WorksheetsNursing Assessments and Interventions
Total questions: 87
Worksheet time: 47mins
A nurse is reinforcing teaching with the parents of an infant who is postoperative following a cleft lip repair. Which of the following parental actions indicate understanding of the teaching?
Preventing the infant from crying or sucking
Positioning the infant on the abdomen for sleep
Gently cleansing the suture line to prevent infection
Applying elbow restraints to prevent the infant from touching the lip
Feeding the infant with a dropper for 1–2 weeks
A nurse is explaining the purpose of the Apgar scoring system to a group of newly licensed nurses. Which of the following statements should the nurse include? (Select all that apply.)
“The score evaluates five objective signs, including heart rate and muscle tone.”
“It predicts the child’s future neurologic outcomes.”
“It is performed at 1 and 5 minutes after birth.”
“It helps determine whether the newborn had difficulties during the birthing process.”
“The scoring system assesses gestational age.”
A nurse is assessing a client for a positive Homan’s sign. Which of the following findings indicates a positive result?
Numbness in the toes when the leg is elevated
Calf pain when the foot is dorsiflexed
Redness along the thigh when palpated
Tingling in the foot with plantar flexion
A client presents with a positive Homan’s sign. Which of the following diagnostic tests should the nurse anticipate to confirm the presence of deep vein thrombosis (DVT)?
MRI
Chest X-ray
Ultrasound with or without Doppler assistance
CT scan of the abdomen
A nurse is reviewing medications used for cervical ripening with a group of students. Which of the following should the nurse include?
Oxytocin (Pitocin) and Terbutaline
Dinoprostone (Cervidil or Prepidil) and Misoprostol (Cytotec)
Magnesium sulfate and Nifedipine
Methylergonovine and Carboprost
A nurse is preparing to administer misoprostol for cervical ripening. Which of the following client conditions is a contraindication for this medication?
History of hypertension
History of uterine myomectomy surgery
History of gestational diabetes
History of hyperemesis gravidarum
A newborn has been diagnosed with jaundice. Which of the following interventions should the nurse anticipate?
Administration of methylergonovine
Phototherapy and frequent bilirubin level monitoring
Administration of magnesium sulfate
IV infusion of oxytocin
A nurse is caring for a client immediately after an amniotomy. Which of the following is the priority assessment?
Maternal blood pressure
Maternal temperature
Fetal heart rate
Uterine contraction frequency
The nurse is assessing the amniotic fluid after an amniotomy. Which of the following findings should the nurse recognize as abnormal?
Clear fluid
Cloudy, yellow fluid
Pink-tinged fluid
Green-stained fluid
A nurse is administering terbutaline to a client. Which of the following side effects should the nurse warn the patient about?
Hypotension and bradycardia
Increased pulse rate, increased blood pressure, and hyperglycemia
Excessive sedation and constipation
Hypoglycemia and nasal dryness
A nurse is preparing to administer terbutaline for preterm labor. The nurse should plan to discontinue the medication at which time?
Immediately after delivery
24 hours before delivery
2 hours before delivery
After the client reports nasal stuffiness
A nurse is caring for an infant who has a shunt placed for hydrocephalus. The nurse notes the fontanelles are sunken. Which position should the nurse place the infant in?
Prone with head elevated
Flat position in bed
Semi-Fowler’s position
Side-lying with head lowered
A nurse is monitoring an infant with a shunt for hydrocephalus and observes bulging fontanelles. Which position should the nurse place the infant in?
Trendelenburg
Semi-Fowler’s
Prone with head turned
Flat supine
A nurse is reinforcing teaching with a group of parents about potential complications for post-term infants. Which of the following conditions are associated with a post-term birth? (Select all that apply.)
Asphyxia caused by chronic hypoxia
Meconium aspiration
Poor nutritional status with hypoglycemia
Polycythemia with risk for jaundice
Difficult delivery due to increased size
A nurse is assessing a newborn and notes soft tissue swelling of the scalp that crosses the suture line. Which condition should the nurse suspect?
Caput succedaneum
Cephalohematoma
Hydrocephalus
Subdural hematoma
A nurse is assessing a newborn and notes a collection of blood beneath the periosteum that does not cross the suture line. The nurse should identify this finding as:
Caput succedaneum
Cephalohematoma
Subgaleal hemorrhage
Craniosynostosis
A nurse is assessing a newborn with suspected neonatal abstinence syndrome (NAS). Which of the following findings should the nurse expect? (Select all that apply.)
Body tremors
Hyperirritability
Diarrhea
Poor feeding
Wakefulness
A nurse is assessing a newborn for developmental dysplasia of the hip. Which of the following are expected manifestations? (Select all that apply.)
Limited abduction of the leg on the affected side
Knee lower on the dislocated side
Shortening of the femur
Asymmetrical thigh skin folds
One buttock appearing higher when prone
A nurse is caring for a newborn immediately after birth. Which situation is an example of heat loss by evaporation?
A newborn lying near a cold wall
A newborn placed on a cold scale without a blanket
A newborn exposed to a fan blowing across the crib
A newborn not dried immediately after a bath
Which of the following situations places a newborn at risk for heat loss through conduction?
A newborn placed under an air vent
A newborn’s crib positioned near a cold window
A newborn lying on a cold mattress without a blanket
A newborn whose skin is still wet after birth
A nurse is teaching a group of students about ways newborns lose heat. Which of the following is an example of convection?
A newborn wrapped in a blanket next to a cold wall
A newborn exposed to drafts from an open door
A newborn wet from amniotic fluid after delivery
A newborn placed on a cold metal scale
A newborn is at risk for heat loss through radiation in which of the following situations?
A newborn placed next to a cold window
A newborn bathed and left wet without drying
A newborn placed on a cold scale
A newborn exposed to blowing air from a fan
A nurse is reinforcing teaching with a postpartum client about the expected changes in lochia. Which statement by the client indicates understanding?
“Lochia rubra is pink and lasts about 10 days.”
“Lochia serosa is red and lasts for the first 3 days.”
“Lochia alba is white and may last from day 10 up to 3 weeks.”
“Lochia rubra is brown and lasts up to 21 days.”
A nurse is preparing a newborn for discharge. Which of the following findings should the nurse recognize as an expected weight change?
A newborn who lost 3% of birth weight
A newborn who lost 8% of birth weight
A newborn who lost 12% of birth weight at term
A newborn who lost 18% of birth weight
A nurse is calculating the quantitative blood loss (QBL) for a postpartum client. Which method should the nurse use?
Estimating the amount of blood on perineal pads by observation
Counting the number of saturated pads in an hour
Measuring the dry weight and subtracting it from the wet weight
Measuring fundal height changes over time
A nurse is caring for a client on postpartum day 2. Which lochia findings should the nurse expect?
Lochia rubra: bright red and lasts for about the first 3 days
Lochia serosa: pinkish brown and lasts for 10–21 days
Lochia alba: yellowish white and lasts for the first week
No vaginal discharge should be present
On postpartum day 5, a client asks what type of vaginal discharge is normal. Which response should the nurse provide?
“You should expect bright red bleeding that soaks a pad in an hour.”
“You should expect pinkish brown discharge that lasts up to 10 days.”
“You should expect yellowish-white mucus that lasts for the first 2 days.”
“You should not have any vaginal discharge at this point.”
A nurse is reinforcing teaching with the parents of a child who has a cleft palate. The nurse should include that children with this condition are at increased risk for which of the following? (Select all that apply.)
Ear infections
Dental decay
Irregular tooth eruptions
Need for intermittent hospitalizations and frequent clinic visits
Difficulty with feedings requiring special nipples
A nurse is assessing a postpartum client and suspects the presence of a hematoma. Which of the following findings supports this suspicion?
Foul-smelling lochia with a fever
A bulging, bluish or purplish mass on the vulva or in the vagina
Uterine atony with a soft, boggy fundus
Bright red bleeding that saturates more than one pad per hour
A nurse is assessing a laboring client who is hyperventilating. Which of the following manifestations should the nurse expect? (Select all that apply.)
Dizziness
Tingling of hands and feet
Cramps and muscle spasms of the hands
Numbness around the nose and mouth
Blurred vision
A nurse is reinforcing teaching with a client experiencing hyperventilation during labor. Which of the following are appropriate interventions? (Select all that apply.)
Breathe slowly, especially during exhalation
Breathe into cupped hands
Place a moist washcloth over the mouth and nose while breathing
Hold breath for a few seconds before exhaling
. Increase respiratory rate to expel carbon dioxide
A nurse is caring for a client with a prolapsed umbilical cord. What is the nurse’s priority action?
Place the client in a side-lying position with hips elevated
Administer oxygen at 10 L/min
Insert a gloved hand into the vagina and push the fetus upward
Displace the fetus upward to relieve cord compression
While awaiting an emergency cesarean section for a prolapsed cord, which nursing intervention is most appropriate?
Apply fundal pressure to aid delivery
Keep a gloved hand in the vagina to elevate the presenting part
Place the client in high Fowler’s position
Insert a urinary catheter
A nurse is positioning a client with a prolapsed cord to relieve pressure on the umbilical cord. Which positions are appropriate?
Supine with legs straight
Knee-chest or Trendelenburg
High Fowler’s with feet dangling
Semi-Fowler’s with a wedge
A nurse is assessing a postpartum client after delivery of the placenta. Where should the nurse expect to palpate the fundus?
Midline, at or slightly below the umbilicus, firm and round
Above the umbilicus, boggy and soft
Right of the umbilicus, enlarged and tender
Two fingerbreadths above the symphysis pubis, firm and flat
A nurse is assessing a postpartum client on day 3 after delivery. Which finding is expected?
Fundus at the level of the umbilicus, boggy
Fundus 3 cm below the umbilicus, firm
Fundus not palpable at this time
Fundus 2 cm above the umbilicus, firm
A nurse is preparing to administer medications for postpartum hemorrhage. Which of the following medications contract the uterus?
Oxytocin, Methylergonovine, and Carboprost
Terbutaline, Nifedipine, and Magnesium sulfate
Misoprostol, Terbutaline, and Oxytocin
Labetalol, Hydralazine, and Oxytocin
A nurse is caring for a preterm infant and notes pauses in breathing. Which of the following meets the definition of apnea in a newborn?
Breathing pauses of 5–10 seconds with mild color changes
Cessation of breathing for 20 seconds or longer
Rapid breathing with grunting sounds
Occasional sighs between breaths
A nurse is caring for an infant who recently had a ventriculoperitoneal shunt placed for hydrocephalus. Which of the following should the nurse monitor closely?
Signs of increased intracranial pressure
Blood glucose levels
Respiratory rate and oxygen saturation only
Heart rate variability
A nurse is caring for an infant with hydrocephalus awaiting shunt placement. Which of the following are appropriate nursing interventions?
Keep the head in a single position to prevent movement
Frequent head position changes to prevent skin breakdown
Head support only when the infant is asleep
Measure head circumference along with vital signs
A nurse is teaching a postpartum client about breast engorgement. Which of the following statements is accurate?
Only non-breastfeeding mothers develop engorgement.
Engorgement can result from mastitis and inadequate emptying of milk
Engorgement is a rare complication occurring immediately after birth.
Engorgement occurs only if the infant is formula-fed.
A breastfeeding mother asks when breast engorgement is most likely to occur. The nurse should respond:
Within the first 24 hours after birth
Several weeks after birth
Only after weaning the baby
Engorgement does not occur in breastfeeding mothers
A laboring client is experiencing tachysystole. Which of the following are potential risks?
Maternal hypotension and fever
Fetal compromise and uterine rupture
Increased amniotic fluid and placental thickening
Decreased maternal cardiac output only
A nurse is assessing a postpartum client’s perineal incision. Which of the following findings would indicate a problem with healing?
Redness with pain
Mild edema that does not interfere with movement
Ecchymosis that is small and localized
Well-approximated suture line
A laboring client is receiving Pitocin (oxytocin). The nurse should stop the infusion if which of the following occurs?
The client complains of mild back pain
Signs of fetal compromise or excessive uterine contractions are noted
The client requests pain medication
The contractions are 3–4 minutes apart and moderate intensity
A postpartum client has a full bladder. The nurse knows this places the client at risk for:
Uterine atony and increased risk of hemorrhage
Hypotension due to bladder distension
Infection of the urinary tract only
Delayed lochia transition
A nurse is assessing a term newborn for hypoglycemia. Which blood glucose level indicates hypoglycemia?
45 mg/dL
42 mg/dL
38 mg/dL
50 mg/dL
A preterm newborn’s blood glucose is measured at 28 mg/dL. How should the nurse interpret this result?
Normal for a preterm infant
Hypoglycemia
Hyperglycemia
Cannot be determined without repeat measurement
A newborn weighs below the 10th percentile for gestational age. How should the nurse classify this infant?
AGA (Average for Gestational Age)
LGA (Large for Gestational Age)
SGA (Small for Gestational Age)
Preterm
A newborn weighs at the 50th percentile for gestational age. How should the nurse classify this infant?
SGA
LGA
AGA
Preterm
A newborn weighs above the 90th percentile for gestational age. Which classification is appropriate?
SGA
AGA
LGA
post-term
A nurse is caring for a newborn and wants to prevent heat loss. Which of the following interventions are appropriate? (Select all that apply.)
Keep the infant’s head covered
Place the infant on a cold surface for a short time to test temperature stability
Keep the infant dry and swaddled
Prevent drafts near the infant
A nurse is caring for a newborn with spina bifida. Which of the following are appropriate nursing interventions? (Select all that apply.)
Place a moist, sterile dressing on the sac
Position the infant prone
Monitor for hydrocephalus
Delay surgery until after 6 months of age
Avoid touching the sac to prevent trauma
A nurse is assessing an infant and notes an unusually large head size. The nurse understands that hydrocephalus is caused by:
A decrease in cerebrospinal fluid within the ventricles
An increase in cerebrospinal fluid within the ventricles
Early closure of the cranial sutures
Hypotension of the brain vessels
Which of the following conditions is a common cause of hydrocephalus in infants?
Congenital hip dysplasia
Obstruction of cerebrospinal fluid, such as from a tumor, infection, or perinatal hemorrhage
Post-term birth
Maternal gestational diabetes
A nurse is caring for a postpartum client with uterine atony. What is the nurse’s first intervention?
Administer oxytocin immediately
Massage the uterus to firmness, then empty the bladder
Place the client in Trendelenburg position
Increase IV fluids to improve circulation
A nurse is caring for a laboring client who received an epidural. Which of the following should the nurse assess regularly? (Select all that apply.)
Bladder distention by palpating the suprapubic area
Maternal hypotension
Maternal pulse rate only
Pain level and sensation in lower extremities
Respiratory rate
A nurse is assessing a preterm infant for respiratory distress syndrome (RDS). Which of the following are signs of RDS? (Select all that apply.)
Cyanosis
Grunting
Tachypnea
Intercostal and sternal retractions
A nurse is educating a postpartum client about afterpains. What is the best description?
Mild cramping caused by uterine involution
Sharp pain caused by episiotomy infection
Pain from uterine rupture
Pain caused by retained placental fragments
What is the primary cause of afterpains in the postpartum period?
Excessive ambulation
Contractions of the uterus as it returns to pre-pregnancy size
Maternal dehydration
Bladder distention
A nurse is monitoring a postpartum client after a vaginal birth. Which amount of blood loss is considered within the expected range?
300 mL
500 mL
700 mL
1000 mL
A nurse is caring for a client who had a cesarean section. What is the expected blood loss for this type of delivery?
400 mL
500 mL
800 mL
1000 mL
A nurse is caring for a macrosomic newborn. Which of the following complications should the nurse monitor for? (Select all that apply.)
Cold stress due to depletion of fat stores
Aspiration of meconium-stained amniotic fluid leading to respiratory distress
Hypoglycemia from depleted glycogen stores
Hyperbilirubinemia due to polycythemia
Hypotension from low blood volume
A nurse is reinforcing discharge teaching with a postpartum client. Which of the following signs should prompt the client to call the healthcare provider or return for reassessment? (Select all that apply.)
Fever higher than 100.4°F (38°C)
Persistent lochia rubra or foul odor
Discharge, pain, redness, or separation of any suture line
Bright red bleeding or lochia that changes from alba/serosa back to rubra
Localized breast tenderness
Which of the following conditions is most likely to cause cardiogenic shock in a postpartum client?
Postpartum hemorrhage
Pulmonary embolism
Drug allergy
Puerperal infection
A nurse is caring for a postpartum client who is experiencing excessive blood loss. Which type of shock is the client at risk for?
Cardiogenic
Hypovolemic
Anaphylactic
Septic
A client develops a sudden allergic reaction to a medication administered postpartum. Which type of shock should the nurse suspect?
Cardiogenic
Hypovolemic
Anaphylactic
Septic
A postpartum client presents with fever, foul-smelling lochia, and hypotension. Which type of shock is most likely?
Cardiogenic
Hypovolemic
Anaphylactic
Septic
Which of the following correctly describes the anterior fontanelle?
Diamond-shaped; located at the junction of the parietal and frontal bones; closes by 12–18 months
Triangular; located between occipital and parietal bones; closes by 2 months
Circular; located at the center of the skull; closes by 6 months
Square-shaped; located at the parietal-occipital junction; closes by 1 month
Which statement accurately describes the posterior fontanelle?
Diamond-shaped and larger than the anterior fontanelle
Triangular; located between occipital and parietal bones; ossified by 2 months
Circular; remains open until 18 months
Located at the frontal-parietal junction; closes by 12–18 months
A nurse is assessing an infant for increased intracranial pressure (ICP). Which of the following findings are consistent with ICP?
Decreased BP, increased pulse, irregular respirations
Increased BP, decreased pulse, decreased respirations
Low-pitched cry, equal pupils, normal fontanelles
Hyperactive reflexes and constipation
Which of the following are signs of increased intracranial pressure in an infant?
High-pitched cry, unequal pupil size, bulging fontanelles
Lethargy, poor feeding, vomiting
Irritability
All of the above
A nurse is caring for a client in latent labor (cervical dilation <4 cm) who reports frequent, painful contractions that are poorly coordinated. What type of labor is this?
Hypotonic labor
Hypertonic labor
Precipitous labor
Prolonged latent labor
A client in active labor (cervical dilation >4 cm) is experiencing weak, ineffective contractions. Which interventions are appropriate?
Provide mild sedation and administer tocolytic drugs
Perform amniotomy and administer oxytocin; encourage walking and upright positions
Monitor for precipitous delivery
Apply forceps delivery immediately
The gate control theory of pain explains that:
Pain impulses are ignored by the brain until a threshold is reached
Nerve fibers can be stimulated to block or interfere with transmission of pain impulses to the brain
Pain is entirely psychological and not transmitted by nerves
Pain cannot be influenced by external stimuli
Which of the following are examples of interventions that utilize the gate control theory to reduce pain?
Stroking or massaging the skin
Rubbing the palm or foot
Gripping a cold bed rail or applying pressure
All of the above
A postpartum client is experiencing hypovolemic shock due to excessive bleeding. Which interventions are appropriate?
Stopping the blood loss and massaging the uterus
Administering IV fluids and blood transfusions
Providing oxygen and monitoring pulse oximetry
Placing a Foley catheter to assess urine output
All of the above
A nurse is assessing a pregnant client and notes a lower-than-normal amount of amniotic fluid. This condition is called:
Polyhydramnios
Oligohydramnios
Hydramnios
Amniotic overload
A client has an excessive amount of amniotic fluid. What is this condition called?
Polyhydramnios
Oligohydramnios
Amniotic insufficiency
Placental edema
The process in which the reproductive organs return to pre-pregnancy size is called:
Retrogression
Regression
Involution
Regression
After delivery, the uterus descends at approximately:
1 cm per hour
1 cm per day
5 cm per day
5 mm per day
Which of the following statements about Terbutaline (Brethine) is correct?
It is a calcium channel blocker used to stop contractions
t is a beta-adrenergic medication given subcutaneously to stop contractions within minutes
It is an NSAID that reduces amniotic fluid
It is used primarily to protect the fetus from cerebral palsy
Magnesium sulfate is primarily used in preterm labor to:
Stop contractions immediately
Protect the fetus from cerebral palsy
Reduce amniotic fluid
Increase uterine tone
Which statement about Indomethacin is correct?
It is commonly used and safe in all pregnancies
It is an NSAID that stops contractions but reduces amniotic fluid and risks ductus arteriosus closure
It is a calcium channel blocker
It is a beta-adrenergic drug
Which statement about Nifedipine (Procardia) is correct?
It is rarely used due to severe side effects
It is a calcium channel blocker commonly used to stop labor contractions
It should be given simultaneously with magnesium sulfate
It is an NSAID that reduces amniotic fluid
A nurse suspects hypovolemic shock in a postpartum client. What is usually the first sign?
Hypotension
Tachycardia
Bradycardia
Decreased respiratory rate
A nurse is educating a postpartum client about options for vaginal birth after cesarean (VBAC). Which type of uterine incision is considered safe for VBAC?
Classic vertical incision
Low transverse incision
High vertical incision
T-shaped incision
