointA. Three to five contractions in a 10-minute period, with resultant cervical dilatationB. One contraction per minute, with resultant cervical dilatationC. Four contractions every 5 minutes, with resultant cervical dilatationD. One contraction every 10 minutes without resultant cervical dilatation17. Approximately 15 minutes after delivery of a viable term neonate, a multiparous patient complains of chilling sensation. Which of the following would the nurse do next?*1 pointA. decrease the rate of IV fluidsB. assess the patient’s pulse rateC. assess the amount of blood lossD. provide the patient with warm blanket18. A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as sign of:*1 pointA. uterine atonyB. hematomaC. placental separationD. placenta previa19. A postpartal client has been complaining about the “afterpains” that occur while breastfeeding and questions you about them. You explain to her that they are due to the fact that:*1 pointA. the baby is sucking too vigorously and should nurse more oftenB. the baby’s sucking stimulates the uterus to contractC. she is tense during breastfeeding, resulting in uterine spasmsD. she is probably recalling her labor experience at feeding20.  A nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:*1 pointA. begin fundal massage and start oxygen by maskB. begin hourly pad counts and reassure the clientC. elevate the head of the bed and assess vital signsD. assess for hypovolemia and notify the health care provider

A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she has been able to breathe easily, but she has also begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which observation is most likely

The nurse is assessing a client who is two days postpartum and is breastfeeding her infant and reports uterine contractions while breastfeeding. The nurse should take which action?A. Perform a vaginal examinationB. Prepare the client for a pelvic ultrasoundC. Reassure the client that this is a normal findingD. Instruct the client to bottle feed the infant until the sensation subsides