340 week 6-10

The nursing assistant has entered vital signs for a group of clients the nurse is caring for. Which client would be a priority for assessment by the​ nurse? A heart rate of 74 in a client who is 18 hr status post postpartum hemorrhage A respiratory rate of 10 in a client who is 12 hr post cesarean on morphine​ patient-controlled anesthesia An oxygen saturation of​ 96% on room air in a client who is 2 days status post cesarean A temperature of 100.5​°F in a client who is 22 hr post vaginal delivery

A respiratory rate of 10 in a client who is 12 hr post cesarean on morphine​ patient-controlled anesthesia

The nurse is making patient assignments for the shift. Which baby could be appropriately assigned to an LPN/LVN? An infant being admitted with hypoglycemia An infant scheduled to receive blood this shift A stable premature infant being fed every two hours An infant with rising bilirubin levels

A stable premature infant being fed every two hours

The nurse is assisting at Mrs.​ Sze's birth. She is a​ 36-year-old woman who has opted for an epidural. Mrs. Sze has been pushing for over 4 hours. She is​ exhausted, and her​ baby's head remains at the​ +3 station. The healthcare provider has attempted a vacuum extraction​ twice, but the suction cup has popped off both times. The nurse anticipates that the healthcare provider will do which action​ next? A​ mid-forceps-assisted birth A cesarean birth A low​ forceps-assisted birth A third attempt at vacuum extraction

A third attempt at vacuum extraction

It is now two hours since Mrs. Romero has​ delivered, and her epidural is wearing off. Once Mrs. Romero is able to move her legs and bear weight on​ them, you assist her to a sitting​ position, and then help her to the bathroom to void. She sits on the toilet for a few minutes but is unable to void.Based on her​ history, what is the most likely reason she is unable to​ void? A two hour second stage of labor. A urinary tract infection from the Foley catheter. Interference from stitches from her fourth degree repair. She is dehydrated because she has not been drinking very much.

A two hour second stage of labor.

Maternal risk factors may impact preterm labor. Which factor may increase this​ risk? African American ethnicity Primigravida Working while pregnant Hispanic ethnicity

African American ethnicity

A client is complaining of painful​ contractions, or​ afterpains, on her second postpartum day. The client asks why she is having these pains. Which response by the nurse is the most​ appropriate? "Afterpains tend to be worse after your second baby is born." "Afterpains occur because you have chosen to​ bottle-feed your newborn." "You are having afterpains because you also have diabetes mellitus." "Because this is your first​ baby, afterpains are to be expected."

"Afterpains tend to be worse after your second baby is born."

The nurse is explaining the stages of lochia to the newly delivered mother. Which statement by the nurse best describes lochia rubra to the​ mother? "It consists of tissue debris and blood." "It consists of placental fragments and blood." "It consists of a mixture of​ mucus, tissue​ debris, and blood." "It consists of​ mucus, placental​ fragments, and blood."

"It consists of a mixture of​ mucus, tissue​ debris, and blood."

What is the recommended daily caloric intake for a​ newborn? 140-160 ​mL/kg/day 8-10 bottles per day 100-115 ​kcal/kg/day 1 oz. of formula per day

100-115 ​kcal/kg/day

At what age is solid food generally introduced to​ infants? 4 months 15 months 12 months 8 months

4 months

The nurse is providing discharge teaching about newborn care to a mother. Which topics will be​ included? Select all that​ apply. Cord care Nutrition Day care Diapering Bathing

Cord care Nutrition Diapering Bathing

Which are risk factors associated with thrombophlebitis during the postpartum​ period? Select all that​ apply. Preterm delivery Cesarean birth Blood type​ A+ Hypercoagulability African American ethnicity

Cesarean birth Blood type​ A+ Hypercoagulability

Later on in your​ shift, you check on Ms. Maxwell on the postpartum unit. She tells you that her baby is doing well and that she is planning to formula feed. She asks you if all of her lab work has come back. You check her chart and note that her toxicology screen came back positive. Which positive lab 2019-2 Home Announcements Jump to Week Course Calendar Grades4 People Bookshelf® Library Help Desk Office 365 My Media Media Gallery Case Study : Intrapartum Hemorrhaging Due Jun 23 at 11:59pm Points 8 Questions 8 Available after Jun 3 at 12am Time Limit None Allowed Attempts Unlimited Instructions Return to Week Check your knowledge of the current concept by answering the following questions. Attempt History Attempt Time Score LATEST Attempt 1 5 minutes 4.5 out of 8 Score for this attempt: 4.5 out of 8 Submitted Jun 17 at 11:02am This attempt took 5 minutes. Question 1 1 / 1 pts You are working as a labor and delivery nurse in a downtown tertiary care hospital. The emergency department​(ED) calls to alert you to an incoming ambulance. The ambulance was called to a homeless shelter after a pregnant resident reported having heavy vaginal bleeding. The ambulance crew arrives to labor and delivery pushing a gurney. On the gurney is​ 23-year-old Jaycee Maxwell. The emergency medical technician​ (EMT) tells you that Ms. Maxwell told them she is pregnant with her first baby and thinks she is due in two weeks. Per the​ EMT, Ms. Maxwell was using the restroom at the homeless shelter and cried out for​ help, reporting that she saw a large amount of blood in the toilet. Ms. Maxwells eyes are​ closed, and she is moaning. Her hands are gripping the blanket on the gurney. You explain to Ms. Maxwell that you will help the EMT crew move her from the gurney onto a labor and delivery bed. As you help move Ms. Maxwell to the​ bed, the EMT tells you her vitals are as​ follows: T 98.8​°​F, P 120​ bpm, R​32/min, BP​ 156/92 mmHg, and her Sp02 on room air is​ 97%. Ms. Maxwell has a left antecubital​ 16-gauge IV infusing normal saline at a rate of 250 ​mL/hr. As you move Ms. Maxwell to the​ bed, you note she has a small amount of dried blood on her thighs. Which nursing activities are appropriate at this​ point? Assist Ms. Maxwell to the bathroom to obtain a UA. Examine Ms. Maxwells cervix. Correct! Apply the external fetal heart rate monitor and tocodynanometer. Assist Ms. Maxwell to the bathroom to change into a gown. Your immediate goal is to begin assessment of fetal status and uterine activity. Based on her report of vaginal​bleeding, you should not examine her​ cervix, as you do not know where her placenta is located. If she has a previa or marginal​ attachment, a cervical exam could worsen her bleeding. You should not assist her to the bathroom for a UA or a gown change until you have assessed the fetuss health. Question 2 0.5 / 1 pts The charge nurse has searched the computer system and located an ultrasound performed on Ms. Maxwell at the ED of another hospital in the same system. Which ultrasound reports would prompt you to check her​ cervix? Select all that apply. You Answered A​ 20-week ultrasound showing a​ low-lying placenta that gives a current EGA of 29 wks. An​ 8-week ultrasound showing an intrauterine pregnancy and left ovarian corpus luteum that gives a current estimated gestational age​ (EGA) of 36 wks. Correct! A​ 24-week ultrasound showing a fundal placenta that gives Ms. Maxwells fetus a current EGA of 41 weeks. Correct! A​ 36-week ultrasound showing a breech presentation and a​ low-lying placenta with the edge 4 cm from the cervical os. None of the above ultrasounds would make you feel comfortable checking her cervix at this time. A​ 36-week ultrasound that measured the placental edge as 4 cm from the cervical os is​ reassuring, although you must still exercise great care with a vaginal exam. A​ 24-week ultrasound with a fundal placenta provides evidence she does not have a previa or a​ low-lying placenta, and you could go ahead and check her cervix. A first trimester ultrasound does not provide enough information about the placental site to make it appropriate for you to check her cervix. A​ 20-week ultrasound with a​ low-lying placenta heightens your suspicions that she may currently have a​ low-lying placenta, a marginal previa or a​ previa; you would not check the cervix given this ultrasound result. Question 3 1 / 1 pts The charge nurse hands you an ultrasound that Ms. Maxwell had at 36 weeks showing a​ low-lying placenta with the edge 4 cm from the cervical os. The fetus was noted to be breech on that ultrasound. By this​ ultrasound, Ms. Maxwell is currently 38 weeks gestation. You check Ms. Maxwell's vital signs and obtain the following​ results: T 98.6​°​F, P 114​ bpm, R​ 23/min, BP​ 160/92 mmHg, and her SpO2 on room air is​ 96%. The electronic fetal monitor shows the​ following: Uterine contractions every two​ minutes, lasting for 60-75 seconds. Fetal heart rate 170​ bpm, minimal long term ​variability, deceleration to 140 bpm noted between contractions. You prepare an oxygen mask at 10 L and ask Ms. Maxwell to put it on. Ms. Maxwell is clearly uncomfortable with contraction​ pain, but she manages to​ ask, 'Why is something ​wrong?"​ What will you tell Ms.​ Maxwell? She needs oxygen because her SpO2 is too low. Her baby has fetal​ bradycardia, an indication her baby needs more oxygen. All pregnant women need supplemental oxygen. Correct! Her baby has fetal​ tachycardia, an indication her baby needs more oxygen. You explain to Ms. Maxwell that the oxygen is indicated due to her baby's tachycardia. Her own oxygenation is ​fine, as shown by a normal SpO2. Fetal bradycardia is diagnosed below 110 beats per minute. It is not true that all pregnant women need supplemental oxygen. Question 4 1 / 1 pts Ms. Maxwell continues to shiver. She looks at you and starts to cry.​ "Are you feeling​ okay?" you ask her. Ms. Maxwell turns white and​ says, "I think Im going to throw​ up." You encourage her to take slow deep​ breaths, and you place a cool cloth in her forehead. You check her vital​ signs, and they are as​ follows: T 97.3​°​F, P 97​ bpm, R​ 23/min, BP​ 136/92 mmHg, and her SpO2 on room air​ 97% You know that Ms. Maxwells symptoms of nausea and shivering are most likely caused​ by: Select all that apply. Correct! Precipitous labor Heroin withdrawal ​Chorioamnionitis, or infection in the uterus Preeclampsia Shivering and nausea can be caused by​ advanced, precipitous​ labor, which is common in cases of placental abruption. Ms. Maxwells temperature is normal so you do not have any indication she has chorioamnionitis at this time. There is no evidence of heroin withdrawal. Preeclampsia presents as a severe​ headache, epigastric​pain, and visual disturbances. Question 5 0.67 / 1 pts The attending health care provider arrives to evaluate Ms. Maxwell. After performing a vaginal​ exam, she states that Ms. Maxwell is 6 centimeters​ dilated, 100%​ effaced, and 0 station. The health care provider requests an amnihook and performs artificial rupture of membranes. The amniotic fluid is dark green and bloody. She inserts an intrauterine pressure catheter to monitor contractions and resting​ tone, and an internal scalp electrode to permit more detailed evaluation of the fetal heart rate.Based on your​ experience, you expect the health care provider will order which labs for Ms.​ Maxwell? Select all that apply. Correct! A urine toxicology screen Correct! A complete blood count A biophysical profile Correct! Liver enzymes You Answered A group B beta strep​ (GBS) culture After informed​ consent, a urine toxicology screen should be obtained as illegal drugs may precipitate a placental abruption. A complete blood count will provide information about Ms. Maxwells hemoglobin and​ hematocrit, as well as a platelet count. Liver enzymes will also assist in giving a more complete picture whether Ms. Maxwell has preeclampsia. While an ultrasound to confirm cephalic presentation might be useful​ (as the baby was breech at 36​ weeks), a biophysical profile would not be useful at this time because Ms. Maxwell is in advanced labor and her amniotic membranes are already ruptured. It is unlikely the provider will order a GBS culture at this​ time, as Ms. Maxwell will certainly be delivered before the culture results would be available. Question 6 0 / 1 pts As the health care provider leaves the​ room, she asks you to place a Foley catheter. You explain to Ms. Maxwell what a Foley catheter is and why it is indicated at this time. Which statements by Ms. Maxwell indicate that she understands the need for a Foley​ catheter? Select all that apply. Correct Answer You need to make sure my kidneys are getting enough blood. Correct! You need to check my urine for protein. I know the hospital is too busy for you to help me to the bathroom. You Answered If I get up to go to the bathroom on my​ own, I might deliver my baby in the toilet. You Answered This is the only way to measure my urine output. Use of a Foley catheter is indicated for Ms. Maxwell as it will provide an accurate picture of her output. She should have an output of at least 30​ mL/hr as an indication that her kidneys are sufficiently perfused. A catheterized urine specimen will also be more accurate as you dip for​ protein, as the urine will not be contaminated by vaginal bleeding or amniotic fluid. You are not inserting a Foley for convenience or because pregnant women in general are at risk of birthing in a toilet.​ Finally, while a Foley catheter is an accurate way to measure​ output, it is not the only way. A hat in the toilet would be accurate enough for a​ lower-risk patient. Question 7 0.33 / 1 pts You assess Ms. Maxwell and obtain the following​ data: T 99.1degrees°​F, P 135​ bpm, R​ 30/min, BP​ 142/86 mmHg, and her SpO2 on 10 L O2 by face mask is​ 99% Fetal heart tones​ 130/s with minimal variability and late decelerations Uterine contractions every two​ minutes, lasting 60-80 ​seconds, uterine resting tone 40 mmHg Ms.​ Maxwell's initial CBC comes back and indicates hemoglobin 9.2​ g/dL, hematocrit​ 27.6%, and platelets ​87,000/​µl. What data supports the diagnosis of placental​ abruption? Select all that apply. Temperature of 99.1degreesF Correct! The abnormal uterine resting tone Correct! Late decelerations You Answered Fetal heart rate of 130 bpm Correct Answer Maternal pulse The uterine resting tone is between 20 and 25 mmHg in a normal uterus. The intrauterine pressure monitor is showing a resting tone of​ 40, which is high and demonstrates increased pressure in the uterus. Late decelerations are another indication of abruption as the fetus is not getting enough oxygen to handle the contractions. Ms. Maxwells pulse is​ tachycardic, indicating blood loss. The fetal heart rate of 130 is within normal range and does not indicate abruption on its​ own, although you will continue to watch closely. Although Ms. Maxwells temperature appears to be​ increasing, a temperature of 99.1 degrees°F would not be related to a placental abruption Question 8 0 / 1 pts Later on in your​ shift, you check on Ms. Maxwell on the postpartum unit. She tells you that her baby is doing well and that she is planning to formula feed. She asks you if all of her lab work has come back. You check her chart and note that her toxicology screen came back positive. Which positive lab results support Ms. Maxwells experience of having placental​ abruption? Opiates You Answered Benzodiazepines Marijuana Correct Answer Cocaine results support Ms. Maxwells experience of having placental​ abruption? Opiates Benzodiazepines Marijuana Cocaine

Cocaine 628

A preterm infant arrives in the nursery. Which initial assessments will the nurse make on this​ infant? Select all that​ apply. Complete blood count Blood glucose monitoring Core temperature readings Signs of respiratory distress Gestational age determination

Core temperature readings Signs of respiratory distress Gestational age determination

Luis Travers is 5 days old. He is kicking his​ feet, jerking his​ arms, and acting fussy. His father is shaking a colorful rattle to entertain him. Based on the​ assessment, which state does the home care nurse anticipate this baby will enter into​ next? Drowsy Active Quiet sleep Crying

Crying

Which tasks will strengthen a father​'s bond with a​ newborn? Select all that​ apply. Diapering Helping with household chores Bathing Feeding Planning activities with siblings

Diapering Bathing Feeding

The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form to help ensure the health of the​ infant? What is the name of the​ baby's father? Do genetic diseases run in the family of the​ baby's father? Where was the father of the baby​ born? Are you married to the father of the​ baby?

Do genetic diseases run in the family of the​ baby's father?

The nurse is preparing a brochure on alternative therapies for nausea and vomiting during pregnancy. Which strategy would the nurse ​include? Drinking carbonated beverages Increasing fluids to​ 2,000 mL per day Adequate exercise Drinking ginger tea

Drinking ginger tea

A nurse has been called to a birth to assess the healthy term infant while the labor nurse continues to care for the mother. What is the second nurse​'s priority in providing immediate care for the​ infant? Drying the baby thoroughly to prevent heat loss Applying wrist bands for identification Initiating breastfeeding Obtaining the correct spelling of the baby​'s name for the birth certificate

Drying the baby thoroughly to prevent heat loss

What​ risk-reduction factor should be included in the collaborative teaching of preventing​ SIDS? Use only one loose blanket in​ infant's crib Encourage prone positioning for sleep Encourage tummy time for play Keep nursery temperature cooler than living space

Encourage tummy time for play

A client tells the nurse that her last period was from May 18 to 24. The nurse uses the N​ägele rule to compute the expected date of birth. Based on this​ information, what would the nurse document as the expected date of​ birth? February 18 of the following year February 25 of the following year February 11 of the following year March 1 of the following year

February 25 of the following year

A nurse is caring for the newborn of a diabetic mother. What should be included in the​ nurse's plan of care for this​ newborn? Withhold feedings until intravenous glucose is given Provide glucose water exclusively Feed the infant soon after delivery Evaluate blood glucose levels at 12 hr after birth

Feed the infant soon after delivery

After you empty Mrs. Romeros​ bladder, her bleeding is normal and she is able to eat dinner and take a nap. Once she wakes​ up, you take the opportunity to perform a​ head-to-toe exam and initiate postpartum teaching.Her​ head-to-toe exam reveals the​ following:Breasts soft and​ non-tender, nipples intact Abdomen soft and non tender Uterus​ firm, 2 finger breadths below the umblilicus Bladder non palpable Perineal inspection reveals intact stitches that are gaping and you note marked fullness Moderate lochia rubra Negative Homans sign bilaterally. Does everything seem​ ok? Mrs. Romero asks you. Which findings give you cause for​ concern? Select all that apply. Her bladder cannot be palpated. Negative Homan sign Lack of breast changes Gaping stitches Marked fullness on her perineum

Gaping stitches Marked fullness on her perineum

A newborn has been admitted to the neonatal intensive care unit with sepsis. Which symptoms will the nurse note in an infant with​ sepsis? Select all that​ apply. Glucose instability Pallor Grunting Irritability Vomiting

Glucose instability Pallor Grunting Irritability

Ran Bin Rui is a​ 50-year-old retired professor of Mandarin languages who has had type 1 diabetes mellitus since she was 18 years old. She began receiving medical disability retirement benefits last year because she was no longer able to see well enough to correct students​' written work. She also had to give up her hobby of doing calligraphy with watercolor paintings of birds. She has never​ married, but maintains a large supportive network of friends. The walls of her condominium are filled with her earlier paintings. Her only relative living nearby is her​ 30-year-old niece, Bi Jing Tan. The two women are close. Ms.​ Tan, who was recently diagnosed with​ lupus, visits her aunt at least weekly and runs errands for her.​ Dr. Rui is now legally blind due to diabetic​ retinopathy, although she still has some perception of light. Because she has lived in the same condominium for 20​ years, she knows her​ neighbors, and they check in on her periodically. She continues to maintain her independence in​ cooking, laundry, and personal care activities. She jokes with​ you, her home health​ nurse, that she was born in the Year of the​ Tiger, and says she is still "fierce as a tiger." Dr. Rui has been your client for the past​ year, with home visits scheduled every two weeks. At each​ visit, you draw up her insulin and assess her​ well-being. Her normal finger stick blood glucose is 130 to 170​ mg/dL. Her usual insulin dosage is Humulin​ 70/30 insulin 20 units every morning before breakfast and 10 units every evening before supper. When Dr. Rui answers the door at 11 a.m. this​ morning, you know immediately that she is not her usual self. Her speech is​ slurred; her face is pale with visible sweat. Her hand trembles as she extends a welcoming handshake. Knowing her​ history, what do you suspect is the most likely cause of her altered​ appearance? Hypotension Hypertension Hypoglycemia Hyperglycemia

Hypoglycemia

Mrs. Evelyn​ Park, 32 years​ old, has just delivered an 8 lb 10 oz baby​ boy, Steven. He is grunting and flaring his nostrils. Mrs. Park asks the nurse what is wrong with her baby. The nurse will base the response from which​ rationale? Tactile stimulation Hypoxia Nonshivering thermogenesis Chest retractions

Hypoxia

The nurse is caring for an infant who is small for gestational age​ (SGA). Which complications will the nurse assess this infant for during the nursing​ assessment? Select all that​ apply. Hypoxia Hyperbilirubinemia Hypoglycemia Aspiration Hypothermia

Hypoxia Hypoglycemia Aspiration Hypothermia

The nurse is assessing the nutritional status of a client at 12 weeks gestation. The nurse asks the client about her lifestyle and eating habits. Which characteristic from the assessment data will have the greatest impact on the client​'s ​nutrition? Marital status Age Income status Occupation

Income status

A client at 39 weeks​' gestation is demonstrating signs of beginning labor. The nurse realizes that which hormonal action is​ occurring, resulting in the onset of​ labor? Decrease in corticosteroids Increase in progesterone Increase in estrogen Decrease in prostaglandins

Increase in estrogen

A nurse is caring for Maia​ Ngyuen, a​ 27-year-old client who is 41 weeks pregnant with her first child. Maia presents to the labor and delivery department after experiencing regular uterine​ contractions, which are now about 5 min apart.​ Maia's nurse is gathering a client gown for Maia when her amniotic fluid ruptures. The nurse notes that the fluid appears greenish. After notifying​ Maia's health care​ provider, what should​ Maia's nurse prepare​ for? Intubation of​ Maia's infant Surfactant replacement Emergency cesarean section Antibiotic administration to treat​ Maia's infection

Intubation of​ Maia's infant

What can the nurse do to lessen the anxiety a woman may be feeling as she goes through the second stage of​ labor? Select all that​ apply. Tell her to push harder Offer ice chips Keep her apprised of her progress Provide an antianxiety medication Praise her efforts

Keep her apprised of her progress Praise her efforts

Which incision is most commonly used for a cesarean​ delivery? High transverse Low transverse Classic Low vertical

Low transverse

During fetal​ circulation, most fetal blood is shunted away from which​ organ? Lungs Heart Kidneys Brain

Lungs

The nurse is interviewing Mrs. Barnes during her initial prenatal visit. Mrs. Barnes states that the first day of her last menstrual period was June​ 6, 2014. What is her estimated date of confinement​ (EDC) based on the​ Nägele rule? March​ 13, 2015 September​ 9, 2015 February​ 10, 2015 January​ 13, 2015

March​ 13, 2015

Which data would be most important for the nurse to note as part of an initial assessment of a newborn's history? Mother received morphine sulfate 4 mg IV 20 minutes before delivery Mother reports drinking a glass of wine with dinner each night Mother's age is 14 Mother's blood type is O negative

Mother received morphine sulfate 4 mg IV 20 minutes before delivery

The nurse is evaluating a new mother following a teaching session. The mother gently brushes the infant​'s cheek with her nipple and the newborn turns toward that side and opens the lips to suck. This demonstration of the rooting reflex is part of which​ assessment? Neuromuscular Apgar score Physical maturity assessment Vital signs

Neuromuscular

The nurse is performing a newborn assessment to determine gestational age. Which assessment findings does the nurse expect for a​ full-term infant? ​(Select all that​ apply.) Heart rate greater than 100​ beats/min Opaque skin Plantar creases on the anterior two thirds of the sole A large amount of lanugo over the back Minimal ear cartilage

Opaque skin Plantar creases on the anterior two thirds of the sole

What are the factors that cause respiratory distress in the preterm​ infant? ​(Select all that​ apply.) Decreased levels of pancreatic lipase Open ductus arteriosus Insufficient surfactant Incomplete muscular coat of pulmonary vessels Increased secretion of glucose

Open ductus arteriosus Insufficient surfactant Incomplete muscular coat of pulmonary vessels

Which term describes a newborn​'s ability to respond to appealing​ stimuli, such as his mother​'s ​face? Habituation Familiarization Orientation ​Self-quieting

Orientation

The nurse is preparing for delivery of a newborn with a myelomeningocele. Which priority action will the nurse perform immediately after delivery of the​ newborn? Place a protective dressing on the defect. Obtain a footprint for the medical record. Place the identification band on the wrist and ankle. Administer​ antibiotics, per order.

Place a protective dressing on the defect.

The nurse is assessing the newborn at the client​'s bedside. Which symptoms would indicate the need to assess the client​'s blood glucose​ levels? Select all that​ apply. Poor feeding Excessive sleeping Tremors Temperature instability Excessive crying

Poor feeding Tremors Temperature instability

The nurse observes that the father of the newborn is reluctant to hold his new son. Which would be the most therapeutic response of the nurse at this​ time? ​State, "I notice you will not hold your​ baby." Provide instruction and demonstrate how to hold an infant. Ask the mother whether she is concerned about the father​'s reaction to the baby. Ignore the father​'s anxiety.

Provide instruction and demonstrate how to hold an infant.

You check Mrs. Abejundios vital​ signs: T 98.8​°​F, P 120​ bpm, R​ 20/min, BP​ 118/68 mmHg, SpO2 on room air​ 97%. As the health care provider arranges for Mrs. Abejundio to go to the hospital triage unit for a blood​ transfusion, you are aware that which of her vital signs reflect her severe​ anemia? Respiratory rate Pulse Temperature Blood pressure

Pulse

Which action is most appropriate if a newborn​'s ​anti-abduction bracelet accidently comes​ off? Notify hospital security. Replace it according to policy. Complete an incident report. Leave it off for comfort.

Replace it according to policy.

Which bonding strategy would the nurse suggest for a postpartum mother and newborn after a cesarean​ delivery? Allowing family members to visit in the nursery Administering a narcotic analgesic ​Rooming-in Admitting the newborn to the nursery

Rooming-in

When initiating​ breastfeeding, the mother attempts to elicit which reflex in the​ newborn? Babinski Startle Rooting Palmar grasp

Rooting

Which early cues indicate a readiness for newborn​ feeding? ​(Select all that​ apply.) Rooting Lip smacking Crying Extending the tongue Sucking on fingers

Rooting Lip smacking Sucking on fingers Extending the tongue

The birth of the fetus ends which stage of​ labor? Fourth Second Third First

Second

If a pregnant woman is planning to travel by​ airplane, you​ realize, as the​ nurse, that she should understand what​ behaviors? Select all that​ apply Stand as long as possible. Stay hydrated. Take time to move around the cabin. Check with the airline to see if they have any specific travel restrictions during pregnancy. Travel by car​ instead; flying while pregnant is unsafe.

Stay hydrated. Take time to move around the cabin. Check with the airline to see if they have any specific travel restrictions during pregnancy.

Which are manifestations of an intraventricular​ hemorrhage? ​(Select all that​ apply.) Sudden drop in hemoglobin level Waxy color Onset of severe metabolic acidosis Hypotension Periods of apnea

Sudden drop in hemoglobin level Waxy color Onset of severe metabolic acidosis Hypotension

Which assessment data would alert the nurse that a newborn infant is experiencing dehydration? (Select all that apply) Urine-specific gravity 1.006 Low serum sodium Urine volume 2 mL/kg/hr Sunken anterior fontanel Poor skin turgor

Sunken anterior fontanel Poor skin turgor

The nurse is counseling a young couple pregnant with their first child. The nurse suggests that the couple enroll in the childbirth classes offered at their hospital. Which benefits will the nurse share with the couple regarding these​ classes? Select all that​ apply. Teaching about the process of childbirth Providing information about pregnancy Improving coping mechanisms during the birth Sharing feelings about pregnancy and birth Ensuring a painless labor and delivery

Teaching about the process of childbirth Providing information about pregnancy Improving coping mechanisms during the birth Sharing feelings about pregnancy and birth

In which phase of cellular division does the cell divide into two daughter​ cells, each containing its own nucleus with 46 chromosomes and the same genetic makeup as its​ parent? Telophase Interphase Metaphase Anaphase

Telophase

You assess Ms. Maxwell and obtain the following​ data: T 99.1degrees°​F, P 135​ bpm, R​ 30/min, BP​ 142/86 mmHg, and her SpO2 on 10 L O2 by face mask is​ 99% Fetal heart tones​ 130/s with minimal variability and late decelerations Uterine contractions every two​ minutes, lasting 60-80 ​seconds, uterine resting tone 40 mmHg Ms.​ Maxwell's initial CBC comes back and indicates hemoglobin 9.2​ g/dL, hematocrit​ 27.6%, and platelets ​87,000/​µl. What data supports the diagnosis of placental​ abruption? Select all that apply. Temperature of 99.1degreesF The abnormal uterine resting tone Late decelerations Fetal heart rate of 130 bpm Maternal pulse

The abnormal uterine resting tone Late decelerations Maternal pulse

A nurse is caring for a couple whose infant has died. When planning​ care, what outcomes are most appropriate for the nurse to​ establish? Select all that​ apply. The couple acknowledges the grieving process. The couple demonstrates effective coping. The couple seeks clarity for the exact cause of death. The couple demonstrates acceptable grief. The couple seeks therapy for psychosocial wellness.

The couple acknowledges the grieving process. The couple demonstrates effective coping. The couple seeks therapy for psychosocial wellness.

The nurse formulates a diagnosis of fear related to fetal outcomes for a laboring client with fetal malpresentation. What is an appropriate client outcome to include in the care​ plan? The mother is able to verbalize understanding of the labor process. The mother identifies two support people for the birth. The mother safely delivers a viable newborn. The mother reports a decrease in fear and anxiety related to the birth.

The mother reports a decrease in fear and anxiety related to the birth.

The nurse is assessing a newborn right after birth. Which assessment will be most helpful initially in identifying an​ at-risk newborn? The newborn​'s color The newborn​'s Apgar score The newborn​'s respiratory efforts The mother​'s pregnancy history

The newborn​'s Apgar score

What is an appropriate way to describe​ colostrum? White Thick and creamy Lacks protein Present by day 4-5 postpartum

Thick and creamy

A postpartum client with an episiotomy reports perineal pain. What is the appropriate nursing intervention for this​ client? Select all that​ apply. Topical anesthetic spray Warm compresses Intermittently placed ice packs Frozen cabbage leaves Sitz baths

Topical anesthetic spray Intermittently placed ice packs Sitz baths

Which marker is used to determine the hydration status of a preterm​ infant? Abdominal girth Feeding frequency Urine output Respiratory rate

Urine output

Which behaviors are considered protective against sudden infant death syndrome​ (SIDS)? (Select all that​apply.) Use of pacifier while sleeping Breastfeeding Prone positioning Neutral ambient room temperature Use of sleeper pajamas

Use of pacifier while sleeping Breastfeeding Neutral ambient room temperature Use of sleeper pajamas

How is the adequacy of feeding often assessed in the​ newborn? Ability to burp Sleeping often Lack of crying Weight gain

Weight gain

What is the preferred type of pushing that will allow the woman and her fetus to maintain​ oxygenation? With a closed glottis Structured pushing With each contraction With an open glottis

With an open glottis

Which percentage of weight loss does the nurse anticipate for a newborn during the first week of​ life? ​5% ​15% ​10% ​20%

​10%

The mother of a preterm infant asks why the baby has a tube in his mouth for feedings. What should the nurse explain to the mother about this feeding​ tube? "Your baby​'s nasal passages are misshapen and there is no other way to provide feedings at this time." "Your baby needs a stomach tube​ placed, so until that can be​ done, a tube is placed through his mouth." "Babies airways are obstructed so there is no other way to pass a tube into the stomach." "Babies are​ nose-breathers so the feeding tube should be placed through his mouth."

"Babies are​ nose-breathers so the feeding tube should be placed through his mouth."

A nurse is caring for a client who is pregnant with her first child. The nurse is providing the client with education about the prevention of SIDS. Which statements made by the nurse are​ correct? Select all that​ apply. "Breastfeed your baby if possible." "The temperature in your baby​'s room should be similar to your room." "It is best to​ co-sleep with your baby." "Place your baby on its back to sleep." "Tuck loose blankets under your baby​'s shoulders during sleep."

"Breastfeed your baby if possible." "The temperature in your baby​'s room should be similar to your room." "Place your baby on its back to sleep."

The nurse educator is providing instruction to​ maternal-newborn students. Which student statement indicates appropriate knowledge regarding the first step to initiate a newborn​'s first​ breath? "Thermal changes that stimulate the respiratory center." "Elastic recoil of the lungs." "Clamping and cutting the umbilical cord." "Squeezing the fetal thorax."

"Clamping and cutting the umbilical cord."

The nurse is teaching a postpartum client who is 4 days postvaginal delivery about​ self-care after she is discharged home. Which statement by the client indicates that more teaching is ​needed? "I​'ll be sure to call my healthcare provider if I have any red vaginal discharge." "I can strengthen my abdominal muscles by holding my urine for as long as I can stand it." "I​'ll keep this​ peri-bottle right on the bathroom sink so I don​'t forget to use it." "I can​'t wait to get home and start eating salads ​again!"

"I can strengthen my abdominal muscles by holding my urine for as long as I can stand it."

The nurse is caring for​ 4-hr-old Tyson​ Carter, who appears healthy and is feeding well by bottle. The nurse is performing the newborn​ assessment, teaching​ Tyson's parents about normal newborn care. The nurse includes teaching regarding how to hold​ Tyson, feed​ him, and diaper him. What incorrect statement made by​ Tyson's father would indicate that the nurse needs to reinforce the original​ teaching? ​"I can give the baby a bath every other​ day." ​"It is fine to use baby wipes without​ alcohol." ​"I should use powder daily to prevent skin​ breakdown." ​"I need to fold down the top of the​ diaper."

"I should use powder daily to prevent skin​ breakdown."

The nurse is evaluating teaching provided to the parents of a preterm infant who is being discharged. Which statement made by the mother indicates that additional teaching is​ required? "I will keep the baby dressed and covered at all times." "I will use warmed whole milk in the baby​'s bottle." "I will use formula with whey protein in the baby​'s bottle." "I will feed the baby slowly so choking does not occur."

"I will use warmed whole milk in the baby​'s bottle."

The nurse is providing education to a pregnant client who has asked for information regarding risk factors related to sudden infant death syndrome​ (SIDS). Which statements by the nurse are​ appropriate? Select all that​ apply. "If your child is​ female, the risk for SIDS increases." "If your child is born​ premature, the risk for SIDS increases." "If your child is exposed to smoke in the​ home, the risk for SIDS increases." "If your child shares your bed during​ sleep, the risk for SIDS increases." "If your family has a history of​ SIDS, the risk for SIDS increases."

"If your child is born​ premature, the risk for SIDS increases." "If your child is exposed to smoke in the​ home, the risk for SIDS increases." "If your child shares your bed during​ sleep, the risk for SIDS increases." "If your family has a history of​ SIDS, the risk for SIDS increases."

A nurse is caring for a couple that is grieving over the death of their​ infant, who is suspected to have died as a result of sudden infant death syndrome​ (SIDS). Which responses made by the nurse support the couple​'s psychosocial needs and provide the couple with collaborative therapy​ resources? Select all that​ apply. "Is there a pastor or clergy member you would like me to ​call?" "What funeral home would you like me to ​contact?" "I will provide you with a list of local grief counselors." "The infant loss support group meets every Tuesday." "I am sorry you are going through this. Would you like to talk to me about your ​child?"

"Is there a pastor or clergy member you would like me to ​call?" "I will provide you with a list of local grief counselors." "The infant loss support group meets every Tuesday." "I am sorry you are going through this. Would you like to talk to me about your ​child?"

The nurse is providing care to a postpartum woman who gave birth 1 day ago. Which physiologic response is considered normal in the early postpartum​ period? Increased motility of the gastrointestinal system Urinary urgency and dysuria Increase in heart rate Rapid diuresis

Rapid diuresis

Which events are signs of true​ labor? Select all that​ apply. Activity does not decrease contractions Regular contraction patterns Cervical dilation Contractions that become more intense Position change lessens contractions

Activity does not decrease contractions Regular contraction patterns Cervical dilation Contractions that become more intense

Ms. Hideki is a 19-​year-old G1 P1 who is postpartum day 1 and Rh negative. Her newborn is tested and the results reveal that he is Rh positive. The nurse anticipates which order for Ms.​ Hideki? Infuse 1 unit of packed red blood cells. Consult with hematology. Administer RhoGAM 300 µg intramuscularly. Collect blood for complete blood count.

Administer RhoGAM 300 µg intramuscularly.

A postpartum client who is​ Rh-negative delivers a newborn who is​ Rh-positive. The nurse anticipates which order will come from the healthcare​ provider? Administer rubella vaccine on postpartum day 2. Send placenta to pathology. Infuse 2 units of packed red blood cells stat. Administer RhoGAM 300 ​µg intramuscularly.

Administer RhoGAM 300 ​µg intramuscularly.

You get a reading of a blood glucose reading of 40​ mg/dL. What action should you take​ immediately? Take Dr.​ Rui's vital signs. Administer glucose or glucagon. Call 911. Ask Dr. Rui is she ate breakfast.

Administer glucose or glucagon.

Nursing responsibilities in the setting of a​ nonreassuring, or category​ III, electronic fetal monitor​ (EFM) tracing​ include: Select all that​ apply. Giving a narcotic analgesic as needed Administering oxygen Notifying the health care provider Giving a bolus of intravenous​ (IV) fluids Repositioning the mother

Administering oxygen Notifying the health care provider Giving a bolus of intravenous​ (IV) fluids Repositioning the mother

During an initial prenatal​ visit, the client discloses she has been taking​ valium, a​ benzodiazepine, daily for several years. She has a prescription but also uses her friend​'s prescription or buys it​ illegally, adding to the prescribed dose. Which action does the nurse anticipate from the healthcare provider when these findings are​ reported? Reporting the illegal drug use to law enforcement and a child welfare agency Recommending that the client cut down her valium use Admission to the hospital for medically supervised withdrawal Contacting the client​'s pharmacy for discontinuation of the valium prescription

Admission to the hospital for medically supervised withdrawal

The nurse is assessing clients in the prenatal clinic. Which are maternal risk factors for preterm​ labor? Select all that​ apply. African American ethnicity Maternal obesity Preterm premature rupture of membranes Intrauterine bleeding Maternal genital tract infection

African American ethnicity Preterm premature rupture of membranes Intrauterine bleeding Maternal genital tract infection

In preparation for​ discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. What would the nurse explain to the client as the most appropriate time for resuming sexual​ intercourse? After the postpartum​ follow-up visit with the healthcare provider In 3​ weeks, when the episiotomy is completely healed Whenever the client is feeling amorous and desirable When the lochia flow and episiotomy pain have stopped

After the postpartum​ follow-up visit with the healthcare provider

The nurse caring for a preterm infant decides to plan interventions to address the potential for apnea of prematurity. Which information does the nurse use to make this​ decision? Select all that​ apply. Extended body posture Age 4 days Irregular breathing pattern Breathing through the nose 34 weeks gestation

Age 4 days Irregular breathing pattern 34 weeks gestation

The nurse is caring for a newborn who has been diagnosed with a metabolic disorder. Which formulas does the nurse anticipate may be prescribed for this​ newborn? Select all that​ apply. Isomil Enfamil Similac Alimentum Nutramigen

Alimentum Nutramigen

You perform a​ head-to-toe exam of Mrs. Turner and observe the​ following:Her lungs are clear to auscultation. She is alert and oriented times​ person, place, and time. Her breasts are soft and nontender. Her abdomen is soft and​ nontender, and you hear sluggish bowel sounds in all four quadrants. Her fundus is firm and 2 fingerbreadths below the umbilicus. Her incisions dressing is dry and intact. Homans sign is negative bilaterally.Her vital signs​ are: T 97.6​° ​ F, P 62​ bpm, R​ 18/min, and BP​ 98/64 mmHg.You remove her Foley catheter and encourage Mrs. Turner to ambulate around the room and to the bathroom. She sits at the bed and dangles her legs before slowly standing and ambulating cautiously around the room.​ Just around​ here? she asks. You​ answer, Id start here. But if you feel​ good, I think we should get you in to the NICU to see your baby. Have you seen her​ yet? Mrs. Turner shakes her head. You tell​ her, The NICUs right next door. Do you want to head on over and see​ her? Mrs. Turners face lights up.You know Mrs. Turner needs to see her baby for a variety of reasons. How will Mrs. Turner going to see the baby help her​ physically? Ambulation will reduce her risk of deep vein thrombosis. Ambulation will increase her heart rate. Shell be able to breastfeed her baby. Ambulation will help normalize her bowel sounds. Ambulation will normalize her blood pressure.

Ambulation will reduce her risk of deep vein thrombosis. Ambulation will help normalize her bowel sounds.

In preparing a client for a nuchal translucency test​ (NTT), what should the nurse include in the teaching​ plan? Select all that​ apply. NTT is performed between 18 and 20 weeks​' gestation. An amniocentesis may be needed after the NTT. There may be​ false-positive results. NTT is a noninvasive test. NTT is a screening​ test, not a diagnostic tool.

An amniocentesis may be needed after the NTT. There may be​ false-positive results. NTT is a noninvasive test. NTT is a screening​ test, not a diagnostic tool.

For which reason would the nurse add a urinary catheter to the delivery room table before a vaginal​ birth? An empty bladder provides more room on the pelvic floor. It is completed as a safety mechanism for the fetus. If the operative vaginal birth​ fails, the nurse must be prepared for a cesarean birth. It is added to enhance the woman​'s comfort during the last stage of labor.

An empty bladder provides more room on the pelvic floor.

The nurse is caring for a client in the second stage of labor. Which nursing action is most appropriate during this​ stage? It is not necessary to assess maternal vital signs in the second stage Assessing the fetal heart rate every 5-15 min Assessing the fetal heart rate every 30 min Assessing the maternal vital signs hourly

Assessing the fetal heart rate every 5-15 min

A nurse is caring for a client going into the fourth stage of labor. Which is the priority nursing assessment during this​ stage? Assessing pulse oximetry every 4 hr Assessing vaginal discharge every 4 hr Assessing vital signs every 1 hr Assessing the uterus

Assessing the uterus

Grace Cho had an uncomplicated vaginal birth 15 min ago. There is a gush of blood from her​ vagina, and the umbilical cord is growing longer. What would the nurse be expected to do in this​ situation? Assist in the delivery of the placenta Assist the health care provider in stopping the vaginal bleeding Inspect the perineum for lacerations Pull on the umbilical cord to remove it

Assist in the delivery of the placenta

The nurse is assisting the health care provider with the circumcision of a newborn client. Which nursing intervention is a priority to decrease the likelihood of a​ post-procedure infection? Obtain informed consent. Wrap the circumcised area with Vaseline gauze. Assist in providing education to parents about the procedure. Assist the provider with sterile supplies during the procedure.

Assist the provider with sterile supplies during the procedure.

A laboring client experiences an amniotic fluid embolism. The nurse should prepare to execute which nursing​ responsibility? Ordering vasopressors Assisting in the insertion of a central line Contacting pastoral care Vacuum extraction of the fetus

Assisting in the insertion of a central line

The nurse is caring for a pregnant client who was seen in the emergency department with symptoms of a foodborne illness. Which practice will the nurse instruct the client to do based on the client​'s ​symptoms? Limit tasting cake batter or cookie dough to a few times a week. Avoid eating​ medium-cooked hamburgers. Avoid eating cheese made from pasteurized milk. Select swordfish when ordering at a restaurant.

Avoid eating​ medium-cooked hamburgers.

A breastfeeding client reports​ that, occasionally, certain foods cause rashes or gastrointestinal upset in her infant. Which suggestion by the nurse would be most​ appropriate? Give the infant a thimble of baking soda. Give the infant diphenhydramine​ (Benadryl) before breastfeeding. Avoid spicy foods. Avoid foods the client suspects of causing distress.

Avoid foods the client suspects of causing distress.

The nurse is educating the parents about safety precautions for their newborn while in the hospital. Which topics should the nurse discuss with the​ parents? Select all that​ apply. Avoid leaving the newborn in the hospital room alone. Wash hands often to protect the newborn from germs. Bring the newborn to the​ nurses' station if parent feels weak or faint. Keep a hand on the newborn when out of the crib. Ask hospital staff for identification if they are not wearing it.

Avoid leaving the newborn in the hospital room alone. Wash hands often to protect the newborn from germs. Keep a hand on the newborn when out of the crib. Ask hospital staff for identification if they are not wearing it.

Ms. Burberry has been doing well and is at 32 weeks gestation. She is anxious and concerned that her fianc​é will not make it home for the delivery. She is also worried because her sister had a premature infant at 33 weeks. What suggestions can you give to Ms. Burberry that may help her prevent premature​ labor? Select all that apply. Avoid prenatal breast preparation or nipple stimulation. Avoid lifting heavy objects for the remainder of the pregnancy. Take​ 2-3 rest periods per day. Engage in​ 30-60 minutes of cardio exercise three times a week to strengthen pelvic muscles. Engage in sexual activity frequently with her fianc​é when he returns.

Avoid prenatal breast preparation or nipple stimulation. Avoid lifting heavy objects for the remainder of the pregnancy. Take​ 2-3 rest periods per day.

The nurse is assisting a new mother breastfeed a​ 2-day-old preterm​ infant, born at 36 weeks gestation. What should the nurse instruct the mother about breastfeeding this​ baby? Select all that​ apply. Burp the baby when alternating breasts Hold the baby like a football Burp the baby after every 10 min of feeding Do not feed for more than 45 min Hold the baby in a​ semi-seated position

Burp the baby when alternating breasts Hold the baby like a football Do not feed for more than 45 min

The nurse is instructing a pregnant client on the signs of impending labor. What should the nurse include as premonitory signs of​ labor? Select all that​ apply. Increased fatigue Burst of energy Bloody show Easier breathing Decreased vaginal discharge

Burst of energy Bloody show Easier breathing

The nursery has been informed of the completion of an uncomplicated vaginal delivery at​ 3:30 p.m. The nurse prepares for her assessment of the newborn. When should this assessment be​ performed? At change of shift By​ 5:30 p.m. By​ 6:30 p.m. By​ 4:30 p.m.

By​ 5:30 p.m.

The nurse educator is teaching a group of students about newborn thermogenesis. Which statement is appropriate for the educator to include in the presentation regarding brown adipose​ tissue? Brown adipose tissue has a depletion of blood supply in the fat layer. Brown adipose tissue is the same for the preterm newborn as for the term newborn. Brown adipose tissue can be found in the​ groin, legs, and arms of the newborn. Brown adipose tissue has a dense cellular content.

Brown adipose tissue has a dense cellular content.

What should be done when​ bottle-feeding a preterm​ infant? ​(Select all that​ apply.) Burp after 0.5-1.0 ounces of formula Feed in a football hold position Feed in a​ semi-sitting position Feed for no more than 30 min Use a​ single-hole soft nipple

Burp after 0.5-1.0 ounces of formula Feed in a​ semi-sitting position Feed for no more than 30 min Use a​ single-hole soft nipple

A laboring client suddenly sits up in​ bed, has​ dyspnea, becomes​ cyanotic, and has frothy sputum from her mouth. The nurse is unable to palpate a pulse. Which initial action by the nurse is the most​ appropriate? Position the client on her side with her feet elevated Call for assistance and start cardiopulmonary resuscitation​ (CPR) Obtain the client​'s blood pressure Assess the fetal heart rate

Call for assistance and start cardiopulmonary resuscitation​ (CPR)

The nurse should provide education regarding the signs of preterm labor. What clinical manifestations should be reviewed with the pregnant​ client? ​Select all that​ apply. Diarrhea Cervical dilation Abdominal pain Lower back pain Decreased vaginal discharge

Diarrhea Cervical dilation Abdominal pain Lower back pain

Mrs. Hernandez is a​ 24-year-old G1 P0 admitted to the hospital in active labor. She is 3 cm dilated and her healthcare provider performs an amniotomy to release her amniotic fluid. What is the​ nurse's role in this​ procedure? Cleanse and clean the client. Decrease the​ client's epidural dose. Document the characteristics of the amniotic fluid. Test the​ client's Bishop Score.

Document the characteristics of the amniotic fluid.

The nurse is performing a thorough fundal check during a postpartum assessment on a newly delivered mother. What components are included in a fundal​ assessment? Fundal location and potential fundal distention Fundal location and height Fundal consistency and height Fundal​ consistency, location, and height

Fundal​ consistency, location, and height

The nurse is assessing a newborn client 12 hr after delivery. Which assessment finding indicates a problem with the cardiopulmonary adaptation to extrauterine​ life? Grunting Hyperglycemia Hypotension Eupnea

Grunting

The parents of a preterm neonate ask why their baby gets cold so easily. The nurse responds with which explanation about preterm neonates? Can shiver to produce body heat Have minimal body fat to retain body heat Have blood vessels that are deep under the skin surface Lose heat faster because they lie in a fetal position

Have minimal body fat to retain body heat

The student nurse is assessing a newborn to determine whether the newborn is small for gestational age​ (SGA), appropriate for gestational age​ (AGA), or large for gestational age​ (LGA). Which items included in the physical examination of the newborn reflect appropriate understanding of this assessment​ process? Select all that​ apply. Head circumference Length Ballard assessment Weight Vital signs

Head circumference Length Ballard assessment Weight

A nurse is caring for a couple whose infant has died. The healthcare provider suspects the death is a result of sudden infant death syndrome​ (SIDS). When asking the couple about the circumstances surrounding the infant​'s ​death, what factors will the nurse focus​ on? Select all that​ apply. History of infant reflux Health of the couple Health of the infant History of infant congenital heart defects Infant​'s dietary intake

Health of the infant History of infant congenital heart defects Infant​'s dietary intake

What is the most common congenital anomaly in​ newborns? Metabolic diseases Hypothyroidism Sickle cell disease Hearing loss

Hearing loss

The nurse is preparing to discharge a postpartum client and will include information about thrombophlebitis in the discharge teaching. Which signs of thrombophlebitis must the nurse educate the client to assess after discharge from the​ hospital? Muscle soreness in her legs after exercise Local​ tenderness, heat, and swelling in the leg Bruising easily Varicose veins in her legs

Local​ tenderness, heat, and swelling in the leg

The nurse is preparing to discharge a postpartum client and will include information about thrombophlebitis in the discharge teaching. Which symptom will the nurse include in the discharge teaching for this​ topic? Local​ tenderness, heat, and swelling in the legs Bruises in the legs Varicose veins in the legs Muscle soreness in the legs after exercise

Local​ tenderness, heat, and swelling in the legs

Which description of lochia on a postpartum client​'s daily chart would require the nurse to notify the healthcare provider during the early postpartum​ period? Lochia has a fleshy odor. Lochia red and plentiful. White lochia noted today. Lochia contains large clots.

Lochia contains large clots.

Which modifiable risk factors for preterm labor will you incorporate into Ms. Burberrys client​ education? Select all that apply. Being African American Physically demanding work Maternal age Altered nutrition Use of alcohol during pregnancy

Physically demanding work Altered nutrition Use of alcohol during pregnancy

A client delivered her infant daughter 2 hours ago. She had an episiotomy to facilitate delivery. Which action is most appropriate for the nurse at this​ time? Help the client take a sitz bath Place an ice pack on the perineum Apply a heat lamp to the perineum Administer an analgesic medication as ordered

Place an ice pack on the perineum

After suctioning to clear the airway of a term neonate who appears in good condition after a spontaneous vaginal​ delivery, which action would the nurse perform​ next? Put identification bracelets on each wrist Obtain the neonate​'s weight Instill erythromycin in the baby​'s eyes Place the neonate skin to skin with the mother

Place the neonate skin to skin with the mother

The nurse knows that what conditions are contraindications to sexual activity during​ pregnancy? Select all that​ apply. Placenta previa Nausea There are no contraindications. Signs of preterm labor Premature rupture of membranes

Placenta previa Signs of preterm labor Premature rupture of membranes

The newborn goes through several behavioral states as it neurologically adapts to extrauterine life. The nurse observes the newborn awake and alert in its crib and reacting to auditory stimuli. Which behavior state will the nurse document in the medical record for this​ client? Crying state Drowsy and dozing Active alert Quiet alert

Quiet alert

By which means can newborns lose​ heat? ​(Select all that​ apply.) Radiation Convection Evaporation Irradiation Conduction

Radiation Convection Evaporation Conduction

A client is told that her pelvic diameters are slightly contracted. The client asks the nurse what this means for her vaginal birth plan. Which response by the nurse is the most​ appropriate? ​"Yes, you can deliver​ vaginally." ​"You will have a trial of labor​ first; a cesarean delivery will occur if the trial is not​ successful." ​"It might be​ possible, but I would count on a cesarean​ delivery." ​"You will have to have a cesarean​ delivery."

​"You will have a trial of labor​ first; a cesarean delivery will occur if the trial is not​ successful."

A pregnant client has delivered her first child at 36​ 1/2 weeks gestation and the baby weighs 5 lbs 3 oz. Which statement by the nurse is​ appropriate? ​"The baby was right on time and she was born at​ term." ​"You delivered a​ near-term baby." ​"Your baby is doing well for a preterm​ infant." ​"The baby​'s skin looks good for being​ post-term."

​"Your baby is doing well for a preterm​ infant."

The nurse is caring for several postpartum families. Which parent may not wish to have their child circumcised due to cultural or religious​ beliefs? Select all that​ apply. ​31-year-old Muslim mother ​20-year-old Caucasian mother ​27-year-old Asian mother ​30-year-old Jewish couple ​34-year-old Hispanic female

​20-year-old Caucasian mother ​34-year-old Hispanic female ​27-year-old Asian mother

The nurse is caring for four newborns. The nurse would question a health care provider​'s order for circumcision for which​ newborn? ​35-week male newborn ​38-week male twins ​40-week male with a fifth digit on the left toe ​39-week male weighing 8 lb 4 oz.

​35-week male newborn

The nurse receives the​ end-of-shift report for a group of postpartum clients. The nurse giving the report states that one of the clients had a vaginal delivery at​ 2:00 pm, the client​'s bladder was emptied by straight catheterization at​ delivery, and she has not yet voided spontaneously. At what time will the nurse assuming care report the client​'s inability to​ void? ​12:00 am ​8:00 pm ​2:00 am ​4:00 pm

​8:00 pm

Which diagnostic test can be used to screen for spina bifida​ cystica? Complete blood count Basic metabolic panel ​Alpha-fetoprotein Glucose tolerance test

​Alpha-fetoprotein

The rubella vaccine is contraindicated for which postpartum​ client? ​HIV-positive single parent Diabetic​ 40-year-old mother Breastfeeding mother Cesarean section client with twins

​HIV-positive single parent

Which element will the nurse include when assessing the neuromuscular maturity of an infant who is 4 hours ​old? Amount of breast bud tissue ​Heel-to-ear extension Development of the genitalia Skin appearance

​Heel-to-ear extension

A pregnant client tells the nurse that​ eggs, tofu, and nuts are her main protein sources. Based on this​ data, which dietary regimen is the client​ following? Vegan Low carbohydrate Lactovegetarian ​Lacto-ovovegetarian

​Lacto-ovovegetarian

The nurse is counseling a breastfeeding client on nutritional intake. The client asks which foods she should avoid while breastfeeding. What should the nurse advise to the​ client? All chocolate and spices Any foods containing lysine​ (e.g., tomatoes) Cabbage and other​ gas-producing foods ​None, except those to which the client is allergic

​None, except those to which the client is allergic

The nurse is preparing to admit Mrs.​ Johnson, a​ 33-year-old G3​ P3, to the postpartum floor after a vaginal birth. Which products will the nurse ensure she has access to for perineal​ care? Cabbage​ leaves, lanolin, and Tylenol Toilet​ paper, perineal​ pads, and lanolin ​Peri-bottle, anesthetic​ spray, and ice packs Tea​ bags, emesis​ basin, and toothbrush

​Peri-bottle, anesthetic​ spray, and ice packs

A family reports having financial difficulties and is worried about purchasing formula for their newborn. Which community resource will the nurse suggest for this​ family? ​Women, Infants, and Children​ (WIC) program Supplemental Nutrition Assistance Program​ (SNAP) Nurse​ home-visiting program ​New-parent support group

​Women, Infants, and Children​ (WIC) program

The nurse is caring for a client who had a classical uterine incision for her cesarean birth. The nurse knows that the client understands implications for future pregnancies that are secondary to her classical uterine incision when the client makes which​ statement? ​"The risk of rupturing my uterus is too high for me to have any more​ babies." ​"The next time I have a​ baby, I can try to deliver​ vaginally." ​"I can only have one more​ baby." ​"Every time I have a​ baby, I will have to have a cesarean​ delivery."

"Every time I have a​ baby, I will have to have a cesarean​ delivery."

If the placenta is not delivered within​ _____ min of giving​ birth, it must be manually removed. 5 10 30 60

30

What percentage of a pregnant client​'s daily caloric intake should be​ carbohydrates? 30-​40% 55-60% Pregnant women should restrict their carbohydrate consumption. 15-​20%

55-60%

Marjorie Stanton has just delivered a 7 lb 8 oz baby girl. The​ newborn's heart rate is 120​ beats/min, her respiratory pattern is​ weak, she is well​ flexed, she has​ coughed, and her color is blue and pale. What is the appropriate Apgar score for this newborn that the nurse will​ document? 9 7 10 3

7

A newborn at 1 min after a vaginal delivery has a heart rate of​ 140, has prompt response to stimulation with​ crying, is pink with blue hands and​ feet, has a lusty​ cry, and maintains minimal flexion with sluggish movement. What will the nurse record as the Apgar​ score? 7 10 9 8

8

Which instructions should be included in parent education about newborn skin​ care? ​(Select all that​ apply.) A mild soap may be used for bathing. Avoid using powders on the baby. Lotions are needed to moisten the skin. Baby wipes should contain alcohol. Bathing should be done daily.

A mild soap may be used for bathing. Avoid using powders on the baby.

The following neonates are admitted to the nursery, the nurse should withhold the scheduled initial feeding on which newborn? A neonate with a sustained heart rate of 118 beats/min A neonate with an axillary temperature of 97.5 F A neonate with a sustained respiratory rate of 68 breaths/min A neonate who is small for gestational age (SGA)

A neonate with a sustained respiratory rate of 68 breaths/min

A newborn at 7 days of age has lost 3 ounces since birth. How would the nurse characterize this weight​ loss? Indicates failure to thrive An emergency situation An expected finding Indicates milk allergy

An expected finding

The nurse is auscultating the fetal heart rate​ (FHR) with a Doppler for a client in active​ labor, and determines that it is 90​ beats/min. What action will the nurse take​ first? Reposition the mother Call the health care provider Apply a continuous electronic fetal monitor Take the mother​'s blood pressure

Apply a continuous electronic fetal monitor

While educating a pregnant client about​ nutrition, which statement by the nurse is the most​ appropriate? "Swordfish is not safe to eat as it can be toxic to the baby." "​Venison, or any wild​ game, should be avoided until after the baby is born." "​Farm-fresh eggs should be avoided because they are high in mercury." "Shrimp can be eaten several times per week."

"Swordfish is not safe to eat as it can be toxic to the baby."

During a home​ visit, a postpartum client complains of a​ reddened, swollen, and tender breast 10 days after delivery. Once this complaint is confirmed on​ assessment, which response by the nurse is the most​ appropriate? "You should mention this to your health care provider at your​ two-week follow-up appointment." "The symptoms you describe indicate an inflammatory or infectious process. You will need to see your provider immediately." "You will need to stop breastfeeding your newborn." "This is normal breast engorgement. You have nothing to worry about."

"The symptoms you describe indicate an inflammatory or infectious process. You will need to see your provider immediately."

The father of a preterm infant with a profound hearing loss is upset because the coordinator of a local early intervention program for child services contacted the parents. The father​ states, "no government agency is going to control the care" that his child receives. Which is the nurse​'s most appropriate response to this​ father? "Not using this agency to help your child could be a form of neglect." "These programs are mandated under the Individuals with Disabilities in Education Act and will help your baby learn and grow." "Most of these agencies do not have any money to control the care that the children need." "These agencies exist in name only and really don​'t do much to provide the care and support that a child like yours needs."

"These programs are mandated under the Individuals with Disabilities in Education Act and will help your baby learn and grow."

The nurse is talking to the parents of a​ newborn, who is peacefully resting on his mother​'s chest after delivery. The mother would like to know when she can feed the baby. Which response by the nurse is the most​ appropriate? "Within the first hour of life." "After admission to the newborn nursery." "Once blood glucose has been assessed." "After the baby​'s first bath."

"Within the first hour of life."

Carly Starnes is​ 29-year-old G2 P2 whom the nurse is assessing on postoperative day 2 after a low transverse cesarean birth. She reports she has not had a bowel movement since her admission 3 days ago and is feeling constipated. Ms. Starnes tells the nurse that she has never experienced constipation before and would like to know why it is happening. Which response bythe nurse is most​ appropriate? ​"I will ask the provider if we can stop the intravenous solution because that is likely the​ cause." ​"All postpartum women have this problem because of the prenatal​ vitamins." ​"Your symptoms are likely due to the Tylenol​ #3 you are taking to manage your​ pain." ​"I see that you are taking Colace and it is likely the​ problem."

"Your symptoms are likely due to the Tylenol​ #3 you are taking to manage your​ pain."

How does meconium aspiration syndrome​ (MAS) present? There are no visible symptoms. As severe respiratory distress As severe jaundice As severe hypoglycemia

As severe respiratory distress

Which laboratory value indicates hypoglycemia in​ newborns? Below 45​ mg/dL Below 55​ mg/dL Below 60​ mg/dL Levels vary and are based on the newborn​'s weight.

Below 45​ mg/dL

While caring for a client in active​ labor, the nurse notes a gradual decline in the fetal heart​ rate, beginning with the onset of a contraction and followed by a gradual return to baseline by the end of the contraction. Which response by the nurse is​ appropriate? Administer oxygen Continue to monitor Notify the health care provider Prepare for operative delivery

Continue to monitor

The nurse is teaching parents to keep the​ newborn's crib away from the air conditioning vent. What type of heat loss is the nurse trying to prevent in the​ newborn? Convection Evaporation Conduction Radiation

Convection

How is retinopathy of prematurity​ treated? ​(Select all that​ apply.) Cryotherapy Laser photocoagulation Lens replacement surgery Corrective lenses ​Beta-blocker eye drops

Cryotherapy Laser photocoagulation

The nurse observes several interactions between a mother and her newborn daughter. Which maternal behaviors will the nurse document as positive indications of mother-infant ​bonding? Select all that​ apply. Cuddles her daughter close to her Does not make eye contact with her daughter Encourages the father to hold the baby Talks and coos to her daughter Requests the nurse take the baby to the nursery for her feedings

Cuddles her daughter close to her Talks and coos to her daughter

Which statement correctly describes the transition phase of the first stage of​ labor? The fetus descends into the maternal pelvis and rotates internally Dilation reaches 8-10 ​cm, ending the first stage of labor Longest​ stage, lasting 8-10 hr Onset of labor through cervical dilation of 3 cm

Dilation reaches 8-10 ​cm, ending the first stage of labor

Leah Wilson is a​ 28-year-old client who is 30 hr post cesarean delivery of a healthy 7 lb 4 oz. male infant. When performing the initial​ assessment, the nurse notes that she has an oral temperature of​ 102.4°F; she is complaining of general​ weakness, malaise, and​ chills; and she states that her vaginal discharge​ "smells bad." Based on these​ findings, what does the nurse report to the health care​ provider? A wound infection Endometritis Normal postsurgical inflammation A urinary tract infection

Endometritis

The nurse is providing care to a newborn client immediately following delivery. The client is experiencing hypothermia due to which specific​ cause? Conduction Evaporation Radiation Convection

Evaporation

A client is experiencing a hypertonic pattern of uterine contractions. How often are her contractions​ occurring? Every 3-5 min Every 2 min or less Less than 6-8 min between contractions Less than 5 min apart

Every 2 min or less

While feeding an infant, the nurse notices white, adherent patches on the infant's gums and buccal cavity. Which action should the nurse take at this time? Document this normal finding Further evaluate for yeast infection Verify that vitamin K (AquaMEPHYTON) was given at delivery Assess for maternal history of herpes simplex

Further evaluate for yeast infection

A pregnant client has two living​ children, one delivered at 41 weeks and the other at 39 weeks​ gestation, and has had two spontaneous abortions. How would the nurse describe this​ client's pregnancy history using the acronym​ GTPAL? G5 T2 P0 A2 L2 G5 T1 P1 A2 L3 G3 T2 P0 A2 L2 G4 T2 P2 A0 L2

G5 T2 P0 A2 L2

Which are causes for apnea of​ prematurity? ​(Select all that​ apply. Gastroesophageal reflux Neuronal immaturity Irregular breathing patterns Altered lung vessel musculature Obstructive apnea

Gastroesophageal reflux Neuronal immaturity Irregular breathing patterns Obstructive apnea

The nurse is preparing to teach the mother of a newborn using a parent teaching form. When teaching about​ breastfeeding, what will the nurse​ include? Select all that​ apply. Getting the baby to latch properly When to feed the baby Proper feeding positions How to use a breast pump Feeding the baby from a bottle

Getting the baby to latch properly When to feed the baby Proper feeding positions How to use a breast pump

The nurse is performing an assessment on a newborn who is 1 hr old. The nurse notes the following on the newborn​'s ​skin: meconium​ staining, poor​ turgor, and a peeling and leathery appearance. Which gestational age is most appropriate for the nurse to document in the medical record based on these assessment​ findings? 37 completed weeks 38-41 completed weeks 34-36 completed weeks Greater than 42 weeks

Greater than 42 weeks

A nurse is caring for a couple whose infant son recently died from sudden infant death syndrome​ (SIDS). The infant​'s father appears withdrawn and refuses to acknowledge the infant​'s death when the nurse discusses the infant with the couple. Which collaborative therapy is most appropriate to help the infant​'s family in the grieving​ process? Cognitive behavioral therapy Grief counseling Antidepressant medication Antianxiety medication

Grief counseling

The nurse is assessing newborn baby​ Thomas, who is 1 hr old. Which assessment finding does the nurse report to the healthcare​ provider? Grunting Nasal secretions Brief periods of apnea Coughing

Grunting

A mother asks the nurse how she will know if her newborn is having difficulty breathing. The nurse would instruct the mother to monitor for which​ symptom? Select all that​ apply. Grunting Central cyanosis Retractions Nasal flaring Crying

Grunting Central cyanosis Retractions Nasal flaring

The nurse is teaching new parents about the newborn​'s sensory capacities. Which items will the nurse include in the teaching session to these new​ parents? Select all that​ apply. Habituation Orientation Active alert Crying ​Self-quieting

Habituation Orientation ​Self-quieting

While the health care provider is completing the repair of Mrs.​ Romero?s fourth degree​ laceration, you begin your initial assessment.Mrs.​ Romero?s vital signs are T​ 98.8°F, P 70​ bpm, R​ 20/min, and BP​ 90/66 mmHg.You palpate her fundus and note it is boggy and​ 1+ fingerbreadths above her umbilicus.You alert her health care​provider, who pauses the repair to wait while you massage her uterus and expel three golf ball size clots.You anticipate your next action to​ be: Manually remove additional clots from her lower uterine segment Provide 600 mg ibuprofen PO Hang a bag of lactated Ringer solution with oxytocin Replace her Foley catheter

Hang a bag of lactated Ringer solution with oxytocin

Which discomforts can the nurse tell a woman she might experience during her​ pregnancy? Select all that​ apply. Dry mouth Heartburn Nasal stuffiness and nosebleeds Leg cramps Excessive energy

Heartburn Nasal stuffiness and nosebleeds Leg cramps

The nurse is making a visit to the home of a preterm infant to evaluate the success of care provided while hospitalized. Which observation indicates that additional teaching or care is​ required? Parents take turns holding the baby when crying or fussy Mother holds the baby en face Infant has lost​ 1% of body weight since discharge Father changes the baby​'s diaper without difficulty

Infant has lost​ 1% of body weight since discharge

An infant with an omphalocele is admitted to the special care nursery​ (SCN). Which assessments will the nurse conduct for this infant based on the​ diagnosis? Select all that​ apply. Input and output Glucose levels Temperature Respiratory rate and effort Abdominal girth

Input and output Temperature Respiratory rate and effort

Which option is appropriate for providing relief of perineal pain after a vaginal​ delivery? Warm compresses Tea bags Frozen cabbage leaves Intermittently placed ice packs

Intermittently placed ice packs

A parent​ asks, "How long should I warm the​ baby's bottle in the microwave before​ feeding?" What is an appropriate response by the​ nurse? ​"I will ask the healthcare provider to speak with you about​ this." ​"It's best to feed the baby while the formula is still very​ cold." ​"It is best to warm the bottle in a container of warm​ water." ​"About one minute per ounce will warm the bottle​ sufficiently."

It is best to warm the bottle in a container of warm​ water."

Which exercise can the nurse recommend to a pregnant woman to strengthen her perineal​ muscles? Pelvic tilt exercises Partial​ sit-ups Swimming Kegel exercises

Kegel exercises

Mrs. Emma Turner is a​ 29-year-old gravida 2 para 1 who presents to labor and delivery at 30 weeks gestation reporting​ heavy, bright red vaginal bleeding. She was diagnosed with a complete placenta previa during a​22-week ultrasound, and she has known since then that she will need to deliver her baby via cesarean section. Her first baby was born three years ago via a normal spontaneous vaginal delivery. She is accompanied by her​husband, Kyle Turner.​ You are assigned to take care of Mrs. Turner. You knock and enter Mrs. Turners labor room. She is in bed crying softly. You introduce yourself to Mrs. Turner and her husband and place the external fetal heart monitor and the external tocodynamometer onto her abdomen and fasten them into place with straps. You transfer Mrs. Turner to the recovery room and begin your postpartum assessment. Mrs. Turner is resting comfortably because her regional anesthesia is still providing her with excellent pain relief.Hows my​ baby? she asks you. You relay to her what you have heard from the​ NICU, which is that her baby is doing very well considering she was born at 30 weeks gestation.You assess Mrs. Turner. Her vital signs​ are: T 99.6​° ​ F, P 109​bpm, R​ 15/min, and BP​ 116/68 mmHg. You gently locate her fundus at the umbilicus. Her dressing is intact. She is unable to move her legs. She has a moderate amount of bright red lochia on her​ peri-pad. You note​blood-tinged urine in her Foley catheter.Im glad my baby is doing​ well, Mrs. Turner tells you. How am I​ doing? Is everything​ okay?Based on the above​ information, what concerns you regarding Mrs. Turners health​ status? Postpartum hemorrhage Infection Lacerated bladder Paralysis

Lacerated bladder

A client is discharged from the hospital and plans to breastfeed for 6 months. Which community resource will the nurse recommend to increase the likelihood of successful breastfeeding after​ discharge? Lactation consultant Home visiting nurse ​New-parent support group Pediatrician

Lactation consultant

Which nursing intervention is appropriate in the care of an infant with respiratory distress syndrome (RDS)? Maintain a neutral thermal environment Perform a complete gestational age assessment Perform chest physiotherapy twice a day Suction meconium from airway as needed

Maintain a neutral thermal environment

Jeremy was born at 35​ weeks' gestation weighing​ 4,025 g​ (8 lb 14​ oz.) and shows no signs of being a​ high-risk newborn. Based on the nursing​ assessment, which classification is most appropriate for​ Jeremy? Moderately preterm and large for gestational age​ (LGA) Term and small for gestational age​ (SGA) Healthy and in no need of special care Late preterm and hypoxic

Moderately preterm and large for gestational age​ (LGA)

The nurse is caring for a client experiencing her first pregnancy. The client​'s cervix is dilated at 8​ cm, the fetus is at​ +1 station, and the client has no analgesia or anesthesia. What is the priority for the​ nurse? Providing frequent perineal cleansing Applying extra blankets for warmth Offering encouragement and support Giving frequent sips of water

Offering encouragement and support

What are the indicators that require electronic fetal monitoring​ (EFM)? Select all that​ apply. Oxytocin administration Maternal complications of pregnancy Fetal complications Labor augmentation Primigravida status

Oxytocin administration Maternal complications of pregnancy Fetal complications Labor augmentation

The health care provider completes the repair of the fourth degree laceration. You inspect Mrs. Romeros perineum to obtain a baseline assessment. What will be your next step after completing the assessment of her​perineum? Perform a rectal exam to ensure there are no stitches in her rectum. Assist her to a sitting position to apply pressure to the wound. Place an icepack on the area. Review with Mrs. Romero that she should try to not have a bowel movement until her perineum starts to heal.

Place an icepack on the area.

Which interventions promote thermoregulation in the preterm​ infant? ​(Select all that​ apply.) Place incubator away from cold external walls Cover the infant​'s head with a cap Measure oxygen saturation Warm and humidify oxygen Warm formula before feeding

Place incubator away from cold external walls Cover the infant​'s head with a cap Warm and humidify oxygen Warm formula before feeding

What state best describes a newborn who is not​ fussing, is fixating on and following​ objects, and is reacting to auditory​ stimuli? Active sleep Quiet alert Crying state Active alert

Quiet alert

A postpartum client who will be​ formula-feeding her baby wants to return to her prepregnancy weight as soon as possible. Which​ teaching point is most appropriate for the nurse to include based on the client​'s desire to lose weight post​ pregnancy? Reduce daily caloric intake by 300 calories a day. Eat 200 additional calories per day. Experiment with​ low-carbohydrate, high-protein diets. Limit dairy products and protein.

Reduce daily caloric intake by 300 calories a day.

A postpartum​ client, who will be​ bottle-feeding her​ baby, wants to return to her prepregnancy weight as soon as possible. Which​ practice should the nurse instruct this client to do regarding weight loss after​ pregnancy? Limit dairy products and protein. Experiment with​ low-carbohydrate, high-protein diets. Reduce daily caloric intake by 300 calories a day. Eat 200 additional calories per day.

Reduce daily caloric intake by 300 calories a day.

Which statement regarding the postpartum diet is most appropriate for a client who is​ formula-feeding her​ newborn? Eat only when very hungry. Reduce the caloric intake by 300 kcal. Increase the caloric intake by 300 kcal. No dietary changes are required.

Reduce the caloric intake by 300 kcal.

The nurse is caring for a preterm infant in the newborn intensive care unit​ (NICU) who is 2 hours old. Which complication will the nurse monitor this infant for based on the diagnosis of​ prematurity? Bronchopulmonary dysplasia Meconium aspiration syndrome Respiratory distress syndrome Patent ductus arteriosus

Respiratory distress syndrome

The nurse is creating a teaching plan for the parents of a preterm infant scheduled for discharge in 2 days. Which aspects of care should the nurse emphasize when instructing these​ parents? Select all that​ apply. Signs of infection or illness Schedule for routine vaccinations Feeding techniques Swaddling to keep the hands away from the face Growth and development expectations

Signs of infection or illness Schedule for routine vaccinations Feeding techniques Growth and development expectations

At​ birth, what is a newborn​'s stomach able to​ digest? Meconium Simple carbohydrates Nothing Complex carbohydrates

Simple carbohydrates

A nursing responsibility while preparing a woman for a cesarean birth would be which​ action? Explaining the risks involved Explaining the details of the procedure Supporting the woman and her partner Obtaining informed consent

Supporting the woman and her partner

How do newborns produce​ heat? Through their central nervous system By shivering Newborns are unable to produce heat. Through the use of brown fat

Through the use of brown fat

As the health care provider leaves the​ room, she asks you to place a Foley catheter. You explain to Ms. Maxwell what a Foley catheter is and why it is indicated at this time. Which statements by Ms. Maxwell indicate that she understands the need for a Foley​ catheter? Select all that apply. You need to make sure my kidneys are getting enough blood. You need to check my urine for protein. I know the hospital is too busy for you to help me to the bathroom. If I get up to go to the bathroom on my​ own, I might deliver my baby in the toilet. This is the only way to measure my urine output.

You need to make sure my kidneys are getting enough blood. You need to check my urine for protein.

You reassure Mrs. Turner that the babys heart rate is within normal limits and that you are observing only a scant amount of blood at this time.Mrs. Turner asks what they should expect over the next few hours. What is your best​ response? Select all that apply. In a couple of​ minutes, Ill help you to the shower to clean off the blood. I need to check your cervix to see if it is dilated. Would you like something to​ eat? You should not take any Tums right now. We will continue to monitor the babys heart rate and watch for bleeding.

You should not take any Tums right now. We will continue to monitor the babys heart rate and watch for bleeding.

A nurse is caring for a client who delivered a​ healthy, term baby girl 8 hours ago. The nurse is providing the client information about sudden infant death syndrome​ (SIDS) as a part of discharge instructions. The client asks the​ nurse, "Why does breastfeeding help to prevent my child from developing​ SIDS?" Which response by the nurse is the most​ appropriate? ​"Breastfed infants are thought to breathe easier than infants who are fed​ formula." ​"Breastfed infants are thought to be larger than infants who are fed​ formula." ​"Breastfed infants are thought to arouse easier from sleep than infants who are fed​ formula." ​"Breastfed infants are thought to sleep longer than infants who are fed​ formula."

​"Breastfed infants are thought to arouse easier from sleep than infants who are fed​ formula."

The nurse is interviewing Linda​ Youngblood, a pregnant client who is in her second trimester. Which is an appropriate assessment question for the nurse to​ ask? ​"What is your labor​ plan?" ​"Have you considering enrolling in childbirth​ classes?" ​"How are you getting relief from your lower back​ pain?" ​"Are you aware we will test you for Group B Strep​ today?"

​"How are you getting relief from your lower back​ pain?"

How much more percentage of oxygen is carried in fetal hemoglobin when compared with adult ​hemoglobin? 75 50 10 25

50

Which are treatment options for​ mastitis? Select all that​ apply. Antibiotics ​"Resting" the breast Increased intake of milk products Bed rest Breastfeeding

Antibiotics Bed rest Breastfeeding

Which vital sign is critical to assess after administration of an​ epidural? Pulse Blood pressure Respirations Temperature

Blood pressure

The nurse is assessing a newborn infant. Which assessment finding would indicate the need for immediate​ intervention? Central cyanosis Nasal flaring Retractions Grunting

Central cyanosis

What does the nurse apply to the circumcision site after the procedure is​ completed? Neosporin bandage Vaseline gauze Adhesive dressing Drainage tube

Vaseline gauze

A new mother overhears the nurse tell the health care provider the Apgar score of the newborn she just delivered. The mother asks the​ nurse, "What does that score ​mean?" What is the nurse​'s best​ response? "It is a score we assign only to newborns who appear to be in respiratory distress." "It is a score used in nursing. It​'s a bit complicated and not necessary for you to understand." "It is a score we assign to all newborns that indicates gestational age." "It is a score we assign to all newborns that reveals a newborn​'s adaptation to birth."

"It is a score we assign to all newborns that reveals a newborn​'s adaptation to birth."

The nurse is caring for a pregnant client in labor whose birth plan states "no pharmacologic pain interventions" during the labor and delivery process. Which statement by the nurse supports the client​'s birth​ plan? "I will have the anesthesiologist come in to talk to you about the benefits of an epidural." "Let me know when you begin to feel uncomfortable. We can change your position and refocus your breathing to help manage the discomfort." "I am going to start an IV because once you enter​ transition, you will need me to administer something to take the edge off the pain." "No one is ever able to labor without needing some form of oral analgesic."

"Let me know when you begin to feel uncomfortable. We can change your position and refocus your breathing to help manage the discomfort."

The nurse is rounding on her clients and their babies and conversing with each of them as she assesses the infants. Which statement from a new mother would require further assessment of bonding and​ attachment? "Do you think you can take him to the nursery on your way​ out? I am so tired I can​'t stand it." "Look at that baby screaming. She​'s mean as a​ snake, just like her daddy." "Thank goodness you​'re here. She​'s been really fussy and I feel like I​'m not feeding her enough." "Be ​careful! I​'m really scared of that big plastic clamp getting pulled ​on!"

"Look at that baby screaming. She​'s mean as a​ snake, just like her daddy."

The nurse is teaching a new mother about the normal stooling pattern of a newborn. Which statement by the client indicates appropriate understanding of the teaching​ session? "Meconium is​ loose, golden yellow." "Meconium is​ sticky, greenish black." "Meconium is​ hard, pale brown." "Meconium is​ soft, pale yellow."

"Meconium is​ sticky, greenish black."

The nurse is evaluating client teaching about labor contractions. Which statement by the client indicates that the teaching has been​ effective? "My contractions are three minutes​ apart, counting from the beginning of one contraction to the end of the next contraction." "My contractions are three minutes​ apart, counting from the beginning to the end of the same contraction." "My contractions are three minutes​ apart, counting from the end of one contraction until the beginning of the next contraction." "My contractions are three minutes​ apart, counting from the beginning of one contraction until the beginning of the next contraction."

"My contractions are three minutes​ apart, counting from the beginning of one contraction until the beginning of the next contraction."

A community health nurse is teaching a group of pregnant clients regarding sudden infant death syndrome​ (SIDS) and the causes associated with the syndrome. Which statement is appropriate for the nurse to include in the teaching​ session? "SIDS is thought to be caused by newborn apnea." "SIDS is thought to be caused by infant immunizations." "SIDS is thought to be caused by respiratory disease." "SIDS is thought to be caused by a combination of factors."

"SIDS is thought to be caused by a combination of factors."

The nurse in a prenatal care setting is caring for a woman at 39 weeks​' gestation. The healthcare provider is going to strip the client​'s membranes. The client asks the nurse what this will do. What would be the best response by the​ nurse? "Stripping the membranes will help stimulate the fetus." "Stripping the membranes releases progesterone that will prevent preterm labor." "Stripping the membranes will cause the fetus to drop lower in the pelvis." "Stripping the membranes releases prostaglandins that may help labor begin."

"Stripping the membranes releases prostaglandins that may help labor begin."

The mother of a preterm infant asks why the baby is scheduled for audiology testing 180 days after birth when information on the Internet states that this testing should be done by age 3 months. Which response by the nurse is most​ appropriate? "It doesn​'t matter when it is performed as long as it is completed within 1 year of birth." "The physician must have calculated the date for the testing incorrectly." "The baby​'s age has been corrected and is based upon expected date and not actual date of delivery." "The information on the Internet is incorrect."

"The baby​'s age has been corrected and is based upon expected date and not actual date of delivery."

A father asks how the bilirubin lights make the newborn's bilirubin level go down. What is the best reply by the nurse? "The lights prevent more bilirubin from being released into your baby's body." "Exposing the skin to the air helps get rid of the jaundice. The bililights really just keep the baby warm while this occurs." "The bililights help convert the bilirubin to a form the baby can get rid of." "The bililights release a substance in the body that attacks the bilirubin and destroys it."

"The bililights help convert the bilirubin to a form the baby can get rid of."

At a routine prenatal​ visit, the nurse and the client are discussing methods of establishing fetal​ well-being while discussing what to expect in labor. The client​ asks, "I read online that the fetal monitor has high sensitivity and low specificity. What does that ​mean?" What is the nurse​'s best​ response? "The electronic monitor doesn​'t do anything for the baby. Its main use is to provide evidence in lawsuits over bad outcomes." "The monitor is very good in reassuring us that the baby is doing well but not so good at confirming that the baby is compromised. If the monitor looks​ good, we know the baby is okay. If we see signs of a​ problem, the baby is often doing well anyway." "That​'s a very complicated question and it​'s nothing for you to worry about. The midwife will decide whether monitoring is appropriate for your baby." "The fetal monitor can tell us with certainty if the baby is in trouble and needs to be delivered right away by cesarean."

"The monitor is very good in reassuring us that the baby is doing well but not so good at confirming that the baby is compromised. If the monitor looks​ good, we know the baby is okay. If we see signs of a​ problem, the baby is often doing well anyway."

The healthcare provider has performed an amniotomy on a client in labor. The client did not understand the healthcare provider​'s explanation of the procedure and asks the nurse what effects the procedure will have. What is the nurse​'s best​ response? "I will call the provider back so you can ask whatever questions you have." "Another name for this procedure is stripping the membranes." "That procedure was to identify where the baby is in relation to the narrowest part of your pelvis." "The provider has ruptured the amniotic membrane in order to stimulate your labor."

"The provider has ruptured the amniotic membrane in order to stimulate your labor."

The nurse is teaching a new mother how to change her newborn​'s diaper. The new mother becomes upset when she sees blood on the diaper. Which explanation is the most appropriate for the nurse to provide to the new​ mother? "This is caused by a withdrawal of the maternal hormones and is a normal occurrence." "Your baby must have cystitis. I will notify the nurse practitioner immediately." "This indicates neonatal candidiasis. We will send you home with a medication to treat this." "Your baby must have experienced some birth trauma."

"This is caused by a withdrawal of the maternal hormones and is a normal occurrence."

The nurse is at the bedside of a client in active​ labor, reviewing the fetal heart tracing. There is moderate​ variability; no decelerations below​ baseline; and periodic accelerations are evident. The client asks how the tracing looks. What is the nurse​'s best​ response? "The baby is having a little difficulty. Let​'s turn you on your side to see whether we can improve his circulation." "This tracing looks very good. The baby is showing all the signs of ​well-being." "There is no way to tell the baby​'s status from this tracing. We will have to monitor him for another hour and​ re-evaluate it." "You might need a cesarean."

"This tracing looks very good. The baby is showing all the signs of ​well-being."

You find that Dr. Rui​'s temperature is 98.2​°​ F, her heart rate is 120 beats per​ minute, weak and​ thready, her respirations are 24 breaths per minute and​ regular, and her blood pressure is​ 80/50 mmHg. Fifteen minutes after giving her the glucose​ tablets, you take her blood glucose reading​ again, and it has risen to 80 ​mg/dL.​ Dr. Rui tells you that she took her usual insulin dose this morning and ate breakfast. Soon​ afterward, she vomited her breakfast. After that​ event, she had such difficult thinking and concentrating that she did not remember her morning glucometer reading. "Do I have to go to the ​hospital?" she asks. What is your response to her​ question? "I will call your endocrinologist and let her decide if you need hospitalization." "Your hypoglycemia has been treated. Can you get a neighbor or your niece to come stay with you for the next 12 ​hours?" "Hypoglycemia can always be treated at​ home, so there will never be a reason for you to consider seeking hospitalization." "I will call ahead to the​ hospital, so that they expect you. I can drive you there."

"Your hypoglycemia has been treated. Can you get a neighbor or your niece to come stay with you for the next 12 ​hours?"

At what intervals will the nurse assess newborn Apgar​ scoring? 1 min and 5 min 1 min and 10 min 5 min and 7 min 10 min and 20 min

1 min and 5 min

What is the maximum length of time a vacuum extractor can be used without increasing the risk of injury to the fetal​ scalp? 10 min 5 min 15 min 30 min

10 min

How many mL of fluid should the postpartum mother intake per day to stay well​ hydrated? 500 2,000 ​1,500 ​1,000

2,000

The sperm and ovum each contain how many​ autosomes? 46 24 22 44

22

Baby​ Gonzalez, a​ 3-day-old preterm infant in the neonatal intensive care​ unit, is prescribed to receive 150 mL of intravenous fluid for every kilogram of weight. This morning Baby Gonzalez weighed 1850 g. How much fluid should the nurse provide Baby​ Gonzalez? 832.5 mL 138.8 mL 555.5 mL 277.5 mL

277.5 mL

There are four laboring clients on the labor and delivery unit. Which client demonstrates the highest risk of a prolapsed​ cord? 38​ weeks, 3 cm​ dilated, 80%​ effaced, 0​ station, intact membranes 39​ weeks, 9 cm​ dilated, 100%​ effaced, +1​ station, ruptured membranes 38​ weeks, 3 cm​ dilated, 50%​ effaced, -5​ station, ruptured membranes 40​ weeks, 8​ cm, 75%​ effaced, 0​ station, intact membranes

38​ weeks, 3 cm​ dilated, 50%​ effaced, -5​ station, ruptured membranes

A client who has undergone a​ vacuum-assisted birth asks the nurse how long the swelling on the infant​'s head will remain. Which would be the best response by the​ nurse? 12-24 hours 48-72 hours 8-12 hours 5-7 days

48-72 hours

Oligohydramnios is diagnosed when the amniotic fluid is less than which percent expected for gestational​ age? 80 65 50 35

50

Which amount of blood loss constitutes a postpartum hemorrhage after a vaginal​ birth? 250 mL 500 mL ​1,000 mL ​1,500 mL

500 mL

The nurse would be concerned if the postpartum client has not voided within how much time after​ delivery? 12 hr 24 hr 6 hr 1 hr

6 hr

A nurse is teaching a postpartum client about the normal voiding pattern of a newborn. Which information should the nurse provide to the client during this teaching​ session? 8-10 wet diapers per day by the end of the first week 6-8 wet diapers per day by the end of the first week 4-6 wet diapers per day by the end of the first week 2-4 wet diapers per day by the end of the first week

6-8 wet diapers per day by the end of the first week

A newborn weighs 7 lb​ (3.17 kg) at birth. At 2 weeks of​ age, the newborn has returned to the original birth weight. What is the expected weight for this​ formula-fed infant at 4 weeks of​ age? 7 lb 7 oz​ (3.37 kg) 8 lb 14 oz​ (4.02 kg) 8 lb 7 oz​ (3.82 kg) 7 lb 14 oz​ (3.57 kg)

7 lb 14 oz​ (3.57 kg)

The attending health care provider enters Mrs. Turners room to evaluate her. He looks at the fetal monitor and evaluates her​ chux, which shows a very scant amount of bright red blood. He tells Mrs. Turner that he is concerned that if her bleeding continues or​ worsens, we may need to deliver your baby. He orders steroids to enhance the maturity of the babys lungs. You anticipate he will also order which additional​ interventions? Select all that apply. A complete blood count and a type and screen A breast pump for colostrum collection Intravenous access and fluids A neonatology consult Internal fetal and uterine monitors

A complete blood count and a type and screen Intravenous access and fluids A neonatology consult

The nurse is caring for a postpartum client 8 hr after a vaginal birth. On​ assessment, the nurse finds the client​'s fundus to be​ firm, but she continues to have heavy vaginal bleeding. Based on the assessment​ findings, what is causing the heavy​ bleeding? A hematoma Uterine atony A laceration Endometritis

A laceration

The nurse is discharging a postpartum client with a newborn infant. Which safety measure will the nurse ensure prior to the official discharge of the​ infant? A properly installed infant car seat A baby monitoring system Cabinet locks on all base units A dishwasher to sanitize all bottles

A properly installed infant car seat

The attending health care provider arrives to evaluate Ms. Maxwell. After performing a vaginal​ exam, she states that Ms. Maxwell is 6 centimeters​ dilated, 100%​ effaced, and 0 station. The health care provider requests an amnihook and performs artificial rupture of membranes. The amniotic fluid is dark green and bloody. She inserts an intrauterine pressure catheter to monitor contractions and resting​ tone, and an internal scalp electrode to permit more detailed evaluation of the fetal heart rate.Based on your​ experience, you expect the health care provider will order which labs for Ms.​ Maxwell? Select all that apply. A urine toxicology screen A complete blood count A biophysical profile Liver enzymes A group B beta strep​ (GBS) culture

A urine toxicology screen A complete blood count Liver enzymes

An infant of a diabetic mother (IDM) is admitted to the newborn nursery. Which nursing intervention has highest priority at this time? Clean the umbilical cord Administer vitamin K (AquaMEPHYTON) intramuscularly Complete a gestational age assessment Assess the infant's blood glucose level

Assess the infant's blood glucose level

You are working as a labor and delivery nurse in a downtown tertiary care hospital. The emergency department​(ED) calls to alert you to an incoming ambulance. The ambulance was called to a homeless shelter after a pregnant resident reported having heavy vaginal bleeding. The ambulance crew arrives to labor and delivery pushing a gurney. On the gurney is​ 23-year-old Jaycee Maxwell. The emergency medical technician​ (EMT) tells you that Ms. Maxwell told them she is pregnant with her first baby and thinks she is due in two weeks. Per the​ EMT, Ms. Maxwell was using the restroom at the homeless shelter and cried out for​ help, reporting that she saw a large amount of blood in the toilet. Ms. Maxwells eyes are​ closed, and she is moaning. Her hands are gripping the blanket on the gurney. You explain to Ms. Maxwell that you will help the EMT crew move her from the gurney onto a labor and delivery bed. As you help move Ms. Maxwell to the​ bed, the EMT tells you her vitals are as​ follows: T 98.8​°​F, P 120​ bpm, R​32/min, BP​ 156/92 mmHg, and her Sp02 on room air is​ 97%. Ms. Maxwell has a left antecubital​ 16-gauge IV infusing normal saline at a rate of 250 ​mL/hr. As you move Ms. Maxwell to the​ bed, you note she has a small amount of dried blood on her thighs. Which nursing activities are appropriate at this​ point? Assist Ms. Maxwell to the bathroom to obtain a UA. Examine Ms. Maxwells cervix. Apply the external fetal heart rate monitor and tocodynanometer. Assist Ms. Maxwell to the bathroom to change into a gown.

Apply the external fetal heart rate monitor and tocodynanometer.

A nurse performs a cervical exam on a client with ruptured membranes and palpates a loop of umbilical cord. What is the initial nursing​ action? Preparing an amnioinfusion to try and float the cord up into the uterus Applying firm pressure on the presenting part to relieve cord compression Stopping oxytocin administration immediately Giving the mother oxygen via face mask at 15​ L/min

Applying firm pressure on the presenting part to relieve cord compression

Which action may be recommended to soften engorged breasts before​ breastfeeding? Taking a pain medication before nursing Cooling breasts with ice packs 1 hr before nursing Applying warm compresses to breasts before nursing Applying frozen cabbage leaves after nursing

Applying warm compresses to breasts before nursing

During the initial​ exam, a newborn estimated at 40 weeks gestation weighs 7 lb 8 oz​ (3,550 g). Which classification is most appropriate for this newborn based on birth weight and gestational​ age? Appropriate for gestational age Small for gestational age Large for gestational age Premature

Appropriate for gestational age

Which amount of maternal weight loss is expected immediately after​ childbirth? ​None; it generally takes 3 months to lose any pregnancy weight. Approximately 12 lb​ (5.4 kg) Approximately 20 lb​ (9 kg) The weight of her baby

Approximately 12 lb​ (5.4 kg)

"Ive never been anemic​ before, even when I was having heavy​ periods," Mrs. Abejundio tells you. "Why were my iron levels always fine then but not​ now? Shouldnt they be higher since Im not having my period right​ now?" What will you tell Mrs.​ Abejundio? Select all that apply. As a​ smoker, you have more red blood cells than nonsmokers. Pregnant women are easily​ dehydrated, which causes anemia. You are conserving iron because your periods have​ stopped, but its not enough. Your body used up most of your iron in the first trimester of pregnancy. Hemodilution causes a reduced hematocrit.

As a​ smoker, you have more red blood cells than nonsmokers. You are conserving iron because your periods have​ stopped, but its not enough. Hemodilution causes a reduced hematocrit.

Mrs. Yumihara admits that sometimes she fantasizes about not being a mother and not having a baby to take care of. She follows up this statement with more tears. This prompts you to wonder whether Mrs. Yumihara has ever considered hurting herself or her baby. When you ask​ this, Mrs. Yumihara denies having such thoughts.​However, if she had admitted to considering hurting herself or the​ baby, what is the next logical question to ask her as part of a risk​ assessment? Ask Mrs. Yumihara if she has been talking with her friends. Ask Mrs. Yumihara if she gets any ideas from television shows. Ask Mrs. Yumihara if she has a specific plan of harm. Ask Mrs. Yumihara if she also thinks about leaving her husband.

Ask Mrs. Yumihara if she has a specific plan of harm.

The nurse is providing newborn teaching to Farrah​ Aziz, a​ 32-year-old female who speaks very little English. The nurse teaches Farrah about complications the newborn may​ experience, and when Farrah should contact the health care provider. Farrah appears confused when the nurse asks whether she has questions. What should the nurse do to ensure Farrah understands the​ teaching? Repeat the​ information, speaking more slowly. Have​ Farrah's 12-year-old niece share the information. Ask for assistance from an interpreter. Speak louder to ensure that Farrah hears the information.

Ask for assistance from an interpreter.

The midwife asks the nurse to assist the laboring client with McRoberts maneuver to help with shoulder dystocia. Which nursing action is appropriate with this​ maneuver? Ask the client to abduct and flex her hips Rotate the fetal shoulder 180 degrees Apply suprapubic pressure for 5 min Apply firm pressure to the fundus until the shoulder releases

Ask the client to abduct and flex her hips

The nurse is assessing a client who delivered 3 hours ago. On completing a fundal​ assessment, the nurse notes the fundus is situated toward the left side of the client​'s abdomen. Which action is​ appropriate? Call the client​'s health care provider for direction ​Straight-catheterize the client for half the volume of urine Ask the client to empty her bladder ​Straight-catheterize the client immediately

Ask the client to empty her bladder

After​ delivery, baby​ Mai-Ling was thoroughly​ cleaned, dried,​ swaddled, and placed in a preheated warmer. Shortly​ after, the nurse helps​ Mai-Ling's mother with breastfeeding techniques for​ Mai-Ling. The nurse notes that​ Mai-Ling is not feeding well and is displaying tremors. Which assessment is appropriate to conduct on​ Mai-Ling at this​ time? Assess for hyperthermia Assess for urinary retention Assess for meconium stool Assess for hypoglycemia

Assess for hypoglycemia

The nurse is caring for a preterm infant with an endotracheal tube who is receiving nutritional support through a central line. What actions should the nurse take to reduce this infant​'s risk of developing an​ infection? Select all that​ apply. Assess heart rate Perform hand hygiene before and after providing care Monitor respiratory rate Secure central line infusion with tape Suction every 2 hr

Assess heart rate Perform hand hygiene before and after providing care Monitor respiratory rate

The charge nurse has searched the computer system and located an ultrasound performed on Ms. Maxwell at the ED of another hospital in the same system. Which ultrasound reports would prompt you to check her​ cervix? Select all that apply. A​ 20-week ultrasound showing a​ low-lying placenta that gives a current EGA of 29 wks. An​ 8-week ultrasound showing an intrauterine pregnancy and left ovarian corpus luteum that gives a current estimated gestational age​ (EGA) of 36 wks. A​ 24-week ultrasound showing a fundal placenta that gives Ms. Maxwells fetus a current EGA of 41 weeks. A​ 36-week ultrasound showing a breech presentation and a​ low-lying placenta with the edge 4 cm from the cervical os. None of the above ultrasounds would make you feel comfortable checking her cervix at this time.

A​ 24-week ultrasound showing a fundal placenta that gives Ms. Maxwells fetus a current EGA of 41 weeks. A​ 36-week ultrasound showing a breech presentation and a​ low-lying placenta with the edge 4 cm from the cervical os.

The nursery nurse has just received the morning report. Which newborn will the nurse consider the priority​ assessment? A​ 3-hr-old newborn with nasal flaring and​ grunting, respirations of 60 A​ 3-hr-old newborn who is sleeping with heart rate of​ 130, respirations​ 40, with periods of apnea lasting 5-8 s A​ 5-hr-old newborn awake with heart rate of 140​ beats/min, temperature 98.8 degrees ​F, respirations of 50 and irregular A​ 6-hr-old newborn who has a positive startle​ reflex; respirations of 44 and irregular

A​ 3-hr-old newborn with nasal flaring and​ grunting, respirations of 60

The nurse is reviewing the status of clients on the​ mother-baby unit for the evening shift and notes that several clients have not been out of bed since giving birth. Which client would be a priority for the nurse to assist with​ ambulation? A​ 31-year-old status post-vaginal birth 2 hr ago with a prepregnant BMI not calculated in the prenatal record A​ 25-year-old 18 hr status postcesarean with a prepregnant BMI of 18 An​ 18-year-old 4 hr status post-vaginal birth with a prepregnant BMI of 22. A​ 38-year-old 24 hr status postcesarean client with a prepregnant body mass index​ (BMI) of 33.

A​ 38-year-old 24 hr status postcesarean client with a prepregnant body mass index​ (BMI) of 33.

A new father shares his concern regarding how the baby will bond with him. He​ states, "I read in the baby book that feeding time is the best time to bond with your baby. My wife is breastfeeding our​ baby, so how can I bond with our​ son?" Which other ways of connecting and strengthening the father​'s relationship with his son can the nurse teach the​ father?​ Select all that​ apply. Bathing the baby Holding and talking to his son Watching over him as he sleeps in the crib Changing the baby​'s diaper Talking to his wife while she is breastfeeding the baby

Bathing the baby Holding and talking to his son Changing the baby​'s diaper

An infant is born after an uneventful labor with Apgar scores of 5 and 6. Within 10 min of birth the infant has no respirations and is centrally cyanotic. What is the nurse​'s initial​ action? Repeat the Apgar test again in 10 min Assess vital signs Administer a glucose feeding Begin neonatal resuscitation

Begin neonatal resuscitation

A pregnant client asks the nurse when the one hour​ post-prandial glucola test will be performed to screen for gestational diabetes. The nurse responds that this test is usually done at how many weeks​ gestation? Between 16 and 20 Between 24 and 28 Between 20 and 24 Between 12 and 16

Between 24 and 28

Which measurement is appropriate for the nurse to use to determine whether the cervix is favorable for​ induction? Bishop Score Apgar score Fetal heart rate Premature rupture of the membranes​ (PROM)

Bishop Score

Which gastrointestinal or genitourinary changes develop in the postnatal recovery​ period? Select all that​ apply. Diarrhea Bladder distention Constipation Diuresis Hemorrhoids

Bladder distention Constipation Diuresis

The cervix of a client in active labor who received epidural anesthesia 4 hr ago is now completely​ dilated, and the client is ready to begin pushing. Before the client begins to​ push, what would the nurse​ assess? Fetal heart rate variability Cervical dilation again Status of membranes Bladder status

Bladder status

A​ 25-year-old first-time mother is admitted to the labor room. She is 3 cm dilated and​ 80% effaced, and the head is at 0 station. Contractions occur every 10​ min, lasting 20-30 s. Membranes are intact. Admitting vital signs are blood pressure​ 112/70, pulse 80​ bpm, respirations​ 16, temperature 98.8​°​F, and fetal heart rate 148. What should the nurse​ monitor? ​Temperature, blood​ pressure, and contractions every 4 hr and fetal heart rate hourly ​Contractions, blood​ pressure, and fetal heart rate every 15 min ​Contractions, effacement and dilation of​ cervix, and fetal heart rate every hour Blood pressure hourly and contractions and fetal heart rate every 30-60 min

Blood pressure hourly and contractions and fetal heart rate every 30-60 min

The nurse is assisting with the administration of an epidural to a laboring client. The nurse ensures that which intervention is included after the​ procedure? Placing client in prone position Suctioning Increasing intravenous fluids Blood pressure monitoring

Blood pressure monitoring

Which premonitory signs may occur before the onset of​ labor? Select all that​ apply. Bloody show Nesting Loss of cervical mucus plug Braxton Hicks contractions Lightening

Bloody show Nesting Loss of cervical mucus plug Braxton Hicks contractions Lightening

What does the nurse assess before transitioning the newborn from a radiant warmer to an open​ crib? Body temperature First feeding Body weight Oral secretions

Body temperature

The nurse is determining the effectiveness of care provided to a​ 10-day-old preterm infant. Which measurement indicates that nutritional support has been​ effective? Body weight changed from 2600 g to 2700 g between days 5 and 10 Body weight changed from 2200 g birth weight to 1760 g on day 10 Body weight changed from 2200 g birth weight to 1810 g on day 10 Body weight changed from 2600 g to 2500 g between days 5 and 10

Body weight changed from 2600 g to 2700 g between days 5 and 10

What is commonly seen in newborns who experience shoulder dystocia during​ delivery? Hydrocephalus Brachial plexus injury Ankle fracture Delayed growth

Brachial plexus injury

The nurse is providing care to a client diagnosed with mastitis. Which teaching topic is the priority for this​ client? Pump from both breasts and discard the milk. Stop breastfeeding totally to allow the infection to heal. Breastfeed from both breasts. Nurse the infant only from the uninvolved breast.

Breastfeed from both breasts.

The nurse is preparing information for a breastfeeding class. What information is appropriate for the nurse to include in the teaching session regarding maternal nutrition during​ breastfeeding? Select all that​ apply. Breastfeeding women should consume 8-10 ​8-oz glasses of fluid daily. A poor diet can decrease milk supply. Breastfeeding women should increase their protein intake. Calcium intake should be decreased while breastfeeding. Breastfeeding women should increase their caloric intake by 150 kcal daily

Breastfeeding women should consume 8-10 ​8-oz glasses of fluid daily. A poor diet can decrease milk supply. Breastfeeding women should increase their protein intake. Breastfeeding women should increase their caloric intake by 150 kcal daily

The nurse is preparing information for a breastfeeding class. Which information should the nurse include regarding maternal nutrition during​ breastfeeding? Select all that​ apply. Calcium intake should be decreased while breastfeeding. Breastfeeding women should increase their caloric intake by 200 kcal daily. Breastfeeding women should increase their protein intake. A poor diet can decrease milk supply. Breastfeeding women should consume 8-10 ​(8 oz) glasses of fluid daily.

Breastfeeding women should increase their protein intake. A poor diet can decrease milk supply. Breastfeeding women should consume 8-10 ​(8 oz) glasses of fluid daily.

What​ long-term complication can occur in a preterm infant being mechanically ventilated with high oxygen​concentrations? Bronchopulmonary dysplasia Chronic bronchitis Pulmonary hypertension Pulmonary hypertension

Bronchopulmonary dysplasia

Before Ms. Burberry leaves the clinic after her​ examination, what will you include in her client​ education? Select all that apply. Call if she experiences an increase in urinary frequency or begins to run a fever. Call if contractions are regular and 10 minutes apart or closer. False labor pains can be relieved by resting on your​ side, taking a warm​ bath, or walking. Call if she has pelvic pain or bleeding. Decrease fluid intake in the last weeks of pregnancy to help with edema.

Call if she experiences an increase in urinary frequency or begins to run a fever. Call if contractions are regular and 10 minutes apart or closer. False labor pains can be relieved by resting on your​ side, taking a warm​ bath, or walking. Call if she has pelvic pain or bleeding.

A nurse is caring for a couple whose infant has died from sudden infant death syndrome​ (SIDS). Which nursing interventions are appropriate for the nurse to​ implement? Select all that​ apply. Calling the parents​' church leader after a request from the parents. Calling the hospital chaplain and requesting his presence immediately. Offering to contact a grief counselor to help the parents Calling the police to begin the death investigation. Offering to contact the parents​' other children to discuss the infant​'s death.

Calling the parents​' church leader after a request from the parents. Offering to contact a grief counselor to help the parents

Other than the vomiting​ episode, you ask Dr. Rui if she has noted any other symptoms of illness. She tells you that she has noticed a​ yellow, cheese-like discharge from her vagina. "It doesn​'t ​smell," she​ adds, "but the whole area is very itchy." Based on her​ description, what condition do you suspect she​ has? E. Coli vaginitis Vaginismus Candida albicans vaginitis Vestibulitis

Candida albicans vaginitis

Which of the following must be ruled out before labor may be augmented with an amniotomy or​ oxytocin? Cephalopelvic disproportion ​Full-term pregnancy status Vertex positioning of the fetus Twin gestation

Cephalopelvic disproportion

A pregnant client is admitted to the hospital in premature labor. The nurse anticipates which of the following assessment​ findings? Headache Decreased fetal movement Cervical dilation Elevated blood pressure

Cervical dilation

The nurse is assessing the power of the uterine muscle during the labor process. The nurse can expect to assess which changes as a result of this​ process? Cervical effacement Cervical lengthening A slowing of uterine contractions An increase in maternal blood pressure

Cervical effacement

The healthcare provider of a client at 40 weeks​' gestation has ordered Cytotec for labor induction. The nurse is aware that Cytotec will produce which change for this​ client? Rupture membranes Cervical ripening Decrease anxiety Decrease pain

Cervical ripening

You prepare to assess Mrs. Burberrys cervix. What measurement of the cervix at 32 weeks would be a concern for possible preterm labor and​delivery? Cervix is firm and a fingertip dilated. Cervix is less than 1 at 32 weeks and intact. Cervix is softening at 32 weeks but not dilated. Cervix is greater than 1 cm at 32 weeks with softening.

Cervix is greater than 1 cm at 32 weeks with softening.

The nurse is caring for a postpartum client. Which factors may interfere with the​ client's ability to​ breastfeed? Select all that​ apply. Twin infants Cesarean birth Postpartum hemorrhage Smoking Alcohol use

Cesarean birth Postpartum hemorrhage Smoking Alcohol use

The nurse is interviewing a mother who has concerns about her​ infant's nutrition status. What should the nurse include in the infant​'s nutritional​ assessment? Select all that​ apply. Chest circumference Allergy testing Physical examination ​24-hr feeding diary Height and weight

Chest circumference Physical examination ​24-hr feeding diary Height and weight

Which data would be considered normal during an initial nursing assessment of a term​ newborn? Chest circumference 38​ cm, head circumference 31.5 cm Chest circumference 32.5​ cm, head circumference 36 cm Chest circumference 31.5​ cm, head circumference 33.5 cm Chest circumference 30​ cm, head circumference 29 cm

Chest circumference 31.5​ cm, head circumference 33.5 cm

The nurse evaluates the diet of a pregnant client and finds that it is low in zinc. The nurse knows that zinc intake should increase during pregnancy to promote protein metabolism. Which food does the nurse suggest to the client to increase her intake of​ zinc? Bananas Cabbage Yogurt Chicken

Chicken

The nurse is preparing a checklist of educational topics for discharge teaching of new parents. Which topics will the nurse​ include? Select all that​ apply. Maintaining a strict feeding schedule Circumcision care Skin and bathing care Infant swaddling How to use a bulb syringe

Circumcision care Skin and bathing care Infant swaddling How to use a bulb syringe

The nurse is assisting a postpartum client in the bathroom. What teaching would the nurse use to help promote hygiene and​ comfort? Cleansing the vulva and perineum with a spray bottle of warm water after voiding Wiping from back to front to prevent urinary tract infection Explaining to only do a sitz bath once home to ensure privacy Wiping with toilet paper instead of patting to ensure cleanliness

Cleansing the vulva and perineum with a spray bottle of warm water after voiding

The nurse reviews a postpartum client​'s chart and notes the client may have Percocet for pain. The nurse will monitor for which complication of the​ medicine? Increased respirations Constipation Frequent urination Dry mouth

Constipation

During the fourth stage of​ labor, the​ client's assessment includes BP​ 110/60 mmHg and P 90 bpm. The fundus is firm and​ midline, and halfway between the symphysis pubis and the umbilicus. What should be the nurse​'s priority​ action? Continue to monitor Turn the client onto her left side Massage the uterine fundus Place the bed in Trendelenburg position

Continue to monitor

The nurse is working with a student nurse during assessment of a​ 2-hr-old healthy newborn. Which action of the student nurse demonstrates an understanding of the neonatal​ assessment? Listens to lung sounds when the newborn is crying Stimulates the newborn so the newborn will be alert for the assessment Counts respirations and apical heart rate for 1 full minute Obtains a blood pressure first

Counts respirations and apical heart rate for 1 full minute

A client who was admitted for induction of labor is now exhibiting a hypertonic contraction pattern. Which is an appropriate nursing​ intervention? Have the client ambulate in the hall. Decrease oxytocin and notify the healthcare provider. Ask the client to begin pushing and bear down. Assist the client to the restroom to void.

Decrease oxytocin and notify the healthcare provider.

Four hours after a vaginal​ delivery, the nurse is assisting a primiparous​ client, who had an epidural​ anesthesia, to the bathroom to void. The client states that she feels dizzy when sitting up on the side of the bed. Which rationale will the nurse use when explaining this phenomenon to the​ client? Decreased blood volume in the vascular system Effects of the anesthetic during labor Hemorrhage during the delivery process Effects of analgesics used during labor

Decreased blood volume in the vascular system

The nurse assesses excessive oral and nasal secretions in a newborn and begins suctioning. Which complication of mechanical suctioning will the nurse monitor​ for? Decreased heart rate Increased temperature Decreased level of consciousness Increased blood pressure

Decreased heart rate

A client has just completed the second stage of labor. Which are the priority nursing assessments before placental​ delivery? Select all that​ apply. Assessment indicating that the umbilical cord is shortening Documenting a gush of blood from the vagina Assessing the shape of the uterus as it changes from a disk shape to a globe Assessment indicating that the top of the uterus is dropping down to the level of the symphysis pubis Assessing that the umbilical cord is lengthening

Documenting a gush of blood from the vagina Assessing the shape of the uterus as it changes from a disk shape to a globe Assessing that the umbilical cord is lengthening

The student nurse is creating a poster that describes the changes from fetal to neonatal circulatory patterns. Which structures will the student nurse indicate are no longer required for neonatal​ circulation? Select all that​ apply. Ductus arteriosus Foramen ovale The ductus venosus Umbilical vein Umbilical artery

Ductus arteriosus Foramen ovale The ductus venosus

When does maternal-infant bonding​ occur? During the mother​'s pregnancy When an infant first makes eye contact with his mother During the first 30-60 min after birth During a process called "finger tipping"

During the first 30-60 min after birth

Which characteristics does the nurse anticipate when assessing a newborn infant born at 33 weeks​ gestation? Full sole​ creases, nails extending beyond​ fingertips, scarf sign shows elbow beyond the midline Testes located deep in the​ scrotum, rugae cover the​ scrotum, vernix covering the entire body ​One-centimeter breast​ bud, peeling skin and veins not​ visible, rapid recoil of legs and arms to extension Ear cartilage remains folded​ over, lanugo present over much of the​ body, some flexion of arms and legs at rest

Ear cartilage remains folded​ over, lanugo present over much of the​ body, some flexion of arms and legs at rest

A client who is 6 hr status post a precipitous vaginal birth of an 8 lb 14 oz. baby has pressed the call bell to report severe and worsening perineal pain and pressure. What will the nurse look for when assessing this​ client? Select all that​ apply. Ecchymosis Nausea Visible outline of a mass on the perineum Fever Tachycardia

Ecchymosis Visible outline of a mass on the perineum Tachycardia

The nurse is planning a teaching session on nutrition for a pregnant client. The nurse knows that several factors will influence the client​'s acceptance of nutritional intervention. Which factors would be most important for the nurse to consider when preparing her teaching​ information? Lifestyle and marital status Age and political affiliation Economics and culture Culture and geographic location

Economics and culture

What actions support the​ nurse's plan of care for the goal of preventing​ SIDS? (Select all that​ apply.) Educating about reducing risk factors for SIDS Providing support for smoking cessation Promoting a safe sleep environment Encouraging the use of formula Collaborating with family to create goals

Educating about reducing risk factors for SIDS Providing support for smoking cessation Promoting a safe sleep environment Collaborating with family to create goals

​Alicia, a term​ infant, was born 30 min ago by cesarean section because of congenital diaphragmatic hernia diagnosed during pregnancy. Alicia is experiencing profound respiratory​ distress, persistent pulmonary​ hypertension, and cyanosis. Which action by the nurse can optimize​ Alicia's lung​ function? Elevate the head and chest on the affected side Elevate the feet on the affected side Place an orogastric tube to full suction Administer​ surfactant, per order

Elevate the head and chest on the affected side

During the fourth stage of​ labor, what can the nurse do to help the mother avoid bladder​ distention? Palpate her fundus. Encourage her to void every 2 hours. Pour cold water over the perineum. Encourage her to get out of bed as soon as possible.

Encourage her to void every 2 hours.

Mrs.​ Lee, a healthy​ 24-year-old G1​ P1, had an uncomplicated vaginal birth 24 hours ago. The nurse palpates her uterine fundus and finds that it is located above her umbilicus. Which action is the most appropriate for the nurse to​ do? Massage it until it softens. Encourage her to void. Do nothing. The uterus is exactly where it should be. Encourage her to walk so that her fundus descends deeper into her pelvis.

Encourage her to void.

Mrs. Yumihara begins to believe that there is something wrong with her. You assure her that many other women suffer from postpartum​ depression, and that many of those women have overcome it. Mrs. Yumihara informs you that she feels disappointed about the fact that nobody warned her that this sort of thing could happen after pregnancy. Although she knows that it has to do with hormonal​ imbalances, she asks you if there are ways to prevent postpartum depression. How might postpartum depression be​ prevented? Select all that apply. Encouraging the client to talk about her anxieties or concerns regarding the​ pregnancy, prior to childbirth. Dispelling myths about perfect motherhood and maternal instincts. Close monitoring for signs and symptoms of depression. Providing client education about PPD during pregnancy. Sending the client home early from the hospital with the baby.

Encouraging the client to talk about her anxieties or concerns regarding the​ pregnancy, prior to childbirth. Dispelling myths about perfect motherhood and maternal instincts. Close monitoring for signs and symptoms of depression. Providing client education about PPD during pregnancy.

Which actions related to contraception would the nurse include in discharge planning for a postpartum​ client? Select all that​ apply. Ensure the client receives a prescription for the contraception method of her choice. Recommend a contraception method for the client. Assess the client​'s contraception preference. Provide information about the client​'s choices. Answer questions from the client about contraceptive methods.

Ensure the client receives a prescription for the contraception method of her choice. Assess the client​'s contraception preference. Provide information about the client​'s choices. Answer questions from the client about contraceptive methods.

Which is the correct definition of a puerperal​ infection? Fever of 100.5​°F or higher within the first 10 days after childbirth Fever of 104​°F or higher within the first 10 days after childbirth Fever higher than 99​°F occurring within the first 48-72 hr after childbirth Fever of 100.4​°F or higher occurring during the first 48 hr after childbirth

Fever of 100.5​°F or higher within the first 10 days after childbirth

While doing a presentation to new graduate nurses who will be working in the newborn​ nursery, the instructor discusses ways to prevent hypothermia in the newborn. Which techniques should the instructor​ include? Select all that​ apply. Establishing kangaroo care between the newborn and the parents Preheating warmers and blankets before use Applying an insulated cap when placing the newborn in an open crib Putting lotion on newborn while under radiant warmer Placing a shirt on newborn under radiant warmer

Establishing kangaroo care between the newborn and the parents Preheating warmers and blankets before use Applying an insulated cap when placing the newborn in an open crib

During the latent and active phases of​ labor, how often in general should maternal vital​ signs, excluding​ temperature, be assessed for​ low-risk women? Every 4 hr Every 60 min Every 15 min Every 2 hr

Every 60 min

Which are the metabolic functions of the​ placenta? Select all that​ apply. Excretion Fetal gas exchange Nutrition Red blood cell production Hormone production

Excretion Fetal gas exchange Nutrition

A laboring client at term is experiencing a prolonged second stage of labor. She has made no progress for more than 2 hours. The fetal scalp is visible between contractions. The client​ says, "I just can​'t push any​ longer, please help ​me!" The nurse notifies the healthcare provider and anticipates the need to perform which​ action? Provide perineal hygiene Provide emotional support Expect an​ instrument-assisted delivery Encourage the client to empty her bladder

Expect an​ instrument-assisted delivery

Sheila Barton had a cesarean birth 24 hr ago. She has not gotten out of bed and reports she is still exhausted. How can the nurse provide the best care for Mrs. Barton in this​ situation? Explain how important it is for her to get up and walk as soon as possible. Explain that she needs to rest and she should stay in bed as long as she can. Offer her more pain medication to relieve her discomfort. Offer her a large meal to improve her energy.

Explain how important it is for her to get up and walk as soon as possible.

The nurse is assessing a pregnant​ client, Joy​ Stevens, who has come to the clinic for her​ 20-week prenatal checkup. Ms. Stevens has gained more than 30 lb.​ (13.6 kg) over her prepregnancy weight. The nurse takes a​ 24-hour diet recall history and learns that Ms. Stevens has eaten a doughnut for​ breakfast, a slice of pizza for​ lunch, and a hamburger with French fries for dinner. What recommendations does the nurse make to Ms. Stevens about her​ nutrition? There is no recommendation to be made because nutrition counseling is not the​ nurse's responsibility. Explain that she should focus on eating healthier​ foods, including fruits and vegetables. Tell her to go on a diet. Tell her she needs to exercise more since her food intake does not seem like too much.

Explain that she should focus on eating healthier​ foods, including fruits and vegetables.

Jasmine Williams complains of severe constipation at her regular prenatal visit. The nurse takes a nutritional​ history, and Ms. Williams divulges that she has been eating clay. What is the​ nurse's most appropriate​ response? Prescribe a laxative. Tell Ms. Williams eating clay is disgusting and she should stop. Refer Ms. Williams to a mental health professional. Explain the health effects pica can have on Ms. Williams and her baby.

Explain the health effects pica can have on Ms. Williams and her baby.

Mrs. Meyers has just received a positive pregnancy test. The nurse notices that she smells like cigarettes even though she noted in her paperwork she is not a smoker. The nurse asks her again if she​ smokes, and she confesses she smokes less than half a pack a day. What type of information can the nurse provide to​ her? Tell her it is okay as long as she is not smoking more than 10 cigarettes a day. Tell her she should not be pregnant if she is a smoker. Refer her to a​ 12-step rehabilitation program. Explain to her the negative effects that cigarettes could have on her pregnancy and refer her to a smoking cessation program.

Explain to her the negative effects that cigarettes could have on her pregnancy and refer her to a smoking cessation program.

Ms. Burberry confirms her understanding that she needs to stay​ hydrated, then​ asks, Can you also tell me how can I tell the difference between a real contraction versus a false ​contraction?​ What difference in the quality of false labor contractions versus true labor contractions will you share with Ms.​ Burberry? True labor will not start before 38 weeks gestation. False contractions gradually get more intense. False contractions do not change vaginal discharge. True labor pains can be relieved with walking or a warm bath.

False contractions do not change vaginal discharge.

The nurse is providing education to parents who have chosen to​ formula-feed their infant. What topics are appropriate to​ include? Select all that​ apply. Feeding the infant safely Stressing that milk allergies may occur Storing formula properly Introducing solids at the appropriate age Reading preparation directions on formula packaging

Feeding the infant safely Storing formula properly Reading preparation directions on formula packaging Introducing solids at the appropriate age

Labor induction is indicated in which maternal or fetal​ conditions? Select all that​ apply. Transverse fetal lie Fetal compromise Infection Unfavorable cervix Preeclampsia

Fetal compromise Infection Preeclampsia

The nurse is caring for a client who is scheduled for induction of labor. Which conditions are indications for​ induction? Select all that​ apply. Preterm labor Fetal demise Preeclampsia ​Post-term gestation Multiple gestation

Fetal demise Preeclampsia ​Post-term gestation

Which description best describes the orientation of the long axis of the​ fetus? Fetal attitude Fetal position Fetal presentation Fetal lie

Fetal lie

Which information will be a part of the admission assessment for a client in the first stage of​ labor? Select all that​ apply. Fetal status Status of the amniotic membranes Status of the nuchal cord Degree of cervical dilation and effacement ​Onset, frequency, and intensity of contractions

Fetal status Status of the amniotic membranes Degree of cervical dilation and effacement ​Onset, frequency, and intensity of contractions

The nurse is assessing baby boy​ Henry, who is 2 hr old. She notes that Henry​'s plantar creases cover his entire foot. Based on this​ information, what does the nurse determine Henry​'s gestational age to ​be? 32 weeks Preterm 36 weeks Full term

Full term

The charge nurse hands you an ultrasound that Ms. Maxwell had at 36 weeks showing a​ low-lying placenta with the edge 4 cm from the cervical os. The fetus was noted to be breech on that ultrasound. By this​ ultrasound, Ms. Maxwell is currently 38 weeks gestation. You check Ms. Maxwell's vital signs and obtain the following​ results: T 98.6​°​F, P 114​ bpm, R​ 23/min, BP​ 160/92 mmHg, and her SpO2 on room air is​ 96%. The electronic fetal monitor shows the​ following: Uterine contractions every two​ minutes, lasting for 60-75 seconds. Fetal heart rate 170​ bpm, minimal long term ​variability, deceleration to 140 bpm noted between contractions. You prepare an oxygen mask at 10 L and ask Ms. Maxwell to put it on. Ms. Maxwell is clearly uncomfortable with contraction​ pain, but she manages to​ ask, 'Why is something ​wrong?"​ What will you tell Ms.​ Maxwell? She needs oxygen because her SpO2 is too low. Her baby has fetal​ bradycardia, an indication her baby needs more oxygen. All pregnant women need supplemental oxygen. Her baby has fetal​ tachycardia, an indication her baby needs more oxygen.

Her baby has fetal​ tachycardia, an indication her baby needs more oxygen.

Maria Abejundio a​ 24-year-old gravida 2 para 1 who presents to the midwifery clinic for a prenatal visit at 30 weeks gestation. Her ethnic background is​ Mexican-American. She is accompanied by her​ 14-month-old son and her husband Michael​ Abejundio, who is African American. Her pregnancy has been complicated by a marginal placenta previa. Mrs. Abejundio is a​ smoker, but she has cut down her use from 1 pack per day to a half a pack per day. She denies having any vaginal bleeding or contractions. "How are you​ feeling?" you ask Mrs. Abejundio. "Im pretty​ tired," she replies, "I spend so much time chasing my son​ around, but I do try to nap when he naps."​ You assess Mrs. Abejundios vital​ signs: T 98.8​°​F, P 83​ bpm, R​ 16/min, BP​ 116/68 mmHg. Her Sp02 on room air is​ 97%. The attending health care provider orders a complete blood count and a​ one-hour 50-gram glucola challenge test drawn for her third trimester labwork. The results of Mrs. Abejundios laboratory results​ indicate: Hematocrit 30%; Hemoglobin 10​ g/dL; Platelets 142,000 ​×​ 103/​µl; One hour glucose tolerance test 126. You review her labs from her first prenatal​ visit; her blood type is​ AB+. Which of these results indicates a possible source of Mrs. Abejundios​ fatigue? Select all that apply. Her hematocrit level Her platelet count Her one hour glucose test Blood type​ AB+ Her hemoglobin level

Her hematocrit level Her hemoglobin level

You assist Mrs. Romero into a comfortable​ side-lying position, and she successfully breastfeeds her baby. After 15​ minutes, you obtain Mrs. Romeros permission to take a set of vital signs and check her fundus.Her vital signs are T 99.8​°​F, P 126​ bpm, R​ 20/min, and BP​ 100/58 mmHg. Her fundus is not immediately​ palpable, but as you massage her lower​ abdomen, you feel it become firm although it deviates to the right side. You note a moderate amount of lochia rubra on the chux. Which assessment findings give you cause for​ concern? Select all that apply. Her pulse is increasing. Her uterus deviates to the right side. Mrs. Romero should have lochia alba. The uterine fundus firms with massage. Her temperature indicates pyelonephritis.

Her pulse is increasing. Her uterus deviates to the right side.

The nurse in the special care nursery​ (SCN) is caring for a newborn diagnosed with a congenital diaphragmatic hernia​ (CDH). Based on the​ diagnosis, in which position will the nurse place this​ infant? ​Side-lying on the unaffected side Supine High Fowler on the affected side Prone

High Fowler on the affected side

Ms. Burberry​ asks, What are some things that can put me at risk for having this baby too​ early? Maybe if I can understand this​ better, I can prevent this from happening to me again.​ What risk factors will you discuss with Ms.​ Burberry? Select all that apply. History of an early pregnancy loss History of previous preterm labor or birth Premature rupture of membranes​ (PROM) Multiple gestations Inadequate prenatal care

History of previous preterm labor or birth Premature rupture of membranes​ (PROM) Multiple gestations Inadequate prenatal care

What information does the nurse provide to new parents during discharge​ teaching? ​(Select all that​ apply.) Promoting toddler safety Holding the newborn Diaper changing Positioning the infant on its back to sleep Using a bulb syringe

Holding the newborn Diaper changing Positioning the infant on its back to sleep Using a bulb syringe

You give Dr. Rui three glucose tablets. While you wait 15 minutes to check on the effect of the​ tablets, you take her vital signs. What do you expect to​ find, based on her being​ hypoglycemic? Elevated temperature Slowed respiratory rate Hypertension Hypotension Rapid pulse

Hypotension Rapid pulse

You are reviewing the teaching you have provided with Mr. and Mrs. Abejundio. Which statement by Mrs. Abejundio indicates she understands your​ teaching? I can take my iron pills with cranberry juice. I can stop taking the iron pills when I have more energy. If my stool turns​ black, I should stop taking my iron pills. The iron pills will fix my anemia right away.

I can take my iron pills with cranberry juice.

You explain Mrs. Abejundios blood results to her and her husband. "Maybe that's why youve been so​ tired," Mr. Abejundio says. "I keep telling you to rest more." He gives her a hug. "You say my blood work shows that I have anemia. How will that affect me during my​ pregnancy?" Mrs. Abejundio asks. You explain the effect of iron deficiency anemia on pregnancy and birth.You know Mrs. Abejundio understands the risks posed to her pregnancy when she makes which​ statements? Select all that apply. I could bleed too much when I give birth. I will tire more easily. I am more susceptible to infection. I will gain too much weight with my pregnancy.

I could bleed too much when I give birth. I will tire more easily. I am more susceptible to infection.

A postpartum client tells the nurse that she would like to know about a birth control method she can start before discharge. What is an appropriate response from the​ nurse? ​"You may be able to have a birth control injection before​ discharge." ​"Why don​'t you ask the doctor. She will be here​ soon." ​"You should take the pills. They work the​ best." ​"You will need to wait 6 weeks before starting any​ method."

Local​ tenderness, heat, and swelling in the leg

What are the chief discomforts a woman may experience during the initial postpartum​ period? Select all that​ apply. Severe cramping Nipples bleeding from nursing Perineal discomfort Hunger Exhaustion

Perineal discomfort Hunger Exhaustion

Mrs. Yumihara is reluctant to answer your​ questions, but she does her best and provides you with a​ well-informed assessment. You learn that Mrs. Yumihara used to battle with depression when she was in her​ twenties, but that she never took any medications for​ it, given her cultural background. She​ explains, the depression passed on its own.​ Knowing​ this, you find it necessary to screen Mrs. Yumihara for more risk factors that may contribute to the probable diagnosis of postpartum depression. Through the second part of your​screening, Mrs. Yumihara makes a lot of noticeable statements. Which of Mrs. Yumiharas statements could be interpreted as risk factors for​ PPD? Select all that apply. I wish my older son was more loving toward his baby brother. I wish I had this baby when I was younger. My body doesnt look the same as it used to. I could really use more support at home. It would be nice if I had more friends and family around to see the baby.

I wish I had this baby when I was younger. My body doesnt look the same as it used to. I could really use more support at home. It would be nice if I had more friends and family around to see the baby.

What are the signs that the placenta is about to​ deliver? Select all that​ apply. Decreased contraction pain Increased contraction pain Change in shape of the uterus from a disk to a globe Change in shape of the uterus from a globe to a disk Lengthening of the umbilical cord

Increased contraction pain Change in shape of the uterus from a disk to a globe Lengthening of the umbilical cord

The nurse caring for a​ 1-day-old preterm infant asks the parents to return to the neonatal intensive care unit because the infant is awake. Which is the most appropriate action for the nurse when the parents arrive in the​ unit? Ask the parents to complete admission assessment forms Instruct the parents on newborn care Leave the parents to hold the baby Discuss the extent of care that the infant will need while hospitalized

Instruct the parents on newborn care

A pregnant client reveals she practices pica. What is the nurse​'s primary concern about pica in caring for this​ client? Preterm labor Interference with proper nutrition Fetal death Placenta previa

Interference with proper nutrition

The nurse is caring for Baby​ Wilson, a​ 33-week-gestation preterm infant who experienced birth asphyxia. For which potential complication should the nurse plan interventions for Baby​ Wilson? Patent ductus arteriosus Anemia Intraventricular hemorrhage Hypotension

Intraventricular hemorrhage

The most recent arterial blood gas results for a preterm infant indicate the development of acidosis. For which complications should the nurse plan care for this​ infant? Select all that​ apply. Intraventricular hemorrhage Patent ductus arteriosus Anemia Gastroesophageal reflux Apnea of prematurity

Intraventricular hemorrhage Patent ductus arteriosus

Which formula preparation is appropriate for an infant with an allergy to cow​'s ​milk? Isomil Similac Good Start Gentle Plus Enfamil

Isomil

A home health nurse is visiting a client who recently delivered a​ healthy, term baby boy. The nurse is providing postpartum care and observation of the newborn. The client tells the​ nurse, "I think my son sleeps longer when he is placed on his tummy for naps." What response by the nurse is most​ correct? It is fine to place your son on his tummy for naps as long as you are in the same room with him. It is fine to place your son on his tummy for naps but not for sleep at night. It is not acceptable to place your son on his tummy for sleep because this can make your son lose his protective reflexes. It is not acceptable to place your son on his tummy for sleep because this can make your son spit up and he can aspirate.

It is not acceptable to place your son on his tummy for sleep because this can make your son lose his protective reflexes.

Why should the prenatal nurse counsel a pregnant woman to avoid eating undercooked​ meat? It would put her at risk for toxoplasmosis. It would put her at risk for mercury poisoning. It would put her at risk for Listeria monocytogenes. It would put her at risk for Salmonella poisoning.

It would put her at risk for toxoplasmosis.

The nurse is receiving the change of shift report from the night​ nurse, and one newborn she will be caring for has been determined small for gestational age​ (SGA). Which data obtained during the physical assessment supports this​ diagnosis? Select all that​ apply. No passage of meconium for 48 hr Head circumference below the 20th percentile Length below the 10th percentile Weight below the 10th percentile Difficulty feeding

Length below the 10th percentile Weight below the 10th percentile

The nurse is caring for a woman after a cesarean delivery with a low transverse incision. What are the advantages of a low transverse uterine incision versus a classical incision for a cesarean​ birth? Select all that​ apply. More appropriate for preterm births or multiple gestations Less likely to rupture with subsequent pregnancies Involves less blood loss Can extend downward into the cervix Easier to repair surgically

Less likely to rupture with subsequent pregnancies Involves less blood loss Easier to repair surgically

The nurse is caring for Sara​ Jenkins, a​ 29-year-old G2​ P0010, who is 8 cm dilated and​ 90% effaced with the fetal head at​ -2 station on direct occiput posterior position. The fetal monitor shows significant variable decelerations. The nurse performs a vaginal exam and detects a prolapsed cord. What is the​ nurse's initial​ action? Place the client in reverse Trendelenburg position. Lift the presenting part off of the prolapsed cord. Go to the​ nurses' station and call the healthcare provider. Replace the section of cord that is protruding from vagina.

Lift the presenting part off of the prolapsed cord.

The nurse is providing discharge teaching to a group of parents in the newborn nursery. What signs are included as early indicators of readiness to feed in the​ newborn? Select all that​ apply. Crying Lip smacking Extending the tongue Rooting Sucking on fingers

Lip smacking Extending the tongue Rooting Sucking on fingers

Which are characteristics of a preterm infant​'s ​skin? ​(Select all that​ apply.) Little subcutaneous fat Reddened Cyanotic Translucent Blood vessels visible

Little subcutaneous fat Reddened Translucent Blood vessels visible

While caring for a preterm​ infant, the nurse notes that the ventilator settings need to be adjusted to ensure adequate oxygenation. What should the nurse suspect is occurring with this​ infant? Bronchopulmonary dysplasia Patent ductus arteriosus Apnea of prematurity Anemia

Patent ductus arteriosus

The nurse manager determines that a staff nurse is implementing interventions to prevent infection in a​ 2-day-old preterm infant. Which actions did the nurse manager see the staff nurse​ perform? Select all that​ apply. Maintained separate equipment for the infant Changed the incubator according to planned schedule Performed​ 3-min scrub with antimicrobial soap before providing care Assessed gastric residual before providing scheduled tube feeding Repositioned the infant every hour

Maintained separate equipment for the infant Changed the incubator according to planned schedule Performed​ 3-min scrub with antimicrobial soap before providing care Repositioned the infant every hour

The nurse is developing a plan of care for an infant born at 28 weeks' gestation. What would be a realistic goal for this infant to be achieved within one week? Drinking from a bottle Recognizing the parents Maintaining respiratory rate at 30-60 breaths/minute Maintaining her body temperature in a bassinet

Maintaining respiratory rate at 30-60 breaths/minute

The nurse is caring for a​ client, Mrs.​ Lin, who is a vegetarian. Mrs. Lin is concerned that she is not eating well enough to support her growing baby. How should the nurse counsel Mrs.​ Lin? Nutritional counseling is not a part of the​ nurse's responsibilities. Make her aware of alternative sources of​ protein, and recommend she increase her calcium intake by 300 mg. Reassure her that vegetarians who are pregnant get all the nutrition they need. Tell her she has to eat meat while she is​ pregnant, and take an iron supplement.

Make her aware of alternative sources of​ protein, and recommend she increase her calcium intake by 300 mg.

What risk factors put an otherwise healthy infant at risk for the development of​ SIDS? (Select all that​ apply.) Male infants Exposure to smoke Family history of SIDS ​High-birth-weight infants ​Co-sleeping infants

Male infants Exposure to smoke Family history of SIDS ​Co-sleeping infants

The nurse is caring for an infant diagnosed with gastroschisis. The parents ask the nurse how this condition occurs. The nurse will base the response on which risk factors associated with this​ anomaly? Select all that​ apply. Malrotation of the intestine Meconium ileus Decreased abdominal capacity Enlarged stomach Intestinal atresia

Malrotation of the intestine Decreased abdominal capacity Intestinal atresia

A mother who gave birth to a baby boy vaginally after Pitocin augmentation 2 weeks ago returns to the office concerned because her lochia flow has​ increased; it is red but not​ foul-smelling. The nurse suspects subinvolution. Which items in the client​'s history may have caused this​ occurrence? Hypertension Manual removal of the placenta Placenta previa Vaginal delivery

Manual removal of the placenta

You inform Mrs. Yumihara that it appears as though she is suffering from postpartum depression. She becomes tearful​ again, and tells you that she wants to feel happy and enjoy the baby stage. Mrs. Yumihara appears to be very anxious upon hearing this diagnosis. What can you tell her to help put the postpartum depression in​perspective? Every woman gets postpartum​ depression, especially after having two children. Many women experience postpartum depression due to hormones. Postpartum depression only lasts for a couple of days. Postpartum depression is nothing to worry about.

Many women experience postpartum depression due to hormones.

The nurse is assessing a postpartum client and finds the client​'s uterus to be boggy. Which nursing action is the​ priority? Administer oxytocin Notify the health care provider Massage the fundus until firm No action​ needed; a soft uterus is a normal assessment

Massage the fundus until firm

The nurse is assessing a postpartum client and finds the client​'s uterus to be boggy. Which intervention would be the most appropriate nursing​ action? Administer oxytocin. No action​ needed, as this is a normal assessment. Massage the fundus until firm. Notify the healthcare provider.

Massage the fundus until firm.

In assessing a client who delivered 2 hours​ ago, the nurse notices heavy bleeding with large clots. Which initial response is most​ appropriate? Massaging the fundus firmly Preforming bimanual compressions Notifying the health care provider Administering uterotonic medications

Massaging the fundus firmly

Which are factors that may classify a newborn as high​ risk? ​(Select all that​ apply.) Maternal age of more than 30 First pregnancy Maternal age of less than 17 Preterm labor Placenta previa

Maternal age of less than 17 Preterm labor Placenta previa

After reviewing the maternal​ record, the nurse is performing an assessment of a newborn. Which maternal factors may contribute to the birth of an​ at-risk infant? Select all that​ apply. Maternal narcotic use ​Long, difficult labor Diabetes Type of delivery Maternal history of infection

Maternal narcotic use ​Long, difficult labor Diabetes Maternal history of infection

A laboring client at 39 weeks​' gestation has been pushing for 2 hours. The nurse anticipates that the healthcare provider may choose to use forceps to assist in the delivery. What criteria must be met to consider​ forceps? Select all that​ apply. Membranes must be ruptured. Cephalopelvic disproportion should be present. Adequate maternal anesthesia should be provided. The cervix must be fully dilated. The maternal bladder should be full.

Membranes must be ruptured. Adequate maternal anesthesia should be provided. The cervix must be fully dilated.

The nurse is preparing to administer RhoGam to a postpartum client. Which nursing interventions are appropriate when giving this​ medication? Select all that​ apply. Monitoring for adverse effects of medication Verifying Rh status of the mother and newborn Verifying the client​'s identity Reminding the mother to avoid caffeine for 12 hr Checking the lot number and expiration date of the medication

Monitoring for adverse effects of medication Verifying Rh status of the mother and newborn Verifying the client​'s identity Checking the lot number and expiration date of the medication

The nurse is reviewing the histories of four new prenatal clients. Which maternal risk factor could indicate the need for antenatal​ testing? Mother with twin pregnancy Maternal age of 25 Maternal history of depression Mother who is a vegan

Mother with twin pregnancy

What brings you in​ today, Mrs.​ Turner? you ask.I know I have a​ previa, she responds. My doctor has told me to take it easy and not to have intercourse. I have been following those​ directions, but when I got up to use the bathroom​ today, I wiped and saw bright red blood on the tissue.Her eyes fill with tears and her husband reaches out and squeezes her hand.Is that the only time you have bled during your​ pregnancy? you ask.She nods her head and takes a breath. Im so scared. I just hope my baby will be okay.You obtain permission to evaluate her chux. You take a look and notice a small amount of bright red blood on the chux. You take Mrs. Turners vital​signs: T 98.8​°​F, P 124​ bpm, R​ 24/min, and BP​ 116/72 mmHg.The fetal heart rate is​ 140/s with average​long-term variability and no decelerations.Uterine activity is one contraction in 10​ minutes, lasting 25 seconds.Her urine dip shows​ 2+ blood, trace​ proteinuria, and no ketones.Mrs. Turner is tachycardic. What is the most likely explanation for ​this?​ Mrs. Turner has acute blood loss. Mrs. Turner is anxious. Mrs. Turner is in preterm labor. Mrs. Turner is hypovolemic.

Mrs. Turner is anxious.

You ask Mrs. Yumihara to describe the feeding method for the​ baby, and she reports that she stopped breastfeeding because she feels like she lacks a bond with this baby. My first child was​ different, she said. We bonded right away. Mrs. Yumihara begins to cry again. My husband is disappointed in​ me, I just know it. And the other day I couldnt even remember what time to feed the baby. Isnt that ​horrible?​ You try to calm Mrs. Yumihara down by listening and acknowledging what she says. In the back of your​ mind, however, you begin to wonder if Mrs. Yumihara has postpartum depression. What are some specific signs or symptoms that Mrs. Yamihara has expressed that are indicative of postpartum​ depression? Select all that apply. Mrs. Yumihara has stopped nursing. Mrs. Yumihara is tearful during the exam. Mrs. Yumihara made statements of failure. Mrs. Yumihara already had a first child. Mrs. Yumihara admits to having a poor memory.

Mrs. Yumihara has stopped nursing. Mrs. Yumihara is tearful during the exam. Mrs. Yumihara made statements of failure. Mrs. Yumihara admits to having a poor memory.

Mrs. Yumihara wants to know how she can work through the postpartum depression. She so desperately wants to be a​ good, happy mother. What are some healthy steps that Mrs. Yumihara can take to mitigate and manage the postpartum​ depression? Select all that apply. Mrs. Yumihara should continue talking to​ you, the​ nurse, on a regular basis for advice and help. Mrs. Yumihara should seek professional help from a behavioral health provider. Mrs. Yumihara should seek assistance with self and infant care. Mrs. Yumihara should work through the PPD on her own. Mrs. Yumihara should talk to her husband about the PPD.

Mrs. Yumihara should seek professional help from a behavioral health provider. Mrs. Yumihara should seek assistance with self and infant care. Mrs. Yumihara should talk to her husband about the PPD.

A client is complaining of painful​ contractions, or​ afterpains, on her second postpartum day. The nurse knows that which condition could increase the severity of​ afterpains? Multiparity ​Bottle-feeding Diabetes Primiparity

Multiparity

A nurse is caring for a client having a precipitous delivery in the emergency department. The nurse anticipates which possible effects on the​ neonate? Select all that​ apply. Neonatal intracranial hemorrhage Decreased intracranial trauma Hypoxia Shoulder dystocia Spinal compression

Neonatal intracranial hemorrhage Hypoxia

What is the identifiable cause of sudden infant death syndrome​ (SIDS)? Infant prematurity Respiratory distress syndrome Congenital anomaly No known etiology

No known etiology

The nurse is preparing an educational brochure about nonpharmacologic pain relief measures during childbirth. What is considered an advantage of these​ methods? Minimally invasive No side effects Slowing of the labor process Eliminates the need for medications

No side effects

The nurse is caring for a woman in the first stage of labor. The fetal position is left occiput anterior. The woman​'s membranes rupture. Which nursing action is most appropriate at this​ time? Perform a vaginal exam. Measure the amount of fluid. Note the time of rupture and the quality​ (color, odor, approximate​ amount) of the fluid Notify the health care provider.

Note the time of rupture and the quality​ (color, odor, approximate​ amount) of the fluid

The nurse is caring for a client in the recovery room 2 hr after a cesarean birth. The client is committed to breastfeeding and wants to be as involved in the baby​'s ​care, as possible. She rates her pain at 9 on a 1-10 scale and is declining "drugs" because she "hates to feel drunk." What can the nurse do to ease the client​'s ​discomfort? Offer her intravenous nonsteroidal​ anti-inflammatory agents​ (NSAIDs) and explain their mechanism of action Respect her decision and hold all narcotics Teach her progressive relaxation Give hydromorphone as​ ordered, as pain control is a priority.

Offer her intravenous nonsteroidal​ anti-inflammatory agents​ (NSAIDs) and explain their mechanism of action

The nurse is caring for a client whose baby is at​ +5 station and is feeling overwhelmed by perineal burning. Which action is a priority for the nurse at this​ time? Giving frequent sips of water Offering encouragement and support Applying extra blankets for warmth Providing frequent perineal cleansing

Offering encouragement and support

The nurse is caring for a primigravid client whose cervix is dilated at 8​ cm; the fetus is at​ +1 station; and the client has no analgesia or anesthesia. Which action would be a priority for the​ nurse? Providing frequent perineal cleansing Giving frequent sips of water Offering encouragement and support Applying extra blankets for warmth

Offering encouragement and support

Ms. Burberry comes to the clinic at 32 weeks with fears of premature labor. What nursing actions will you perform to assess for premature​ labor? Select all that apply. Palpate the abdomen for signs of contractions and measurement of the fundus Ultrasound for assessment of fetus Urine test Vaginal exam to determine if the cervix is dilating A complete set of maternal vital signs and fetal heart tones

Palpate the abdomen for signs of contractions and measurement of the fundus Ultrasound for assessment of fetus Vaginal exam to determine if the cervix is dilating A complete set of maternal vital signs and fetal heart tones

The WIC​ (Women, Infants, and​ Children) program provides​ low-income pregnant women with vouchers for​ what? Select all that​ apply. Childcare Peanut butter Dairy foods Fruits and vegetables Prenatal care

Peanut butter Dairy foods Fruits and vegetables

The nurse is trying to determine whether a newborn is appropriate for gestational age​ (AGA). Which data collected during the physical assessment will help the nurse determine this classification for the​ newborn? Plantar creases present on anterior two thirds of sole Anterior and posterior fontanels nonbulging Umbilical cord moist to touch Milia present on bridge of nose

Plantar creases present on anterior two thirds of sole

The nurse is conducting a gestational age assessment on a newborn. Which physical assessment finding would the nurse record during this​ assessment? Umbilical cord moist to touch Plantar creases present on anterior two thirds of the sole Anterior and posterior fontanelles not bulging Milia present on bridge of nose

Plantar creases present on anterior two thirds of the sole

Mrs. Yumihara is hesitant to discuss her postpartum depression with her​ husband, but she assures you that she will tell him about it. She is also concerned about seeing a behavioral health​ provider, and asks you what the provider will do with her. You explain that there are a variety of interventions that a behavioral health provider may use. Which is NOT an appropriate intervention for postpartum​ depression? Journaling Play therapy Medication management Suicidal and risk assessments

Play therapy

Which are the early signs of hypoglycemia in a​ newborn? ​(Select all that​ apply.) Nasal flaring Poor feeding Tremors Temperature instability Grunting

Poor feeding Tremors Temperature instability

Why is a preterm infant at risk for​ aspiration? ​(Select all that​ apply.) Poor sucking Poorly developed gag reflex Extended body position Poor swallowing Incompetent cardiac sphincter

Poor sucking Poorly developed gag reflex Poor swallowing Incompetent cardiac sphincter

The client about to have a​ forceps-assisted delivery asks what complications can occur. The nurse understands that which event is a potential maternal complication of a forceps​ delivery? Maternal hypertension Erb​ palsy Uterine rupture Postpartum infection

Postpartum infection

The nurse is assessing the general appearance of a newborn. Which data will the nurse document as part of this​ assessment? Select all that​ apply. Posture at rest Relationship of head size to body Lung sounds Apgar scoring Rectal temperature

Posture at rest Relationship of head size to body

A new mother reports an income level just above the guidelines for receiving WIC​ (Women, Infants, and​ Children) assistance. She has decided to​ formula-feed her newborn. What type of formula preparation would the nurse suggest using for bottle​ feeding? Concentrated formula Powdered formula The client should breastfeed. ​Ready-to-feed formula

Powdered formula

Ms. Maxwell continues to shiver. She looks at you and starts to cry.​ "Are you feeling​ okay?" you ask her. Ms. Maxwell turns white and​ says, "I think Im going to throw​ up." You encourage her to take slow deep​ breaths, and you place a cool cloth in her forehead. You check her vital​ signs, and they are as​ follows: T 97.3​°​F, P 97​ bpm, R​ 23/min, BP​ 136/92 mmHg, and her SpO2 on room air​ 97% You know that Ms. Maxwells symptoms of nausea and shivering are most likely caused​ by: Select all that apply. Precipitous labor Heroin withdrawal ​Chorioamnionitis, or infection in the uterus Preeclampsia

Precipitous labor

The nurse will recommend pelvic rest and no sexual activity for what types of complications during​ pregnancy? Select all that​ apply. Premature rupture of membranes Signs of preterm labor Placenta previa Gestational diabetes Twin gestation

Premature rupture of membranes Signs of preterm labor Placenta previa

The nurse is providing education to a pregnant client who continues to smoke during pregnancy. Which complications will the nurse share with this​ client? Select all that​ apply. Prematurity Low birth weight Abruptio placentae Hypotension Preterm rupture of membranes

Prematurity Low birth weight Abruptio placentae Preterm rupture of membranes

What is the most likely cause of newborn vernix caseosa at​ birth? Hypoglycemia Hypoxia Preterm Large for gestational age​ (LGA)

Preterm

The nurse is educating parents about safety precautions for their newborn. Which topics are appropriate for the nurse to discuss before​ discharge? Select all that​ apply. Proper way to heat a bottle Supine positioning for sleep Proper use of an infant car seat Using "tummy time" for play Prone positioning for sleep

Proper way to heat a bottle Supine positioning for sleep Proper use of an infant car seat

Alicia​ Norris, a​ 19-year-old primigravida at 31 weeks​ gestation, is being transferred to the​ nurse's unit in preterm labor. She is worried about the​ baby's prognosis and is concerned about missing work. What is the​ nurse's responsibility to Ms. Norris at this​ time? Administering​ anti-anxiety medications Providing emotional support Contacting her employers to secure work release Restricting family visitors

Providing emotional support

Marina Sopova is a healthy​ 34-year-old G2 P1001 at 39 weeks gestation planning a trial of labor after a cesarean birth for her last delivery. She has come to labor and delivery reporting uncomfortable contractions for a whole day and being unable to sleep last night. The​ midwife's exam reveals that her cervix is 3​ cm, 50%​ effaced, and the baby is at​ -2 station. The​ baby's heart rate is 144​ beats/min and contractions are palpable every​ 5-7 min. What can the nurse anticipate doing for Marina at this​ time? Discuss the possibility of cesarean delivery Assist with artificial rupture of membranes Begin an oxytocin drip Push fluids by mouth

Push fluids by mouth

Rachel Aronson is recovering from a long second stage and extensive perineal repair after labor and birth with her first baby. She had made her desire to breastfeed​ clear, but her newborn was not able to take the breast immediately. She is exhausted. Which action by the nurse is the most​ appropriate? Reassure her that it takes some time for the baby to learn to take the breast Give her newborn a bottle so that Mrs. Aronson can sleep Ask her permission to take her baby to the nursery so that she can get some sleep Have the lactation consultant come to educate her on breastfeeding techniques

Reassure her that it takes some time for the baby to learn to take the breast

Marina Sopova has been in the second stage of labor with her first baby for almost 2 hours. The nurse has made her as comfortable as​ possible, but now she is panicking. She feels she is losing control and wants a cesarean section. Which action by the nurse is the most appropriate​ response? Reassure​ her, praise her​ efforts, and keep her apprised of her progress Offer her ice chips and tell her the baby will come when it is ready Prepare the operating room and call the anesthesiologist for an epidural Offer her an antianxiety medication to help calm her down

Reassure​ her, praise her​ efforts, and keep her apprised of her progress

The nurse receives report on Mrs.​ O'Malley, a​ 29-year-old G2P2 who is on postoperative day 1 from a planned repeat cesarean birth. The following information is in the​ report: Vital signs are​ stable, breastfeeding​ well, has positive bowel​ sounds, tolerated clear liquids​ well, and ambulated twice today. The nurse anticipates an order for which type of​ diet? Full liquids Clear liquids Soft diet Regular diet

Regular diet

Janna Hall is having a nonstress test because she has recently been diagnosed with gestational diabetes. Her results indicate a nonreactive test. What is the​ nurse's initial nursing​ action? Repeat the nonstress test. Contact the operating room for urgent cesarean section. Notify the provider and administer oxygen. Administer oxytocin.

Repeat the nonstress test.

A client undergoing labor induction is uncomfortable with contractions and declines​ analgesia, preferring to walk and change positions frequently. The nurse notes frequent gaps in the fetal heart rate tracing and sections showing wide disparities in baseline fetal heart rate. What is the nurse​'s best response to these​ findings? Reposition the ultrasound transducer Continue to monitor Notify the health care provider of a suspected fetal arrhythmia Position the mother on her left side for maximum uteroplacental circulation

Reposition the ultrasound transducer

The nurse is caring for a client who does not speak English and who requires discharge instruction. Which nursing action is the most appropriate for this​ client? Providing written instructions in English Requesting an interpreter for assistance Informing the client that she will get instructions from the Health Department Speaking slowly and loudly

Requesting an interpreter for assistance

The nurse is assessing a​ sleeping, 1-hr-old newborn. Which data would necessitate the need to notify the healthcare​ provider? Brief periods of apnea lasting less than 5 seconds Respirations 78​ breaths/min Temperature 97.9​°F Heart rate 122​ beats/min

Respirations 78​ breaths/min

The nurse is preparing a teaching session for the new staff during orientation to the newborn intensive care unit​ (NICU). Which information should the nurse include about the causes of death for premature​ infants? Select all that​ apply. Malabsorption syndromes Respiratory infections Neurologic defects Retinopathy of prematurity Sudden infant death syndrome

Respiratory infections Neurologic defects Sudden infant death syndrome

Which is a common cause of​ late-onset postpartum​ hemorrhage? Retained placental fragments Endometritis Operative vaginal delivery Labial laceration

Retained placental fragments

A postpartum client reports having difficulty voiding. Which strategies would the nurse suggest to promote urine​ elimination? ​Select all that​ apply. Running water in the sink Administering docusate sodium​ (Colace) as ordered Encouraging voiding in the shower or during a sitz bath Administering pain medication Ensuring privacy when voiding

Running water in the sink Encouraging voiding in the shower or during a sitz bath Administering pain medication Ensuring privacy when voiding

Juanita Botella is a​ 30-year-old woman who is pregnant with her first child. She has decided to take a prenatal class offered at the local hospital on the risks and prevention of sudden infant death syndrome​ (SIDS). In​ class, Mrs. Botella admits to smoking half of a pack of cigarettes every other day. What other health history factor would place Mrs.​ Botella's infant at higher risk for​ SIDS? Placenta previa Previous miscarriage SIDS within family Gestational diabetes

SIDS within family

The nurse is making a first visit to the home of a preterm infant diagnosed with bronchopulmonary dysplasia. On what should the nurse focus during this​ visit? Select all that​ apply. Level of sensory stimulation Safe use of oxygen in the home Infection control practices Parental involvement in care Frequency of oral feedings

Safe use of oxygen in the home Infection control practices

Which are clinical manifestations of congenital diaphragmatic​ hernia? ​(Select all that​ apply.) Scaphoid abdomen Absent breath sounds on the affected side ​Barrel-shaped chest Concave chest Protruding abdomen

Scaphoid abdomen Absent breath sounds on the affected side ​Barrel-shaped chest

The nurse is assessing a newborn baby girl while her mother sleeps. The nurse assesses an increased pulse and respiratory rate and an increase in mucus secretions that is causing the newborn to regurgitate. Based on the assessment​ findings, which period of activity will the nurse document for this​ client? Second period of reactivity Fourth period of reactivity Third period of reactivity First period of reactivity

Second period of reactivity

Sarah Martinez is a​ 34-year-old client who delivered a 10 lb 8 oz. female infant with vacuum assistance at​ 3:00 a.m. this morning. During the​ nurse's postpartum​ assessment, the nurse notes that the​ client's heart rate is 136​ beats/min and her blood pressure is​ 94/50 mmHg. Ms. Martinez states that she has changed her​ peri-pad four times in the past hour. Which assessment is the most appropriate for the nurse to perform at this​ time? To reassess the blood pressure in 15 min To palpate the fundus To review the chart for total blood loss during delivery To elevate the​ client's feet and legs

To palpate the fundus

Leticia Burberry is a​ 21-year-old gravida 2 para 0​ single, African American female. Her first pregnancy at age 15 ended with a spontaneous abortion​ (SAB). No causative factor for the SAB was​ identified, and no further treatment was needed. Ms. Burberry is nervous and anxious over this planned pregnancy. She is confused about the symptoms of true labor versus false labor and will require emotional support and education. Her fianc​é is in the military and is not available for daily emotional support. What risk factors apply to Ms.​ Burberry? Check all that apply. She is African American. She is experiencing domestic violence at home. Her fiance is in the military. She is of low socioeconomic status.

She is African American. Her fiance is in the military.

The next​ day, you are taking care of Mrs. Romero once again. You enter her room and ask her how she is​doing.Ok, I​ guess, she says. I did get some sleep​ earlier, but my baby is crying and wanting to breastfeed all the time. I dont think she is getting any milk. Do you think I should give her some​ formula? She sighs. Maybe I should just let her cry it out. My aunt says I am spoiling her by holding her too much. What is your best​response? You should feed her on a schedule so you can rest. She wants to breastfeed all the time because she is not getting any milk. She is cluster feeding. Crying is good for her because it opens her lungs.

She is cluster feeding.

Which topics are included in the discharge teaching for a postpartum​ client? Select all that​ apply. Signs and symptoms of illness ​Follow-up instructions Maternal​ self-care Activity Newborn care

Signs and symptoms of illness ​Follow-up instructions Maternal​ self-care Activity Newborn care

Dr. Rui​'s niece responds to the voicemail message that you left for her. She is able to come over right​ away, drive her aunt to her​ same-day appointment, and monitor her for the rest of the day. What information should you review with Ms. Tan regarding her aunt​'s ​condition? Signs that Dr. Rui is worried about her independence Symptoms that Dr. Rui​'s vaginal infection is getting worse Symptoms that Dr. Rui is developing a urinary infection Signs and symptoms that indicates Dr. Rui is having another hypoglycemic reaction

Signs and symptoms that indicates Dr. Rui is having another hypoglycemic reaction

What areas of the health history should the nurse focus on when assessing an infant for​ SIDS? (Select all that​ apply.) Sleep patterns Exposure to smoke Breathing patterns Family history of SIDS Maternal history of miscarriage

Sleep patterns Exposure to smoke Breathing patterns Family history of SIDS

Which recommendation is appropriate when educating parents about safe sleeping for the​ newborn? Sleeping on the back Sleeping in an infant car seat ​Co-sleeping with parents Sleeping on the tummy

Sleeping on the back

The nurse is conducting a newborn assessment for baby girl​ Roper, born 2 hr ago. The​ newborn's weight, head​ circumference, and length all fall below the 10th percentile. Which classification will the nurse document in the medical record for this​ newborn? Small for gestational age Postterm Large for gestational age Appropriate for gestational age

Small for gestational age

The nurse is caring for Joyce​ Stanley, who just gave birth an hour ago. Which nursing assessment requires further​ evaluation? Complaints of feeling chilly Soft uterine fundus Mild uterine cramping Moderate amount of lochia rubra

Soft uterine fundus

The nurse performs a gestational age​ assessment, as part of the newborn​ assessment, to evaluate physical characteristics. Which data will the nurse collect as part of the gestational assessment for this​ newborn? Scarf sign Square window sign Sole creases Startle reflex

Sole creases

A mother asks the nurse when she can breastfeed her infant who has just been born. Which response by the nurse is the most​ appropriate? Before the first bath Soon after​ birth, before the infant is taken to the nursery After all prophylactic medications have been administered in the nursery After the first bath

Soon after​ birth, before the infant is taken to the nursery

The nurse is caring for a primigravida in the second stage of labor who feels the urge to push. The client has had no analgesia or anesthesia. Which position might the nurse suggest for​ pushing? Dorsal recumbent Squatting Lithotomy Standing in the shower

Squatting

The new mother of a preterm infant asks why kangaroo care is important to do when holding the baby. Which responses by the nurse are most appropriate when explaining this care technique to the​ mother? Select all that​ apply. Promotes digestion Stabilizes vital signs Improves infant oxygenation Enhances bonding Supports body temperature regulation

Stabilizes vital signs Improves infant oxygenation Enhances bonding Supports body temperature regulation

The nurse observes a new mother​ bottle-feed her preterm infant and notes a slight bluish tinge around the baby​'s mouth. Which action should the nurse take​ first? Determine amount of urine output Assess respiratory rate Measure heart rate Stop the feeding

Stop the feeding

Although Mrs. Yumihara agrees to see a behavioral health​ provider, she also expresses interest in learning about​ natural, nonpharmacological alternatives for managing the postpartum​ depression, because, for cultural​ reasons, she doesn't want to have to take medication. What are some nonpharmacological options for Mrs.​Yumihara? Select all that apply. Stress management​ activities, such as meditation ​Candle-lighting ceremony Energy work Exercise Acupuncture

Stress management​ activities, such as meditation Energy work Exercise Acupuncture

The nurse is completing the assessment of the gestational age of baby girl Samuels. Which action is appropriate for the nurse to take when assessing the Babinski reflex for this​ newborn? Stroke the​ infant's cheek Stroke the lateral aspect of the​ infant's sole from the heel upward Place a gloved finger in the​ infant's mouth Startle the infant while on the warmer

Stroke the lateral aspect of the​ infant's sole from the heel upward

Why are the mouth and oropharynx of a newborn suctioned before the nose is​ suctioned? Because newborns breathe through their mouths To prevent the newborn from aspirating any contents of the nasopharynx The order is unimportant To allow the newborn to cry

To prevent the newborn from aspirating any contents of the nasopharynx

"Thank goodness a pill will fix my​ anemia," Mrs. Abejundio says. You explain that the iron supplements will​ help, but Mrs. Abejundio should also incorporate some dietary changes to improve her anemia. You ask Mrs. Abejundio to recall everything she has had to eat and drink in the past 24 hours. She begins with last nights​ dinner. Dinner: cheeseburger, sweet potato​ fries, salad made of spinach and​ tomatoes Breakfast: sugary flakes breakfast cereal with​ milk, a glass of milk Morning​ snack: string​ cheese, pear Lunch: bean burrito on flour​ tortilla, tortilla​ chips, soda Which dietary suggestions would improve Mrs. Abejundios iron​ intake? Select all that apply. Take her iron pill with milk at breakfast. Substitute a​ hard-boiled egg for her string cheese. Suggest she add ground beef to her burrito. Replace her spinach salad with an iceberg lettuce mix. An extra serving of milk will help increase her iron.

Substitute a​ hard-boiled egg for her string cheese. Suggest she add ground beef to her burrito.

Which may be assessed in the fetus with a prolapsed umbilical​ cord? Select all that​ apply. Fetal heart rate accelerations Sustained fetal bradycardia Variable decelerations Increased uterine contractions Late decelerations

Sustained fetal bradycardia Variable decelerations

Which common side effect is associated with the use of vacuum​ extraction? Fetal hair loss Fetal distress Memory loss Swelling of the scalp

Swelling of the scalp

A new mother is upset and​ states, "My baby is calm as long as I cuddle and hold her. Once I put her down in the​ crib, she starts to​ cry." Based on the new mother​'s ​description, which sensory capacity is the baby​ experiencing? Orientation sensory capacity Tactile sensory capacity Habituation sensory capacity Quieting sensory capacity

Tactile sensory capacity

Darius Jackson was just delivered at 31 weeks gestation. He has no visible medical issues that might require immediate attention. Which action is the nursing priority related to his gestational age at​ birth? Take extra care to ensure his airways are clear. Do nothing outside of normal protocol. Take extra care to ensure he is warm. Place him immediately with his mother.

Take extra care to ensure he is warm.

Jasmine Harper gave birth 12 hr ago and successfully bonded with her newborn. Which activity can the nurse recommend to best encourage attachment between Jasmine and her​ daughter? Bathing Swaddling Talking to the baby while making eye contact Diapering

Talking to the baby while making eye contact

The nurse is assessing a breastfeeding mother with engorged breasts. Which intervention should the nurse teach the breastfeeding​ mother? Applying ice Applying a breast binder Teaching how to express her breasts in a warm shower Administering bromocriptine

Teaching how to express her breasts in a warm shower

The nurse is caring for a postpartum client who had a cesarean delivery 1 day ago. Which nursing interventions will help prevent stasis of lung fluids and respiratory​ infection? Select all that​ apply. Teaching the client to cough correctly Providing education about the use of an incentive spirometer Monitoring the client​'s urinary output Encouraging healthy meals and fluid intake Encouraging the client to breathe deeply

Teaching the client to cough correctly Providing education about the use of an incentive spirometer Encouraging the client to breathe deeply

After Mrs. Abejundio sees her health care​ provider, she checks in with you before she leaves the clinic. She​ says, "I want to take good care of myself and the baby. Is there anything else I can do to help the iron pills work​ better?" How should you respond to Mrs.​ Abejundio? Tell her that taking iron with a vitamin C​ source, such as orange​ juice, will help her body absorb it better. Suggest she drink milk when she takes her iron pill. Explain that Mrs. Abejundios blood work shows she is deficient in Vitamin C. Advise her to grind up her iron tablet and mix it with orange juice.

Tell her that taking iron with a vitamin C​ source, such as orange​ juice, will help her body absorb it better.

The nurse is performing a Ballard gestational age assessment for baby boy​ Jefferys, born 1.5 hr ago. Which will the nurse assess during the physical characteristic portion of this​ examination? Rooting reflex Babinski reflex The amount of breast tissue Scarf sign

The amount of breast tissue

You are performing a​ 24-hour chart check on Mrs. Romeros chart. You note that her prenatal labs are as​follows:Blood type A​ negative, antibody screen negativeRubella​ immuneOne-hour glucola 125HIV negativeYou know that she may be a candidate for a​ rho(D) immune globulin​ (RhoGAM) injection, and you check her chart and the babys chart for more information. What result confirms that Mrs. Romero needs​ rho(D) immune globulin​(RhoGAM)? Mrs. Romeros indirect Coombs is positive. The babys blood type is B positive. The babys blood type is O negative. The babys blood type is A negative.

The babys blood type is B positive.

Which definition describes the term​ involution? Bladder distention Palpation of the uterine fundus The descent of the uterine fundus into the pelvis A boggy or soft fundus

The descent of the uterine fundus into the pelvis

A nurse is involved in investigating the death of an infant. A​SIDS-related death is suspected. What is true regarding the process of investigating this type of​ death? The focus of the investigation does not involve the​ infant's family. The focus of the investigation involves determining the cause of infant death. The focus of the investigation is to determine blame for the​ infant's death. The focus of the investigation is on the​ infant's parental behavior.

The focus of the investigation involves determining the cause of infant death.

Which is the best indication of health in the unborn​ fetus? The fetus​' sex The fetus​' culture The health of the fetus​' mother The health of the fetus​' father

The health of the fetus​' mother

A nurse is caring for a newborn whose mother had no prenatal care. What information does the nurse understand as true regarding a newborn born without prenatal​ care? The health of the infant is based on the prenatal care of the mother. The mother of the infant is likely of low socioeconomic status. The mother of the infant is likely to belong to a minority culture. The health of the infant is independent of the prenatal care of the mother.

The health of the infant is based on the prenatal care of the mother.

The nurse is caring for a newborn who is small for gestational age​ (SGA). The newborn​'s parents ask the nurse how this happened. Which rationales will the nurse use to respond to these​ parents? Select all that​ apply. The newborn had intrauterine exposure to bacteria. The newborn weighs less than​ 2,500 g​ (5.5 lb). The newborn​'s head circumference is in the 50th percentile. The newborn​'s weight falls below the 10th percentile. The newborn may have suffered from intrauterine growth restriction​ (IUGR).

The newborn​'s weight falls below the 10th percentile. The newborn may have suffered from intrauterine growth restriction​ (IUGR).

"I remember when my​ sister-in-law took iron pills during her​ pregnancy," Mrs. Abejundio says. "She got really nauseated and then constipated. I hope that doesnt happen to me." How will you​ respond? Select all that apply. The prescribed stool softener may help prevent constipation. There is no way to avoid an upset stomach with iron pills. You should start with a small dose of iron and increase over time. Your stool may turn black. Taking iron pills with food reduces iron absorption.

The prescribed stool softener may help prevent constipation. You should start with a small dose of iron and increase over time. Your stool may turn black. Taking iron pills with food reduces iron absorption.

A nurse is preparing a brochure about different types of antenatal testing. Which​ indicators, related to a fetal nonstress test​ (NST), are appropriate to​ include? Select all that​ apply. The test is used to assess fetal heart rate pattern and oxygenation status. The test is easy to perform and has no known side effects. A rise in the fetal heart rate is associated with fetal movement. A nonstress test​ (NST) usually takes 2-3 hours for completion. A reactive NST has two accelerations that are 15 beats above baseline for 15 s in 20-40 min.

The test is used to assess fetal heart rate pattern and oxygenation status. The test is easy to perform and has no known side effects. A rise in the fetal heart rate is associated with fetal movement. A reactive NST has two accelerations that are 15 beats above baseline for 15 s in 20-40 min.

A woman has just delivered an 8​ lb, 8 oz baby boy. After the​ delivery, the nurse notices that the mother is chilly and her fundus has relaxed. The nurse administers the oxytocin ordered by the health care provider. What is the expected assessment finding for this​ client? The baby cries The uterus becomes firm The mother states she feels warmer now The mother falls asleep

The uterus becomes firm

The nurse is assessing a newborn right after birth. Which assessment will be most helpful initially in identifying an​ at-risk newborn? The​ newborn's Apgar score The​ mother's pregnancy history The​ newborn's color The​ newborn's respiratory effort

The​ newborn's Apgar score

A preterm male newborn is admitted to the nursery. Which assessment findings support the diagnosis of​ prematurity? ​Select all that​ apply. Minimal lanugo Thin skin Covered in vernix caseosa Undescended testes Flexed extremities

Thin skin Covered in vernix caseosa Undescended testes

Why does a preterm infant lose body​ heat? ​(Select all that​ apply.) Flexed body position Thinner skin Inefficient constriction of blood vessels Less subcutaneous tissue Higher body surface to body weight ratio

Thinner skin Inefficient constriction of blood vessels Less subcutaneous tissue Higher body surface to body weight ratio

The nurse is preparing an education program on breastfeeding. What is the appropriate timeframe to include in regards to the recommendation for exclusive​ breastfeeding? Through 6 months of age Exclusive breastfeeding is not recommended. 2 yr old 1 yr old

Through 6 months of age

How is chorionic villus sampling​ (CVS) beneficial for a pregnant woman and her​ fetus? Occurs before 8 weeks gestation Noninvasive testing procedure Time in which results become available No risk to developing fetus

Time in which results become available

Renee Romero is an​ 18-year-old gravida 2 para 1001 who just had a successful vaginal birth after a previous cesarean section. She had an epidural and a Foley​ catheter, which was removed prior to second stage pushing. After 2 hours of​ pushing, her health care provider obtained her consent and placed a vacuum to assist with the birth. Mrs. Romero had a fourth degree perineal laceration that the health care provider is in the process of repairing when you take over Mrs. Romeros care from her labor and delivery nurse. She has plain lactated Ringer solution infusing via IV. You hang the oxytocin and bolus the IV​ fluid, which is her third liter of fluid. You massage Mrs. Romeros​ uterus; it is now​ firm, and the fundus is at the umbilicus. The health care provider is continuing to repair her fourth degree laceration.The nursery nurse has finished her evaluation of Mrs. Romeros baby girl. She weighed 7 lbs 4​oz, and her appearance is consistent with 38 weeks estimated gestational age. The nurse tells you that her vital signs are all normal and that she gave the baby her vitamin K injection and the erythromycin ointment.The baby is swaddled in a blanket and has her fist by her face. The baby touches her cheek with her​ fists, and you recognize the baby is rooting and showing signs of being ready to breastfeed. Mrs. Romero is in​ semi-Fowler position for the repair.​ You tell Mrs. Romero that the baby is showing signs she would like to nurse. She​ says, Oh, good. I want to breastfeed her. I was not able to breastfeed my last baby. What is your next​ step? To assist Mrs. Romero to breastfeed her baby. To assess the baby for signs of hypoglycemia. To check the babys blood glucose level before she breastfeeds. To give the baby formula because Mrs. Romero is having her repair done.

To assist Mrs. Romero to breastfeed her baby.

What indications would call for a woman to have an ultrasound test during the first trimester of​ pregnancy? Select all that​ apply. To verify location of the pregnancy To confirm pregnancy viability To determine gender of the fetus To estimate amniotic fluid volume To assist with amniocentesis

To verify location of the pregnancy To confirm pregnancy viability To assist with amniocentesis

Ms. Burberry tells you that she has concerns about being able to recognize the true signs of​ labor, especially because her first pregnancy ended in a spontaneous abortion. What are some of the classic differences you can explain that will clarify the difference between true labor and false​ labor? Select all that apply. True labor contractions will not be relieved by​ rest, a warm​ bath, or repositioning. False labor contractions are random and do not increase in intensity. True labor contractions continue to increase in duration and intensity. False labor contractions are not regular. False labor contractions will cause a change in the cervix.

True labor contractions will not be relieved by​ rest, a warm​ bath, or repositioning. False labor contractions are random and do not increase in intensity. True labor contractions continue to increase in duration and intensity. False labor contractions are not regular.v

How can the nurse enhance the bonding process between parents and their​ newborn? Select all that​ apply. Turn down the room lights. Delay the administering of eye prophylaxis. Immediately administer eye prophylaxis. Create a quiet space for the parents and newborn. Turn up the room lights.

Turn down the room lights. Delay the administering of eye prophylaxis. Create a quiet space for the parents and newborn.

You start Mrs. Turners IV in her left forearm with an 18 gauge needle and begin administering lactated Ringer solution at 125​ mL/hr. The lab tech comes in and draws Mrs. Turners blood. You recheck her vital​ signs: T 98.6​°​F, P 120​ bpm, R​ 19/min, and BP​ 120/78 mmHg.The fetal heart rate is​ 140/s with minimal​ long-term variability. Mrs. Turner has a​ contraction, which traces well on the​ monitor, and the fetal heart rate shows a late deceleration following the contraction.You look at Mrs. Turner and notice shes wrinkling her nose. I feel really weird down​ there, she tells you. You tug back on the sheets to check her perineum and a blood clot the size of a dinner plate slides out of her vagina onto the chux. You wipe it away and observe brisk red bleeding from her introitus.As you page the health care​ provider, what steps will you take to improve the oxygen blood flow to the​baby? Turn her to her left side. Turn down her IV rate to prevent pulmonary edema. Apply compression stockings to her lower extremities. Place her in Trendelenburg position.

Turn her to her left side.

A pregnant client is lactose intolerant. Which strategy does the nurse suggest to the client to ensure that she consumes adequate​ protein? Select all that​ apply. Use soymilk to replace​ cow's milk. Mix milk with fruit juices. Eat two servings of cream cheese every day. Tofu can be used to replace cottage cheese. Add milk to soup and custards.

Use soymilk to replace​ cow's milk. Tofu can be used to replace cottage cheese.

Which strategies are appropriate for the nurse to implement to promote ambulation for a client recovering after a cesarean​ delivery? Select all that​ apply. Using a folded sheet as an abdominal splint Encouraging fluid intake to prevent constipation Administering an analgesic 30 min before walking Providing encouragement to the mother Teaching​ turning, coughing, and deep breathing

Using a folded sheet as an abdominal splint Administering an analgesic 30 min before walking Providing encouragement to the mother

If the nurse administers the ripening agent Cervidil or Prepidil to a pregnant​ client, which situations can the nurse expect to be associated with the​ drug? Select all that​ apply. The need for more oxytocin during labor Uterine tachysystole Postpartum hemorrhage Nonreassuring fetal status Difficulty in administration

Uterine tachysystole Postpartum hemorrhage Nonreassuring fetal status

The nurse is caring for four postpartum clients. The nurse would question a provider​'s order for administering the rubella vaccine to which​ client? Vaginal​ delivery, HIV-positive Cesarean section​ delivery, received 1 unit of blood Breastfeeding mother of twins Caucasian with negative rubella titer

Vaginal​ delivery, HIV-positive

The night shift nurse gets report on four clients who delivered between​ 7:00 a.m. and​ 8:00 a.m. that morning. The nurse is going to assess which client​ first? Vaginal​ delivery, episiotomy, has not voided since delivery Cesarean​ section, pain medication 30 min​ ago, tolerated clear liquids Vaginal​ delivery, ambulating​ well, docusate sodium​ (Colace) due in 30 min Cesarean​ section, twins,​ breastfeeding, requests assistance with nursing

Vaginal​ delivery, episiotomy, has not voided since delivery

A​ 3-week-old preterm infant is diagnosed with anemia. Which intervention does the nurse expect the healthcare provider will prescribe for this​ infant? Infusions of fresh frozen plasma Vitamin E supplements Arterial blood gas analysis every 2 hr Serum electrolyte levels every hour

Vitamin E supplements

The nurse is caring for a pregnant client whose family has a very low income. The nurse discusses the​ Women, Infants, and Children​ (WIC) program with the client. Which services provided by this program should the nurse include in her​ teaching? Select all that​ apply. All pregnant women are able to utilize the services of WIC. WIC provides nutritional education and counseling to women. WIC can provide food stamps for​ low-income women. WIC provides vouchers for certain foods. WIC services continue after pregnancy.

WIC provides nutritional education and counseling to women. WIC provides vouchers for certain foods. WIC services continue after pregnancy.

You call to make a​ same-day appointment for Dr. Rui to see her primary health care provider to diagnose and treat her vaginal infection. What​ self-care interventions should you review with Dr. Rui to prevent ​reoccurrence?​ Select all that apply. After​ voiding, wipe from back to front. Douche regularly. Wear cotton underwear. Avoid wearing nylon pantyhose. Avoid wearing tight jeans.

Wear cotton underwear. Avoid wearing nylon pantyhose. Avoid wearing tight jeans.

The nurse is providing care to a family who recently welcomed a second baby. The couple also has a​ 4-year-old son. Which behavior would indicate regression for the​ son? Wetting the pants during a hospital visit Asking to hold the baby with mom​'s help Yelling at the father for holding the baby Giving the baby a present while visiting

Wetting the pants during a hospital visit

A client is in the recovery room after completing a cesarean birth. She is stable and alert. What should be the nurse​'s focus for teaching during this​ time? Future birth control options When to follow up with her healthcare provider What to expect during the postpartum period How to bathe the newborn

What to expect during the postpartum period

You inform Mrs. Yumihara that you will need to ask her some questions about her health history. Having worked with this client and her husband​ before, you know that there are cultural parameters and that sometimes Mrs. Yumihara feels as though medical questions are invasive. You do your best to explain to Mrs. Yumihara that it is important for you to ask these questions to make sure​ she, her​ husband, and the new baby are safe and healthy. She agrees to go along with the health history​ assessment, and you make a conscious effort to be delicate with the way you ask the questions. Which question is NOT consistent with a health history assessment for postpartum​ depression? Have you ever been diagnosed with a behavioral health​ condition? Do you have a history of drug or alcohol​ abuse? Has there been a history of depression or bipolar disorder in your​ family? What was your age of​ menarche?

What was your age of​ menarche?

A nurse is caring for Zoe​ Hernandez, a​ 3-hr-old newborn. The nurse understands that​ Zoe's parents require teaching regarding newborn care. What time does the nurse determine is best to perform this​ teaching? When Zoe is in the​ nursery, allowing the parents time alone to hear the teaching. When Zoe is​ sleeping, allowing the parents quiet time to absorb the teaching. When performing​ Zoe's newborn​ assessment, allowing the parents to visualize the teaching. When performing the postpartum​ assessment, allowing the parents an opportunity to hear both infant and postpartum teaching.

When performing​ Zoe's newborn​ assessment, allowing the parents to visualize the teaching.

Why might it be difficult for the prenatal nurse to recognize bulimia in a pregnant​ woman? Bulimia does not cause​ pregnancy-related problems. Pregnancy hides weight gain. Women with bulimia are often very underweight. Women with bulimia are often a normal weight.

Women with bulimia are often a normal weight.

The mother of Tommy​ Hamilton, a​ 5-day-old preterm​ infant, wants to know when the baby will no longer need tube feedings so she can start feeding the baby. Which response from the nurse is most​ appropriate? ​"Tommy will tolerate bottle feedings when he stops sucking on the​ pacifier." ​"Bottle feedings can be started when his belly stops gurgling so much before receiving a​ feeding." ​"Tommy can start bottle feedings when his belly​ doesn't increase in size after​ feedings." ​"Bottle feeding can start when Tommy has a gag​ reflex."

​"Bottle feeding can start when Tommy has a gag​ reflex."

The father of a preterm infant is upset and fears the baby is going to be paralyzed. Which response by the nurse is​ appropriate? ​"As long as a brain hemorrhage does not​ occur, the infant will not develop​ paralysis." ​"Brain cells and nerve impulse pathways increase and develop between the second and fourth months of​ gestation, so there is little chance your child will be​ paralyzed." ​"Since the period of most rapid brain growth and development occurs during the third​ trimester, the infant may have mobility​ problems." ​"Paralysis will only occur if a cerebral aqueduct is​ blocked, causing​ hydrocephalus."

​"Brain cells and nerve impulse pathways increase and develop between the second and fourth months of​ gestation, so there is little chance your child will be​ paralyzed."

The nurse is assessing a pregnant client​'s understanding of her preterm labor. What questions are appropriate for the nurse to include with​ education? Select all that​ apply. ​"Do you have any questions about your​ pediatrician?" ​"Can you share with me what you know about the risks of preterm​ delivery?" ​"Tell me what you understand about causes of preterm​ labor." ​"How is this affecting your​ pregnancy? What concerns do you​ have?" ​"We will be doing fetal monitoring. Have you learned about this​ already?"

​"Can you share with me what you know about the risks of preterm​ delivery?" ​"Tell me what you understand about causes of preterm​ labor." ​"How is this affecting your​ pregnancy? What concerns do you​ have?" ​"We will be doing fetal monitoring. Have you learned about this​ already?"

A postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find when reviewing this client​'s medical​ record? ​"Cesarean birth performed secondary to arrest of​ dilation." ​"Vaginal delivery with epidural​ anesthesia." ​"Client has history of​ pregnancy-induced hypertension." ​"Rupture of membranes occurred 2 hr prior to​ delivery."

​"Cesarean birth performed secondary to arrest of​ dilation."

Carmelina​ Picagli, a​ 22-year-old primigravida, has been admitted to the labor and birth unit in the active phase of the first stage of labor at term. She is​ healthy; has had an uneventful​ pregnancy; plans an unmedicated​ labor; and wants to remain as active as possible. Which order would the nurse suspect has been entered in​ error? ​"Continuous electronic fetal​ monitoring" ​"Fetal heart rate check Q 30​ minutes" ​"Vitals signs Q 4​ hr" ​"Activity as​ tolerated"

​"Continuous electronic fetal​ monitoring"

The nurse provides education to new parents about recommendations for the infant​'s sleeping position. Which nursing documentation note is​ appropriate? ​"Informed parents that the infant should sleep in the car seat until 1 month​ old." ​"Prone position recommended for sleeping when in​ crib." ​"Discussed placing infant on back when​ sleeping." ​"Encouraged sleeping in the same bed with parents for 1​ month."

​"Discussed placing infant on back when​ sleeping."

The prenatal clinic nurse is caring for an​ 18-year-old client who is at 10 weeks gestation in her first pregnancy. The client is 64 in.​ (1.6 m) tall and weighs 115 lb​ (52 kg). The client asks the nurse why she is supposed to gain so much weight during the pregnancy. What is the best response by the​ nurse? ​"Inadequate weight gain delays lactation after​ delivery." ​"Gaining 25 to 35 pounds is recommended for healthy fetal​ growth." ​"It's what your certified​ nurse-midwife recommended for​ you." ​"Weight gain is important to ensure that you get enough​ vitamins."

​"Gaining 25 to 35 pounds is recommended for healthy fetal​ growth."

The nurse is providing education to Mr.​ Johnson, a new father to baby​ Anna, who is 2 days old. The nurse is teaching Mr. Johnson about proper​ bottle-feeding. Which statement by the nurse is appropriate for the nurse to include in the teaching​ session? ​"Propping the bottle while feeding Anna will decrease the chance of​ choking." ​"Holding the bottle upright will improve​ Anna's bowel​ function." ​"Feeding Anna from the bottle will decrease her risk of otitis​ media." ​"Holding Anna in an upright position reduces the amount of air she​ swallows."

​"Holding Anna in an upright position reduces the amount of air she​ swallows."

The nurse in a prenatal clinic is caring for a client in her second trimester of pregnancy. What statement made by the client would indicate that she understands the daily calorie allowance for a pregnant​ woman? ​"I am eating an additional 300 calories per​ day." ​"Since I am eating for two​ now, I have increased my calories by​ 500, or 250 kilocalories for each of​ us." ​"Since the nausea has decreased I am eating​ 3,000 calories per​ day." ​"I continue to eat the same number of calories as I did before I was​ pregnant."

​"I am eating an additional 300 calories per​ day."

The nurse is evaluating teaching about normal newborn care. Which statement by the parents indicates that further teaching is​ needed? ​"I will cleanse the baby​'s diaper area after each soiled​ diaper." ​"It is okay if I give the baby a bath every other​ day." ​"I can use powder to help prevent diaper​ rash." ​"I will fold down the top of the diaper so it will not cover the​ cord."

​"I can use powder to help prevent diaper​ rash."

Esperanza Jimenez is 16 weeks postpartum and breastfeeding exclusively. She is concerned that she has only lost 15 of the 20 lb​ (6.8-9 kg) she gained while pregnant. Which statement to the nurse indicates that Mrs. Jimenez requires further​ education? ​"I don't want to reduce my calories too much because it may affect my milk​ supply." ​"I should drastically cut my calories so I can lose the rest of my baby​ weight." ​"I know it could take up to a year to lose the rest of my baby​ weight." ​"I should exercise a little​ more."

​"I should drastically cut my calories so I can lose the rest of my baby​ weight."

The nurse is evaluating a new​ mother's knowledge of breastfeeding after a teaching session. Which statement indicates the need for further​ teaching? ​"If it's in the​ refrigerator, I can keep the breast milk for up to 8​ days." ​"I should warm the breast milk in the microwave for 30​ seconds." ​"It will stay good for up to 3-4 months in the​ freezer." ​"Fresh breast milk can stay out at room temperature for 4-10 ​hours."

​"I should warm the breast milk in the microwave for 30​ seconds."

The nurse is discussing exercise during pregnancy with a client who is at 30 weeks gestation. Which statement made by the client would require further assessment by the​ nurse? ​"I hold on to the handles when I am on the​ treadmill." ​"When I do my exercise​ video, I stop if I feel​ tired." ​"I walk on the treadmill for 4 hours a​ day." ​"I am swimming 20 minutes each day at the​ YMCA."

​"I walk on the treadmill for 4 hours a​ day."

Alisha​ Kimble, a​ 27-year-old G2​ P1001, has just arrived in the labor and birth unit for a scheduled external cephalic version at 38​ weeks' gestation with a transverse lie. She is talking from the bathroom to the nurse about the procedure as she puts on her gown. Which statement from Alisha alerts the nurse that the client needs further teaching on what to expect from the​ procedure? ​"I will have an ultrasound done after the​ procedure." ​"I will be starting labor after the​ procedure." ​"The procedure is​ uncomfortable." ​"I will need to get an IV started for the​ procedure."

​"I will be starting labor after the​ procedure."

The nurse is caring for a client who will be having a cesarean delivery. Which statement by the client would cause the nurse to determine that the client does not understand what to expect during a cesarean​ delivery? ​"I will receive a blood transfusion during​ surgery." ​"I may be given an antacid before​ surgery." ​"An indwelling​ (Foley) catheter will be inserted before​ surgery." ​"My husband can be present during​ birth."

​"I will receive a blood transfusion during​ surgery."

Leah Wilson is a​ 28-year-old woman who is 3 days​ post-cesarean delivery resulting in a healthy 7 lb 4 oz.​ boy, little Ted. The nurse is completing a client teaching at the bedside. Which statement by the client indicates that more teaching is​ needed? "If I develop a temperature above 100.4° ​F, I'll call our healthcare provider right​ away." ​"We'll bring little Ted back to see our healthcare provider in about 10​ days." ​"I'll call the healthcare provider if​ Ted's circumcision wound starts to smell​ bad." ​"If my baby turns​ yellowish, it's just from the formula​ he's eating."

​"If my baby turns​ yellowish, it's just from the formula​ he's eating."

Ms. Tan​ arrives, and hugs her aunt. The three of you talk about recognizing the signs and symptoms of hypoglycemia and how triggers such as vomiting could cause this. Ms. Tan​ says, "If my aunt vomits​ again, or looks pale and​ sweaty, I will check her blood glucose." What statement suggests that Ms. Tan understands what she needs to do to correct her aunt​'s blood glucose if​ necessary? ​"If my​ aunt's blood glucose is​ high, I will give her glucose​ tablets." ​"If my​ aunt's blood glucose is​ low, I will give her glucose​ tablets." ​"If my​ aunt's blood glucose is​ low, I will call​ 911." ​"If my​ aunt's blood glucose is​ low, I will check it again in 15​ minutes."

​"If my​ aunt's blood glucose is​ low, I will give her glucose​ tablets."

A postpartum client who had a vaginal delivery is about to be discharged. The client asks the nurse how soon she can begin training for an upcoming running marathon. Which response by the nurse is most​ appropriate? ​"Check with your personal trainer and see what he or she​ advises." ​"You'll have to wait another three months to be sure your lochia has stopped before you start exercising at​ all." ​"It's best to wait until​ you've had your​ six-week follow-up appointment and your healthcare provider clears you to exercise that​ strenuously." ​"You can start running again as soon as you feel​ better."

​"It's best to wait until​ you've had your​ six-week follow-up appointment and your healthcare provider clears you to exercise that​ strenuously."

After delivering a healthy baby boy 2 days​ ago, 32-year-old Erica Chambers is now being discharged after a brief hospitalization. The nurse is providing discharge teaching to Ms. Chambers regarding the prevention of SIDS. Which statement by the nurse is not correct and will not be included in the discharge​ teaching? ​"Place your baby on his back to​ sleep." ​"Do not allow anyone to smoke around your​ baby." ​"Keep your​ baby's nursery temperature at 85​ degrees." ​"Breastfeeding is preferred over formula for your​ baby."

​"Keep your​ baby's nursery temperature at 85​ degrees."

Lenny​ Jackson, a​ 1-month-old preterm​ infant, is scheduled for laser photocoagulation surgery to treat retinopathy of prematurity.​ Lenny's father wants to know what the​ long-term effect of this health problem will be. What should the nurse explain to​ Lenny's father? ​"Lenny could be facing early​ blindness." ​"Most problems resolve without​ long-term vision​ effects." ​"Lenny will have profound vision​ deficits." ​"Surgery will need to be repeated throughout​ Lenny's life."

​"Most problems resolve without​ long-term vision​ effects."

A client is going to have a cephalic version at 38 weeks​' gestation for a breech presentation. Which statement by the client indicates appropriate understanding of the​ procedure? ​"After the baby is​ turned, I must remain in​ bed." ​"My baby​'s head will be turned slightly to make the delivery​ easier." ​"The procedure cannot be stopped even if my baby shows signs of​ distress." ​"My baby will be turned to a​ head-down position."

​"My baby will be turned to a​ head-down position."

A nurse is caring for a pregnant client during a routine prenatal visit. While performing the​ assessment, which statement by the client may indicate the infant is at a greater risk for sudden infant death syndrome​ (SIDS)? ​"My father was diagnosed with diabetes last​ year." ​"I delivered my first baby​ vaginally." ​"I miscarried my fist pregnancy at ten​ weeks." ​"My sister died during infancy while we were​ sleeping."

​"My sister died during infancy while we were​ sleeping."

The nurse is providing education to a mother who is initiating breastfeeding. How does the nurse explain the process of the​ "let-down" reflex? ​"Oxytocin is​ released, leading to the​ let-down of​ milk." ​"Estrogen levels increase during pregnancy to cause​ this." ​"Progesterone may cause this​ effect." ​"Prolactin stimulates milk​ production."

​"Oxytocin is​ released, leading to the​ let-down of​ milk."

A client​ asks, "Why do I need an ultrasound and all of these tests while I am​ pregnant?" Which response by the nurse is the most appropriate regarding the purpose of antenatal​ testing? Select all that​ apply. ​"Ultrasounds are painless and your insurance will pay for​ it." ​"Tests such as ultrasounds can help screen for birth​ defects." ​"I will ask the doctor to explain these tests to you​ later." ​"These tests help us see how your baby is growing and​ developing." ​"These tests help make sure your baby is​ healthy."

​"Tests such as ultrasounds can help screen for birth​ defects." ​"These tests help us see how your baby is growing and​ developing."

The nurse is assessing a​ 2-week-old infant in the office. Which statement by the parent would indicate the need for further assessment of infant feeding​ patterns? ​"The baby usually has two wet diapers a​ day." ​"The baby has a dirty diaper about once a​ day, sometimes​ twice." ​"The baby burps after taking about 20 mL of​ formula." ​"I feed the baby about every 3 to 4​ hours."

​"The baby usually has two wet diapers a​ day."

The new mother of Timothy​ Henderson, an infant born at 30 weeks​ gestation, asks why the baby only receives medication once a day. What should the nurse respond to this​ mother? ​"The medication can cause diarrhea and lead to​ dehydration." ​"The kidneys​ aren't fully developed and it takes longer for the drugs to leave the​ body." ​"Protective cells did not cross from the placenta into the baby before delivery and the medication works​ faster." ​"There isn't enough glucose in the​ baby's body to metabolize the​ medications."

​"The kidneys​ aren't fully developed and it takes longer for the drugs to leave the​ body."

A pregnant client in her first trimester is scheduled for an abdominal ultrasound. Which statement by the nurse most accurately reflects the reason for early ultrasound during​ pregnancy? ​"The test will help to determine the gender of your​ baby." ​"The test will help determine how many weeks pregnant you​ are." ​"The test will help to determine whether you have enough amniotic​ fluid." ​"The test will help determine if your baby is in good position for​ delivery."

​"The test will help determine how many weeks pregnant you​ are."

The nurse is assessing a​ 2-day-old infant in the hospital. The parents express concern when the nurse informs them that the newborn has lost​ 2% of its birth weight. Which response by the nurse is the most​ appropriate? ​"I will let you speak with the healthcare provider about this. We may need to notify the​ hospital, also." ​"This is concerning because we expect the newborn to gain one pound per​ day." ​"This is an expected finding. Most infants will regain this weight within 2 weeks after​ birth." ​"This is okay. We expect babies to lose about half of their weight in the first few days of​ life."

​"This is an expected finding. Most infants will regain this weight within 2 weeks after​ birth."

Baby Jennifer is at the healthcare​ provider's office for her​ 1-week well-baby checkup. As the nurse assesses the baby before the healthcare provider sees​ her, Jennifer's​ mother, who is​ breastfeeding, says she is concerned because her baby has lost 4 ounces from her original birth weight. Which response by the nurse is most appropriate to​ Jennifer's mom? ​"Your baby might be very ill. I will notify the healthcare provider​ immediately." ​"This could indicate you are eating something the baby​ doesn't agree​ with." ​"This is expected and the baby should regain all weight by the next​ visit." ​"Your baby may be suffering from failure to​ thrive."

​"This is expected and the baby should regain all weight by the next​ visit."

Todd is a healthy​ newborn, delivered an hour ago. In the delivery​ room, his mother asks the nurse about the benefits of breastfeeding. Which response by the nurse is most​ appropriate? ​"Didn't you talk about this with your doctor when you were​ pregnant?" ​"I will call the healthcare provider so you can discuss this with​ her." ​"The baby could have more colic with​ breastfeeding, but it is​ free." ​"This may help your baby be​ healthier, and you could have less bleeding after​ delivery."

​"This may help your baby be​ healthier, and you could have less bleeding after​ delivery."

During a postnatal home health​ visit, you teach Ms.​ Henderson, a​ 31-year-old woman, about the importance of supine positioning for infant sleep for the prevention of SIDS. Ms. Henderson tells you that her infant does not like sleeping on his back and only sleeps on his tummy. What is your best response when explaining to Ms. Henderson the importance of supine positioning for infant​ sleep? ​"This position is protective in preventing​ suffocation." ​"This position decreases aspiration should your baby spit​ up." ​"This position prevents digestive​ problems, which can contribute to​ SIDS." ​"This position will allow your child to sleep​ longer."

​"This position is protective in preventing​ suffocation."

Angelique Chambers is a​ 31-year-old primigravida who is being admitted to the labor and birth unit for induction of labor for​ post-dates pregnancy. While the nurse is taking her​ history, she tells the nurse that she is worried about how long it will take and she is afraid it will be too tiring and painful. She asks if it​ wouldn't just be easier to have a cesarean now. Which response from the nurse is most​ appropriate? ​"The process of inducing your labor could take several days and be very uncomfortable. Would you like to speak to your obstetrician about the​ process?" ​"Vaginal birth is usually the safest for the mother and baby. Cesarean surgery carries several​ risks, has a longer​ recovery, and can cause complications in future pregnancies. We only recommend it if the benefits clearly outweigh the​ risks." ​"You should avoid having a cesarean at all costs. Your body is designed to give birth vaginally and there is no doubt you can do​ it." ​"That will be so much more convenient for you. Then you can schedule the delivery of your next baby by repeat cesarean and you​ won't even have to go through all​ this."

​"Vaginal birth is usually the safest for the mother and baby. Cesarean surgery carries several​ risks, has a longer​ recovery, and can cause complications in future pregnancies. We only recommend it if the benefits clearly outweigh the​ risks."

A client who had a cesarean section asks the nurse why she needs to ambulate. What is an appropriate response by the​ nurse? ​"Walking will help prevent blood clots in your​ legs." ​"You can ask the doctor when he​ comes." ​"It will help you feel better to get out of your​ room." ​"The doctor wrote orders for you to walk three times a​ day."

​"Walking will help prevent blood clots in your​ legs."

A client who had a cesarean section asks the nurse why she needs to ambulate. Which response by the nurse is the most​ appropriate? ​"You can ask the doctor when she​ comes." ​"Walking will help prevent blood clots in your​ legs." ​"The doctor wrote orders for you to walk three times a​ day." ​"It will help you feel better to get out of your​ room."

​"Walking will help prevent blood clots in your​ legs."

John is a​ 4-week-old infant who is being breastfed. His mother asks the nurse about his weight gain and what she should expect. Which statement by the nurse is the most​ appropriate? ​"We expect John to gain about half an ounce each​ day." ​"John should gain an ounce a day until he is about 1 year​ old." ​"John's weight will fluctuate each​ day, so it is hard to​ answer." ​"John will lose weight for a few months because he is​ breastfeeding."

​"We expect John to gain about half an ounce each​ day."

Janice Johnson is being admitted to the hospital in early labor. When completing her admission​ assessment, which question would allow the nurse to evaluate​ Janice's emotional​ state? ​"How do you like this​ hospital?" ​"Have you chosen a name for the baby​ yet?" ​"What are your expectations of your current​ pregnancy?" ​"Walking may take your mind off the​ contractions."

​"What are your expectations of your current​ pregnancy?"

birth control method she can start before discharge. What is an appropriate response from the​ nurse? ​"You may be able to have a birth control injection before​ discharge." ​"Why don​'t you ask the doctor. She will be here​ soon." ​"You should take the pills. They work the​ best." ​"You will need to wait 6 weeks before starting any​ method."

​"You may be able to have a birth control injection before​ discharge."

Ms.​ Willis, who is 35 weeks​ pregnant, is scheduled for a prenatal visit today. The nurse plans to provide education about the premonitory signs of labor. Which statement is appropriate to include in the​ teaching? ​"Expect to see bleeding each day from now​ on." ​"You may notice that you breathe easier when the baby drops down into your​ pelvis." ​"Your swelling will start to go away​ now." ​"Watch for less urinary frequency as a sign of​ labor."

​"You may notice that you breathe easier when the baby drops down into your​ pelvis."

The nurse is teaching a postpartum client about her nutritional needs. What statement is appropriate to​ include? ​"Because you are​ breastfeeding, you will need fewer​ calories." ​"You should continue to take your prenatal​ vitamins." ​"Drinking cold water is what will help hydrate​ you." ​"Limit fluid intake so you won​'t have problems with​ swelling."

​"You should continue to take your prenatal​ vitamins."