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The nurse is assessing a pregnant client who has a long history of asthma treated with albuterol and montelukast. The client states, "I am trying not to use my asthma medications because I do not want my baby exposed to them." Which response should the nurse prioritize? "In fact, most modern asthma medications are categorized as safe for use in pregnancy." "Actually, having uncontrolled asthma is much riskier for your baby than the medication." "I am glad to hear that you are focused on ensuring your baby's health." "Your health care provider will likely agree with your decision."

"Actually, having uncontrolled asthma is much riskier for your baby than the medication." The priority is for pregnant clients with asthma to keep taking their medications because the risks of exacerbations exceed the risks of the medications to both the client and fetus. Some medications used to treat asthma (short-acting inhaled bronchodilators, antileukotriene agents, some inhaled corticosteroids) have minimal to no effects on the pregnancy. The other statements would be inappropriate.

A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer? "The antibodies may be those transferred across the placenta; the baby may not develop AIDS." "HIV is transmitted at birth; having a cesarean birth prevented transmission." "She already has AIDS. That's what being HIV positive means." "HIV antibodies do not cross the placenta; this means the baby will develop AIDS."

"The antibodies may be those transferred across the placenta; the baby may not develop AIDS." Infants born of HIV-positive women test positive for HIV antibodies at birth because these have crossed the placenta. An accurate disease status cannot be determined until the antibodies fade at about 18 months. Testing positive for HIV antibodies does not mean the infant has AIDS. Having a cesarean birth does decrease the risk of transmitting the virus to the infant at birth; it does not prevent the transmission of the disease. HIV antibodies do cross the placenta, which is why babies born of HIV positive mothers are HIV positive.

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? "Physiologic jaundice usually begins in the first week after birth." "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." "Breastfed babies need supplements of glucose water to help lower bilirubin levels." "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)."

"Breastfed babies need supplements of glucose water to help lower bilirubin levels." Physiologic jaundice (hyperbilirubinemia) is characterized by a yellowish skin, mucous membranes, and sclera that occurs within the first 3 days of life. Physiologic jaundice is caused by accelerated destruction of fetal RBCs that have a shortened life span (80 days compared with the adult 120 days). Normally the liver removes bilirubin (the by-product of RBC destruction) from the blood and changes it into a form that can be excreted. As the red blood cell breakdown continues at a fast pace, the newborn's liver cannot keep up with bilirubin removal. Thus, bilirubin accumulates in the blood, causing the characteristic signs of physiologic jaundice. Expose the newborn to natural sunlight for short periods of time throughout the day to help oxidize the bilirubin deposits on the skin. Glucose water supplementation should be avoided since it hinders elimination.

A pregnant client is diagnosed with syphilis. Which response would demonstrate respect for the client and therapeutic communication? "I noticed that you seem fidgety. Is there something wrong besides your STI?" "Why didn't you use protection when having intercourse with your partner?" "I am sure it is frightening to you to be diagnosed with a disease that can affect your baby." "You should have thought about what diseases you could be exposed to. At least you are HIV negative."

"I am sure it is frightening to you to be diagnosed with a disease that can affect your baby." The nurse needs to be supportive, empathic and accepting of the client, asking open-ended questions and acting calm and reassuring to her. By acknowledging her fears for her fetus, the nurse is demonstrating respect for her and conveying confidence that the client is trying to take care of her fetus.

A nurse is teaching a woman diagnosed with gestational diabetes about meal planning and nutrition. The nurse determines that additional teaching is needed based on which client statement? "Having a bedtime snack is good for me." "I should get most of my calories from good complex carbs." "I need to avoid any fat with my meals." "It's okay to eat small meals or snacks throughout the day."

"I need to avoid any fat with my meals." Recommendations for nutrition and diet with gestational diabetes include: eating three meals a day plus three snacks to promote glycemic control with 40% of calories from good-quality complex carbohydrates, 35% of calories from protein sources, and 25% of calories from unsaturated fats; eating small frequent feedings throughout the day; having bedtime snacks; and including protein and fat at each meal.

The parents of a 2-day-old newborn are getting ready to go home with their baby. The mother is breastfeeding the newborn. In preparation for discharge, the nurse obtains the newborn's weight. The newborn weighs 7 lb (3180 g) this morning. The parents voice concern, saying, "Our newborn lost weight since being born. Our newborn was 7 lb 8 oz (3404 g) and now our newborn is less. What is going on?" Which response by the nurse would be most appropriate? "This is an interesting change. Let me talk to your health care provider about the weight loss." "I understand your concern. It is normal for this to happen but your newborn will gain it back quickly." "This weight loss is from not eating enough. You will need to breastfeed your newborn more often." "Looks like there might be a problem with your breast milk. Let's try formula and see what happens."

"I understand your concern. It is normal for this to happen but your newborn will gain it back quickly." Newborns can lose up to 10% of their initial birth weight by 3 to 4 days of age secondary to loss of meconium, extracellular fluid, and limited food intake. This weight loss is usually regained by the 10th day of life. The weight loss is a normal finding. There is no need to talk to the health care provider, increase the number of breastfeeding sessions, or switch to formula.

The nurse is teaching a client with gestational diabetes about complications that can occur either following birth or during the birth for the infant. Which statement by the mother indicates that further teaching is needed by the nurse? "Beginning at 28 weeks' gestation, I will start counting with my baby's movements every day." "If my blood sugars are elevated, my baby's lungs will mature faster, which is good." "My baby may be very large and I may need a cesarean birth to have him." "I may need an amniocentesis during the third trimester to see if my baby's lungs are ready to be born."

"If my blood sugars are elevated, my baby's lungs will mature faster, which is good." Elevated blood sugars delay the maturation of fetal lungs, not increase maturation time, resulting in potential respiratory distress in newborns born to mothers with diabetes. Doing fetal movement (kick) counts is standard practice, as is the possibility of an amniocentesis to determine lung maturity during the third trimester. Health care personnel should also prepare the mother for the potential of a cesarean birth if the infant is too large.

A neonate born by cesarean birth required oxygen after the birth. The mother expresses concern because this was not a factor with her previous vaginal birth. What response by the nurse is most appropriate? "You are older now and that can impact how your neonate adapts to the birth process." "Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." "Neonates born by cesarean tend to need oxygen supplementation due to the rapid change in fetal circulation when the uterus was cut during the birth." "This is likely just coincidence." "Normally, neonates born by cesarean do better after delivery since it is a much gentler birth."

"Neonates born by cesarean do not benefit from the squeezing of the contractions, which helps to clear the lungs." During labor and delivery, the contractions provide pressure on the fetus. These forces "squeeze" the fetus's thoracic cavity. This aids the fetus in forcing the amniotic fluid from the lungs. The neonate born by cesarean does not have this experience, which may result in some initial periods of tachypnea and a need for oxygen supplementation. Maternal age and the uterine incision do not impact this phenomenon.

The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption (abruptio placentae) are discussed. Which comment validates accurate learning by the parents? "I need a cesarean section if I develop this problem." "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." "Since I am over 30, I run a much higher risk of developing this problem." "If I develop this complication, I will have bright red vaginal bleeding,"

"Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain." Placental abruption (abruptio placentae) occurs when there is a spontaneous separation of the placenta from the uterine wall. It can occur anywhere on the placenta and will cause painful, dark red vaginal bleeding. If the abruption is small, the ob/gyn will try to deliver the fetus vaginally. But if severe bleeding occurs or there is fetal distress, a cesarean birth will be performed. Women older than 35 are also at higher risk for developing placental abruption.

A pregnant woman who has had cardiovascular disease for the last 3 years asks the nurse why this disorder makes her pregnancy an "at-risk" pregnancy. What is the nurse's best response? "Pregnancy taxes the circulatory system of every woman." "Don't worry. You have an excellent primary care provider." "Our facility has a lot of experience in dealing with this." "The fact that you are receiving prenatal care will help."

"Pregnancy taxes the circulatory system of every woman." Pregnancy taxes the circulatory system of every woman because both the blood volume and cardiac output increase by approximately 30% to 50%. Half of these increases occur by 8 weeks; they are maximized by mid-pregnancy.

A client experiencing a threatened abortion is concerned about losing the pregnancy and asks what she can do to help save her baby. What is the most appropriate response from the nurse? "Restrict your physical activity to moderate bed rest." "Strict bed rest is necessary so as not to jeopardize this pregnancy." "Carry on with the activity you engaged in before this happened." "There is no research evidence that I can recommend to you."

"Restrict your physical activity to moderate bed rest." With a threatened abortion, moderate bedrest, light activities, and supportive care are recommended. Regular physical activity may increase the chances of miscarriage. Strict bedrest is not necessary and may hide additional bleeding as it pools in the vagina, only to begin again as the woman ambulates. Activity restrictions are part of standard medical management.

A newborn weighing 5 lb (2250 g) needs to eat 3 oz (90 ml) of formula every 3 hours. To meet this goal, how many ounces of formula per day will the parent need to feed the newborn? Record your answer using a whole number.

24 Feeding every 3 hours equates to 8 feedings per day. 3 oz × 8 = 24 oz. This can also be calculated in milliliters and converted back into ounces. 90 ml × 8 = 720 ml.

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen? When the infant is 48 hours old Just before discharge home 36 hours before the infant is discharged home with its parents 24 hours after the newborn's first protein feeding

24 hours after the newborn's first protein feeding The laws in most states require this initial screening, which is done within 72 hours of birth. The ideal time to collect the specimen is after the newborn is 36 hours old and 24 hours after he has his first protein feeding.

The nurse is explaining to the parents about the various laboratory tests which will be conducted on their newborn. The nurse should point out that testing for phenylketonuria will be conducted in which time frame? 24 to 72 hours after birth. within 24 hours after birth. within 1 hour after birth. 4 weeks after solid food is first eaten.

24 to 72 hours after birth. PKU is an inherited disease involving a specific enzyme necessary in the production of amino acids. Without this enzyme, phenylalanine builds up in the blood and can lead to serious consequences, such as brain damage. Phenylketonuria testing measures the amount of phenylalanine present in the blood. The infant must have taken breast milk or formula for an abnormal amount to be present. The blood sample is obtained via a heel stick and is best conducted 2 to 3 days after birth, allowing time for the infant to eat. The main treatment for this condition is life-long dietary restrictions, so it needs to be identified quickly so appropriate care can be started.

A nurse is caring for a client with hyperemesis gravidarum. Which nursing action is the priority for this client? Administer an antiemetic. Set up for a percutaneous endoscopic gastrostomy. Administer total parenteral nutrition. Administer IV normal saline with vitamins and electrolytes.

Administer IV normal saline with vitamins and electrolytes. The first choice for fluid replacement is generally normal saline with vitamins and electrolytes added. If the client does not improve after several days of bed rest, "gut rest," IV fluids, and antiemetics, then total parenteral nutrition or percutaneous endoscopic gastrostomy tube feeding is instituted to prevent malnutrition.

A newborn is receiving ampicillin and gentamicin every 12 hours. When would this client have his hearing screen performed? 1 day after birth After the newborn has completed the antibiotic therapy Before discharge from the hospital 1 month after discharge

After the newborn has completed the antibiotic therapy It is recommended that all newborns undergo a hearing screening before they are discharged from the hospital. If the newborn is treated with an ototoxic medication such as gentamycin, the hearing screen must be conducted after completion of the antibiotic therapy.

A 28-year-old client and her current partner present for the first prenatal appointment with the ob/gyn. The client has no children but does question a possible miscarriage 2 years ago; however, she never sought medical attention because she felt fine. Labs reveal both client and partner are Rh negative. Which action should the nurse prioritize? Assess client for anti-D antibodies. Perform direct Coombs test. Continue with routine procedures and tasks. Arrange for an amniocentesis.

Assess client for anti-D antibodies. The client should be checked for sensitization to Rh-positive blood. It is unknown if the client did have a miscarriage earlier, and if so, what the blood type was of the fetus. The risk is high for the current fetus to be affected with hemolytic disease, and this can be easily ruled out by assessing the mother for sensitization. If this screening is negative, then no further testing is required. If the father were Rh positive, then the mother be given Rho(D) immune globulin to prevent the woman from developing antibodies to the Rho(D) factor. However, if it is positive, the health care provider may order an amniocentesis to evaluate the fetus for hemolytic disease so proper treatment and monitoring may be given. It is too early to perform a direct Coombs test. It would be improper to ignore the potential of serious complications and simply continue with routine tasks and procedures at this time.

The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize? Assess the mother for isoimmunization. Assess the Rh of the baby. Administer rubella vaccine to the mother before discharge. Administer Rho(D) immune globulin to the mother.

Assess the Rh of the baby. The cord blood should be assessed to determine the infant's Rh type. If it is negative, there is no need for any further treatment or concern. However, if it is Rh positive the mother needs to be assessed for possible administration of Rho(D) immune globulin. The criteria for giving Rho(D) immune globulin are as follows: The woman must be Rho(D) negative The woman must not have anti-D antibodies (must not be sensitized) The infant must be Rho(D) positive (fetus cord blood is checked after birth) A direct Coombs test (a test for antibodies performed on cord blood at delivery) must be weakly reactive or negative This all needs to be completed within the first 72 hours of birth, so the mother can receive Rho(D) immune globulin within the proper time frame.

A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that the skin looks yellow. What action will the nurse take? Assist the mother to feed the newborn. Notify the health care provider. Assess the bilirubin level. Proceed with the discharge.

Assess the bilirubin level. If a nurse notices that a newborn appears jaundiced, the nurse will assess the newborn's bilirubin level. Current guidelines recommend newborns be screened for jaundice and high bilirubin levels prior to discharge from the hospital. The nurse will then notify the health care provider based on the results. The nurse may assist the mother to feed in newborn if needed, as this may facilitate decreasing jaundice. The newborn should not be discharged at this time.

A client reports bright red, painless vaginal bleeding during at 32 weeks' gestation. A sonogram reveals that the placenta has implanted low in the uterus and is partially covering the cervical os. Which immediate care measure(s) should the nurse initiated? Select all that apply. Attach external monitoring equipment to record fetal heart sounds and kick counts. Place the client on bed rest maintaining the supine position. Determine the time the bleeding began and about how much blood has been lost. Obtain baseline vital signs and compare to those vital signs previously obtained. Assist the client into stirrups and perform a pelvic examination.

Attach external monitoring equipment to record fetal heart sounds and kick counts. Determine the time the bleeding began and about how much blood has been lost. Obtain baseline vital signs and compare to those vital signs previously obtained. Assessment is a priority in the immediate care period. Determining the extent of the blood loss, obtaining vital signs and monitoring the fetus provides data. With the exception of performing a pelvic examination and placing the client in the supine position, all of the answers are appropriate immediate care measures. The nurse should never attempt a pelvic or rectal examination with painless bleeding late in pregnancy because any agitation of the cervix might tear the placenta further and initiate massive hemorrhage, which is possibly fatal to both client and fetus. The nurse should not place the client in the supine position for extended periods due to the possibility of supine hypotension. Left side lying position is suggested.

The parents of a newborn are upset that their newborn needs treatment for ophthalmia neonatorum. The nurse should explain this is related to which maternal infection? Select all that apply. Trichomonas Candidiasis Gonorrhea Chlamydia Syphilis

Chlamydia Gonorrhea Colonization of chlamydia and gonorrhea in the vaginal tract can lead to ophthalmia neonatorum in the newborn, which infants contract at birth. The treatment is the use of an antibiotic ophthalmic ointment that is usually applied within the first hour. Trichomonas, syphilis, and candidiasis do not cause ophthalmia neonatorum.

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? Monitor the client's beta-hCG level. Monitor the client's vital signs and bleeding. Monitor the fetal heart rate (FHR). Monitor the mass with transvaginal ultrasound.

Chromosomal defects in the fetus Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.

The nurse is monitoring an infant who was born at 0515 hrs. At 1315 hrs, the same day, the nurse determines the infant is starting to show yellowish staining on the head and face. Which action should the LPN prioritize? Continue monitoring, report if spreads. Document and report to RN. Repeat bilirubin levels. Start phototherapy.

Document and report to RN. Jaundice that appears in the first 24 hours may be a sign of excessive bilirubin in the blood and is now seeping into the tissues. This needs to be further evaluated and should be reported to the RN immediately so further assessments, including lab work, can be ordered. Jaundice in the first 24 hours is considered pathologic and needs to be evaluated immediately. Physiologic jaundice usually occurs on the second or third day after birth and is considered a normal event as the bilirubin levels rise. It should clear up with the use of phototherapy.

Parents are taking home their second child. They also have a 2-year-old at home. The nurse would anticipate which behavior by these parents? Confidence since they have another child already No questions of the nurse Only questions specific to breastfeeding General questions about different aspects of newborn care

General questions about different aspects of newborn care Just because parents have had a previous child does not mean that they will not have questions about their newborn infant. Each newborn is different and parents my not feel comfortable this time caring for the newborn.

A woman with class II heart disease is experiencing an uneventful pregnancy and is now prescribed bed rest at 36 weeks' gestation by her health care provider. The nurse should point out that this is best accomplished with which position? Lie flat on her back. Stay in high Fowler position. Lie in a semi-recumbent position. Use pillows and wedges to stay in a fully recumbent position.

Gestational diabetes Glycosuria, glucose in the urine, may occur normally during pregnancy; however, if it appears in the urine, the client should be sent for testing to rule out gestational diabetes. Preeclampsia, anemia, and hyperthyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hypothyroidism instead of hyperthyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.

A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia? Take a low-dose antihypertensive prophylactically. Take one aspirin every day. Have her blood pressure checked at every prenatal visit. Monitor the client for headaches or swelling on the body.

Have her blood pressure checked at every prenatal visit. Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention—nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors.

A nursing student will pick which value as a correct laboratory value for a newborn? hemoglobin (Hbg) 17 g/dL (170 g/L) white blood cell (WBC) count 40,000/mm³ (40 ×109/L) hematocrit (Hct) 40% (0.4) platelet count 75,000/µL (75 ×109/L)

Hemoglobin (Hbg) 17 g/dL (170 g/L) The normal laboratory values for a newborn include Hgb 16 to 18 g/dL (160 to 180 g/L), Hct 46% to 68% (0.46 to 0.68), platelet count 4,500,000/µL to 7,000,000/µL, (4,500 to 7,000 ×109/L) and W BC count 10 to 30,000/mm³ (0,1 to 30 ×109/L). From the values noted, only Hbg of 17 g/dL (170 g/L) is within normal range.

The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? HiB Vitamin K HBV immunoglobin Hep B

Hep B Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit. Vitamin K is given soon after birth to reduce the risk of bleeding

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help. Try walking with the newborn around the house then place her back in the crib to let her cry for a while. Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. Holding and comforting the newborn will not cause the infant to become spoiled.

Holding and comforting the newborn will not cause the infant to become spoiled. Newborns often have periods of crying; the parents should first check for a physical reason for crying such as hunger or a soiled diaper. If this is not the cause, then the parents need to try to soothe the newborn by holding, walking, rocking the newborn or even taking the infant for a ride in the car. Reassure the parents that they will not spoil the newborn by meeting its needs.

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? It takes energy to keep warm, so the neonate has to remain in an extended position. The neonate will stabilize his or her temperature by 8 hours after birth if kept warm and dry. Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. If the neonate becomes cold stressed, he or she will eventually develop respiratory distress.

If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. If cold stressed, the infant eventually will develop respiratory distress; oxygen requirements rise (even before noting a change in temperature), glucose use increases, acids are released into the bloodstream, and surfactant production decreases bringing on metabolic acidosis. A flexed position, not an extended position, keeps the neonate warm.

A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant? Bed rest for the next 4 weeks Intravenous administration of a tocolytic Immediate surgery Internal uterine monitoring

Immediate surgery The client presents with the signs and symptoms of an ectopic pregnancy, which is confirmed by the transvaginal ultrasound. Ectopic pregnancy means an embryo has implanted outside the uterus. Surgery is necessary to remove the growing structure before damage can occur to the woman's internal organs. Bed rest, a tocolytic, and internal uterine monitoring will not correct the situation. The growing structure must be removed surgically.

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). This is an abnormal finding and needs to be reported immediately. If the fontanel (fontanelle) feels full, then this is normal.

It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle). Feeling a pulsation over the fontanel (fontanelle) correlating to the newborn's heart rate is normal. The pulsation should not be felt in the posterior fontanel (fontanelle). The fontanel (fontanelle) should not be bulging under any circumstance in a newborn.

A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply. The epidermis is thicker than in adults. It is thinner and more fragile than an adult's Substances are easily absorbed. Sweat glands are fully functioning at birth. Skin is less susceptible to the sun.

It is thinner and more fragile than an adult's Substances are easily absorbed. An infant's skin is more fragile than that of adult's and is more susceptible to breakdown as well as the effects of the sun. The epidermis of an infant's skin is much thinner than an adult's and does not reach the thickness of adult skin until late adolescence. Sweat glands are immature at birth, contributing to the difficulty infants have in regulating temperature. Sweat glands do mature as the infant grows.

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history reveals gestational hypertension. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored? Low temperature and hypertonia Frequent activity and jitteriness Jitteriness and irritability Hypotonia and fever

Jitteriness and irritability Infants born to women gestational hypertension are at a greater risk for developing hypoglycemia. Early signs of hypoglycemia in the newborn include jitteriness, poor feeding, listlessness (not frequent activity), irritability, low temperature (not fever), weak or high-pitched cry, and hypotonia (not hypertonia).

The head nurse of the newborn nursery is teaching new employees ways to reduce the transmission of infection in the nursery. What information would be included in this session? It is acceptable to share diapers and wipes between newborns but nothing else. Scrub your hands for 3 minutes before entering the nursery if you are wearing artificial nails. Keep all of the newborn's belongings together in the bassinet. Newborns should be kept in the nursery except for feedings.

Keep all of the newborn's belongings together in the bassinet. By keeping all the newborn's belongings in the bassinet and not sharing items, the risk of cross-contamination is greatly reduced. Rooming-in, not staying in the nursery, also reduces the likelihood of cross-contamination. Artificial nails are shown to increase infection transmission and should not be worn.

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client? Keep the suction equipment readily available. Keep head of bed slightly elevated. Provide a well-lit room. Place the client in a supine position.

Keep the suction equipment readily available. The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.

A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client? An ultrasound will be done to reassess the correctness of gestational dates. Lab work will be drawn to rule out acid-base imbalances. The nurse will encourage the woman to lie down and rest whenever she feels ill. Since morning sickness is a common problem for pregnant women, the nurse will suggest the woman drink more fluids and eat crackers.

Lab work will be drawn to rule out acid-base imbalances. Morning sickness that lasts all day and is severe is called hyperemesis gravidarum. It is much more serious than "morning sickness" and can lead to significant weight loss and electrolyte imbalance. Lab work needs to be drawn to determine the extent of electrolyte loss and acid-base balance. An ultrasound is performed but it is done to determine if the mother is experiencing a molar pregnancy. Treatment for hyperemesis gravidarum requires much more care than just rest, drinking fluids and eating crackers.

A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? scarf sign popliteal angle square window Moro reflex

Moro reflex There are six activities or maneuvers that are evaluated to determine the newborn's degree of neuromuscular maturity: posture, square window, arm recoil, popliteal angle, scarf sign, heel-to-ear. The Moro reflex is an indication of the newborn's neurologic status.

The LPN is assessing a 1-day-old newborn and notices a large amount of white drainage and redness at the base of the umbilical cord. What is the best response by the nurse? Notify the charge nurse, because it represents a possible complication, and document the finding. Carefully clean the area with a damp washcloth and cover it with an absorbent dressing and document finding and intervention. Call the doctor immediately to ask for intravenous antibiotics and document finding. Show the mother how to clean the area with soap and water, and document the intervention.

Notify the charge nurse, because it represents a possible complication, and document the finding. The base of the cord should be dry without redness or drainage, and the umbilical clamp should be fastened securely. The white drainage and redness are potential signs of an infection and would need to be reported immediately to the RN by the LPN. Antibiotics may or may not be necessary, however.

A client at 25 weeks' gestation presents with a blood pressure of 152/99 mm Hg, pulse 78 beats/min, no edema, and urine negative for protein. What would the nurse do next? Document the client's blood pressure Provide health education Notify the health care provider Assess the client for ketonuria

Notify the health care provider The client is exhibiting a sign of gestational hypertension, elevated blood pressure greater than or equal to 140/90 mm Hg that develops for the first time during pregnancy. The health care provider should be notified to assess the client. Without the presence of edema or protein in the urine, the client does not have preeclampsia.

A pregnant woman diagnosed with diabetes should be instructed to perform which action? Ingest a smaller amount of food prior to sleep to prevent nocturnal hyperglycemia. Discontinue insulin injections until 15 weeks gestation. Notify the primary care provider if unable to eat because of nausea and vomiting. Prepare foods with increased carbohydrates to provide needed calories.

Notify the primary care provider if unable to eat because of nausea and vomiting. During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia.

The nurse understands the need to be aware of the potential of bleeding disorders in pregnant clients. Which action(s) will the nurse teach clients to complete at home if vaginal bleeding occurs during pregnancy? Select all that apply. Notify the primary health care provider. Note the amount and color of the blood. Increase oral fluid intake. Monitor blood pressure. Perform a repeat pregnancy test.

Notify the primary health care provider. Note the amount and color of the blood. Increase oral fluid intake. Bleeding may result from placenta previa, spontaneous abortion, hydatidiform mole, or ectopic pregnancy during pregnancy. Vaginal bleeding can occur at any time during the pregnancy and should be assessed for complications. The nurse will teach pregnant clients to notify the primary health care provider for guidance and assessment; note the amount, odor, and color of any blood to help determine the severity and cause; increase oral fluid intake to maintain appropriate circulation; and monitor fetal movements and uterine contractions if appropriate. The client would not be instructed to complete a pregnancy test at home or monitor blood pressure. These actions would be completed in the health care facility by the nurse.

A nurse is observing respiratory effort in a newborn as part of Apgar scoring. Which method should the nurse use to do this? Observe response to a suction catheter in the nostrils. Observe chest movement. Observing and count the pulsations of the umbilical cord. Observe resistance to any effort to extend the newborn's extremities.

Observe chest movement. Respirations are counted by observing chest movement. Reflex irritability may be evaluated by observing response to a suction catheter in the nostrils or response to having the soles of the feet slapped. Heart rate is typically determined by auscultation with a stethoscope but may also be obtained by observing and counting the pulsations of the umbilical cord at the abdomen, if the cord is still uncut. Muscle tone is evaluated by observing resistance to any effort to extend the newborn's extremities.

A nurse caring for a pregnant client suspects substance use during pregnancy. What is the priority nursing intervention for this client? Determine if the client has emotional support. Obtain a urine specimen for a drug screening. Provide education material on cessation of substance use. Determine how long the client has been using drugs.

Obtain a urine specimen for a drug screening. Substance use during pregnancy is associated with preterm labor, spontaneous abortion (miscarriage), low birth weight, central nervous system and fetal anomalies, and long-term childhood developmental consequences. It is most important to know what the client is taking in order to provide the best care for the client and newborn.

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? Obtain a voided urine specimen and determine blood type. Measure fundal height. Check deep tendon reflexes. Palpate the fundus and check fetal heart rate.

Palpate the fundus and check fetal heart rate. The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? The infant may sleep through the night around 2 months of age. Place the infant on the back when sleeping. Newborns usually sleep for 16 or more hours each day. Caregivers need to sleep while the baby is sleeping.

Place the infant on the back when sleeping. It is most important to educate caregivers on how to place the newborn while sleeping to ensure safety and reduce the risk of SIDS. The other information is good to include, but not priority.

A nurse is assessing the temperature of a newborn using a skin temperature probe. Which point should the nurse keep in mind while taking the newborn's temperature? Place the temperature probe over the liver. Tape the temperature probe on the forehead. Use the skin temperature probe only in open bassinets. Ensure that the newborn is lying on its abdomen.

Place the temperature probe over the liver. The nurse should place the temperature probe over the newborn's liver. Skin temperature probes should not be placed over a bony area like the forehead or used in an open bassinet with no heat source. The newborn should be in a supine or side-lying position.

The nurse is conducting a prenatal class explaining the various activities that will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment? Protect the urethra from fecal material Prevent infection of the umbilical cord Protect tear ducts from vaginal bacteria Prevent infection of the eyes from vaginal bacteria

Prevent infection of the eyes from vaginal bacteria Antibiotic ointment is used in the infant's eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra.

A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal? Decrease blood pressure Prevent maternal seizures Reverse edema Decrease protein in urine

Prevent maternal seizures The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.

The nurse wants to maintain a neutral thermal environment for her assigned neonatal clients. Which intervention would best ensure that this goal is met? Keep the infant transporter temperature between 80° and 85°F (27° and 29°C). Avoid skin-to-skin contact with the mother until the infants are 8 hours old. Promote early breastfeeding for the infants. Avoid bathing the newborn until he or she is 24 hours old.

Promote early breastfeeding for the infants. The nurse should promote early breastfeeding to provide fuels for nonshivering thermogenesis. The nurse can bathe the newborn if he or she is medically stable. The nurse can also use a radiant heat source while bathing the newborn to maintain the temperature. Skin-to-skin contact with the mother should be encouraged, not discouraged, if the newborn is stable. The infant transporter should be kept fully charged and heated at all times.

Under which circumstances should gloves be worn in the newborn nursery? Select all that apply. Changing a diaper Feeding the newborn a bottle Providing the first bath Performing a heel stick Accucheck Taking the newborn's crib to the mother's room

Providing the first bath Changing a diaper Performing a heel stick Accucheck Universal precautions, such as wearing gloves, is necessary whenever the nurse is likely to come in contact with bodily fluids, such as when changing a diaper, performing the initial bath after birth, and drawing blood for testing. Gloves are not needed with formula feedings or when transporting the newborn in its crib to the mother's room.

The nurse is conducting a safety class for a group of new parents in the hospital. What tips would the nurse provide for these parents? Select all that apply. It is ok to release your newborn to hospital personnel when they come into your room to transport the newborn back to the nursery. Don't leave the newborn unattended unless the mother is going to the bathroom. Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Do not remove the identification bands until the newborn is discharged from the hospital. Know when the newborn is scheduled for any tests and how long the procedure will last.

Question anyone who is not wearing proper identification even if they are dressed in hospital attire. Don't leave the newborn unattended unless the mother is going to the bathroom. Know when the newborn is scheduled for any tests and how long the procedure will last. Do not remove the identification bands until the newborn is discharged from the hospital. To ensure the safety of their newborn, parents must understand how to keep their infant safe. They are to never leave their newborn unattended at any time, be sure to ask to see identification of anyone who comes into the room to remove the infant, don't remove the newborn's identification bands until leaving the hospital at discharge, and know when any test or procedures are scheduled for their newborn. Parents are instructed to question anyone who does not have proper identification or acts suspiciously.

A woman with known cardiac disease from childhood presents at the obstetrician's office 6 weeks' pregnant. What recommendations would the nurse make to the client to address the known cardiac problems for this pregnancy? Select all that apply. Plan periods of rest into the workday. Increase the amount of sodium in your diet to compensate for the expanding fluid needs of the fetus. Let the physician know if you become short of breath or have a nighttime cough. Continue taking the scheduled warfarin. Receive pneumococcal and influenza vaccines.

Receive pneumococcal and influenza vaccines. Let the physician know if you become short of breath or have a nighttime cough. Plan periods of rest into the workday. Women with known heart conditions need to be closely followed by both the obstetrician and a cardiologist. Recommendations would include rest periods, reduction of stress, getting immunizations, and monitoring for heart failure as demonstrated by a nighttime cough and shortness of breath. Consuming more sodium in the diet is not recommended due of the potential of developing hypertension. Warfarin is contraindicated during pregnancy since it crosses the placental barrier and can cause spontaneous abortion (miscarriage), stillbirth or preterm birth.

The nurse notes a newborn has a temperature of 97.0oF (36.1oC) on assessment. The nurse acts to prevent which complication first? Respiratory distress Cardiovascular distress Seizure Hypoglycemia

Respiratory distress It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia.

A nurse is describing the use of Rho(D) immune globulin as the therapy of choice for isoimmunization in Rh-negative women and for other conditions to a group of nurses working at the women's health clinic. The nurse determines that additional teaching is needed when the group identifies which situation as an indication for Rho(D) immune globulin? maternal trauma amniocentesis molar pregnancy STIs

STIs Indications for Rho(D) immune globulin include isoimmunization, ectopic pregnancy, chorionic villus sampling, amniocentesis, prenatal hemorrhage, molar pregnancy, maternal trauma, percutaneous umbilical sampling, therapeutic or spontaneous abortion, fetal death, or fetal surgery.

The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for placental abruption (abruptio placentae). Which assessment finding should the nurse prioritize? An increased blood pressure and oliguria Pain in a lower quadrant and increased pulse rate Painless vaginal bleeding and a fall in blood pressure Sharp fundal pain and discomfort between contractions

Sharp fundal pain and discomfort between contractions A placental abruption (abruptio placentae) refers to premature separation of the placenta from the uterus. As the placenta loosens, it causes sharp pain. Labor begins with a continuing nagging sensation. Painless vaginal bleeding and a fall in blood pressure are indicative of placenta previa. Pain in a lower quadrant and increased pulse rate are indicative of an ectopic pregnancy. Hypertension and oliguria are indicative of preeclampsia.

The nurse is caring for a woman at 32 weeks' gestation with severe preeclampsia. Which assessment finding should the nurse prioritize after the administration of hydralazine to this client? Halos around lights Gastrointestinal bleeding Sweating Tachycardia

Tachycardia Hydralazine reduces blood pressure but is associated with adverse effects such as palpitation, tachycardia, headache, anorexia, nausea, vomiting, and diarrhea. It does not cause gastrointestinal bleeding, blurred vision (halos around lights), or sweating. Magnesium sulfate may cause sweating.

The nurse is looking over a newborn's plan of care regarding expected outcomes. Which outcome would not be appropriate according to a newborn's nursing care? The newborn's body temperature will stabilize between 97.8ºF and 99.5ºF (36.6ºC and 37.5ºC). The newborn's blood glucose will remain above 50 mg/dl The newborn will experience no bleeding episodes lasting more than 5 minutes. The newborn will be correctly identified prior to separation from the parents.

The newborn will experience no bleeding episodes lasting more than 5 minutes. : Bleeding episodes should not be occurring at all, and any episodes should be reported to the physician immediately if not responsive to immediate action to stop it. All other outcomes are pertinent to the newborn's care.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply. The penis is small. The father is uncircumcised. There is a family history of hemophilia. The infant is at 33 weeks' gestation. The newborn was febrile at birth but temperature is now normal.

There is a family history of hemophilia. The infant is at 33 weeks' gestation. Circumcision is contraindicated for several reasons including prematurity, family history of a bleeding disorder, and illness. A fever at birth is not a problem as long as it comes back down to normal shortly after birth. A small penis or a father who was never circumcised are not reasons to delay circumcision.

A young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting? Cervical insufficiency Habitual abortion Threatened abortion Ectopic pregnancy

Threatened abortion Spontaneous abortion (miscarriage) occurs along a continuum: threatened, inevitable, incomplete, complete, missed. The definition of each category is related to whether or not the uterus is emptied, or for how long the products of conception are retained.

What supplies would the nursery nurse collect in preparation for bathing a newborn infant? Select all that apply. Talc powder Thermometer Hexachlorophene soap A washcloth Warm tub of water

Warm tub of water Thermometer A washcloth The initial bath for a newborn is done using warm water, a mild soap (not hexachlorophene, which can be absorbed through the skin), and a thermometer to check the newborn's temperature following the bath. Talc powder is not recommended because of the risk for aspiration.

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize? Clean hands with a betadine scrub. Use infection transmission precautions. Perform a 3-minute surgical-type scrub. Wear clean gloves.

Wear clean gloves. Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? Turn the temperature up in the birth room. Wrap the infant in a warm, dry blanket. Bathe the infant immediately after birth. Place the infant on the mother's abdomen after birth.

Wrap the infant in a warm, dry blanket. Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat. Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem.

A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition? a client with a history of alcohol use disorder a client with a structurally defective cervix a 23-year-old multigravida client a client who had a myomectomy to remove fibroids

a client who had a myomectomy to remove fibroids A previous myomectomy to remove fibroids can be associated with the cause of placenta previa. Risk factors also include maternal age greater than 30 years. A structurally defective cervix cannot be associated with the cause of placenta previa. However, it can be associated with the cause of cervical insufficiency. Alcohol ingestion is not a risk factor for developing placenta previa but is associated with placental abruption (abruptio placentae).

Which newborn neuromuscular system adaptation would the nurse not expect to find? an extrusion reflex at 9 months of age a plantar grasp reflex at 7 months of age a positive Babinski sign at 2 months of age a Moro reflex at 3 months of age

an extrusion reflex at 9 months of age An extrusion reflex usually disappears around 4 months of age. A positive Babinski sign can be seen until 3 months of age. The plantar grasp disappears around 8 to 9 months of age. The Moro reflex disappears around 4 to 5 months of age.

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? hyperglycemia shivering metabolic alkalosis apnea

apnea Preterm newborns are at a greater risk for cold stress than term or postterm newborns. Cold stress can cause hypoglycemia, increased respiratory distress and apnea, and metabolic acidosis. Preterm infants lack the ability to shiver in response to cold stress.

A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum? inspecting the extremities for edema ensuring that the client consumes a high fiber diet assessing for cardiac decompensation limiting sodium intake

assessing for cardiac decompensation The nurse should assess the client with heart disease for cardiac decompensation, which is most common from 28 to 32 weeks' gestation and in the first 48 hours postpartum. Limiting sodium intake, inspecting the extremities for edema, and ensuring that the client consumes a high-fiber diet are interventions during pregnancy not in the first 48 hours postpartum.

A nurse is conducting a refresher program for a group of nurses returning to work in the newborn clinic. The nurse is reviewing the protocols for assessing vital signs in healthy newborns and infants. The nurse determines that additional education is needed when the group identifies which parameter as being included in the assessment? blood pressure respirations pain pulse temperature

blood pressure Because the readings can be inaccurate, blood pressure is not routinely assessed in term, normal healthy newborns with normal Apgar scores. It is assessed if there is a clinical indication such as suspected blood loss or low Apgar scores. Pain is assessed by objective signs of pain such as grimacing and crying in response to certain stimuli.

A primiparous mother gave birth to an 8 lb 12 oz (3970 g) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? formula feeding Rh positive blood type cephalohematoma hepatitis A vaccine female gender

cephalohematoma Risk factors for the development of jaundice include bruising as seen in a cephalohematoma, male gender, and being breastfed. Blood type incompatibility is only an issue if the infant's blood type differs from the mother and the maternal blood type is not stated. Administering hepatitis A vaccine does not increase the risk of jaundice.

A pregnant client with a history of heart disease has been admitted to a health care center reporting breathlessness. The client also reports shortness of breath and easy fatigue when doing ordinary activity. The client's condition is markedly compromised. The nurse would document the client's condition using the New York Heart Association (NYHA) classification system as which class? class II class III class IV class I

class III The nurse should classify the client's condition as belonging to class III of NYHA. In class III of NYHA classification, the client will be symptomatic with ordinary activity, and her condition is markedly compromised. The client is asymptomatic with all kinds of activity and is in uncompromised state in class I. The client is symptomatic with increased activity and is in slight compromised state in class II. The client is symptomatic when resting and is incapacitated in class IV.

When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which source? unsaturated fats complex carbohydrates saturated fats protein

complex carbohydrates The pregnant woman with diabetes is encouraged to eat three meals a day plus three snacks, with 40% of calories derived from good-quality complex carbohydrates, 35% of calories from protein sources, and 35% of calories from unsaturated fats. The intake of saturated fats should be limited during pregnancy, just as they should be for any person to reduce the risk of heart disease.

A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition? diabetes hypertension isoimmunization late maternal age

diabetes Approximately 18% of all women with diabetes will develop hydramnios during their pregnancy. Hydramnios occurs in approximately 2% of all pregnancies and is associated with fetal anomalies of development.

The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize? shortness of breath, bradycardia, and hypertension dyspnea, crackles, and irregular weak pulse regular heart rate and hypertension increased urinary output, tachycardia, and dry cough

dyspnea, crackles, and irregular weak pulse The nurse should be alert for signs of cardiac decompensation due to congestive heart failure, which include crackles in the lungs from fluid, difficulty breathing, and weak pulse from heart exhaustion. The heart rate would not be regular, and a cough would not be dry. The heart rate would increase rather than decrease.

A nurse is conducting a refresher program for a group of perinatal nurses. Part of the program involves a discussion of HELLP. The nurse determines that the group needs additional teaching when they identify which aspect as a part of HELLP? hemolysis low platelet count elevated lipoproteins liver enzyme elevation

elevated lipoproteins The acronym HELLP represents hemolysis, elevated liver enzymes, and low platelets. This syndrome is a variant of preeclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose diseases are labeled as severe.

Assessment of a newborn reveals microcephaly. The nurse develops a teaching plan for the parents about the need for follow-up care based on the understanding that the newborn is at risk for developing which complication(s)? Select all that apply. hydrocephalus achondroplasia hearing disorders cerebral palsy epilepsy

epilepsy cerebral palsy hearing disorders Infants with microcephaly are also noted to have additional complications such as epilepsy, cerebral palsy, intellectual disability, and ophthalmologic and hearing disorders. Hydrocephalus and achondroplasia are more commonly seen with macrocephaly.

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate? cord compression infection fetal distress related to hypoxia central nervous system (CNS) involvement

fetal distress related to hypoxia When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

On an Apgar evaluation, how is reflex irritability tested? tightly flexing the infant's trunk and then releasing it raising the infant's head and letting it fall back dorsiflexing a foot against pressure resistance flicking the soles of the feet and observing the response

flicking the soles of the feet and observing the response Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of the neonate's first breath? foramen ovale ductus venosus ductus arteriosus umbilical artery

foramen ovale Before birth, the foramen ovale allowed most of the oxygenated blood entering the right atrium from the inferior vena cava to pass into the left atrium of the heart. With the neonate's first breath, air pushes into the lungs, triggering an increase in pulmonary blood flow and pulmonary venous return to the left side of the heart. As a result, the pressure in the left atrium becomes higher than in the right atrium. The increased left atrial pressure causes the foramen ovale to close, thus allowing the output from the right ventricle to flow entirely to the lungs. The closure of the ductus arteriosus depends on the high oxygen concentration of the aortic blood that results from aeration of the lungs at birth. Closure of the ductus venosus occurs because shunting from the left umbilical vein to the inferior vena cava is no longer needed. The umbilical arteries and vein begin to constrict at birth because with placental expulsion blood flow ceases.

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy for the first 24 hours after birth? glucose carbohydrate protein brown fat

glucose Glucose is the main source of energy for the first several hours after birth. With the newborn's increased energy needs after birth, the liver releases glucose from glycogen stores for the first 24 hours. Stored protein, brown fat, or carbohydrate are not associated with energy production in the newborn.

A client has been admitted with placental abruption (abruptio placentae). She has lost 1,200 ml of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae? grade 1 grade 3 grade 4 grade 2

grade 2 The classifications for placental abruption (abruptio placentae) are: grade 1 (mild) - minimal bleeding (less than 500 ml), 10% to 20% separation, tender uterus, no coagulopathy, signs of shock or fetal distress; grade 2 (moderate) - moderate bleeding (1,000 to 1,500 ml), 20% to 50% separation, continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia; grade 3 (severe) - absent to moderate bleeding (more than 1,500 ml), more than 50% separation, profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased blood pressure, significant tachycardia, and development of disseminated intravascular coagulopathy. There is no grade 4.

A nurse in the hospital is caring for a client at 37 weeks' gestation who experienced premature rupture of the membranes (PROM) more than 24 hours prior to coming to the hospital. The client presents with a fever of 100.4°F (38°C). Complete the following sentence(s) by choosing from the lists of options. Due to the client's PROM more than 24 hours prior to arriving to the hospital, the nurse determines the client is at risk for contracting Select... bacterial vaginosis group B streptococcus trichomoniasis chlamydia and should plan to implement Select... administer intravenous antibiotics administer metronidazole recommend including probiotics in their diet request fluconazole for external use to prevent complications.

group B streptococcus administer intravenous antibiotics Group B streptococcus infection is a bacterial infection that can be transmitted to the fetus during labor. This can have cause serious complications to the newborn, including respiratory distress and sepsis. Group B streptococcus infection can be transmitted to the fetus during labor. The client is at risk for contracting group B streptococcus due to premature rupture of membranes (PROM) more than 24 hours prior to arriving at the hospital. The nurse will plan to administer intravenous antibiotics to the client prior to birth of the fetus. Chlamydia, trichomoniasis, and bacterial vaginosis are sexually transmitted infections (STIs). Unlike group B streptococcus infection, these infections are not transmitted to the fetus during labor. As STIs, the client is not at risk for contracting these infections because of PROM. Metronidazole is an anti-infective that is used to treat bacterial vaginosis, not group B streptococcus. Probiotics are used to maintain natural flora in the gastrointestinal (GI) system, not to treat group B streptococcus. Fluconazole is used to treat vaginal candidiasis, not group B streptococcus infections.

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common? genetic-linked hearing skeletal malformations vision

hearing Hearing loss is the most common birth defect in the United States: one in 1,000 newborns are profoundly deaf, and 3 in 1,000 have some degree of hearing impairment. Newborn hearing screening is required by law in most states. Vision, genetic-linked, and skeletal malformations are other forms of birth defects that can occur.

A nurse is providing care to a client who has been diagnosed with a common benign form of gestational trophoblastic disease. The nurse identifies this as: placenta accrete. ectopic pregnancy. hydatidiform mole. hydramnios.

hydatidiform mole. Gestational trophoblastic disease comprises a spectrum of neoplastic disorders that originate in the placenta. The two most common types are hydatidiform mole (partial or complete) and choriocarcinoma. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Ectopic pregnancy, placenta accreta, and hydramnios fall into different categories of potential pregnancy complications.

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? hyperbilirubinemia respiratory distress syndrome transient tachypnea of the newborn polycythemia

hyperbilirubinemia Neonatal red blood cells have a life span of 80 to 100 days and normally have a higher count at birth. This combination leads to increased hemolysis. Complications of this process include hyperbilirubinemia.

A nurse is conducting a class on gestational diabetes for a group of pregnant women who are at risk for the condition. The nurse determines that additional teaching is needed when the class identifies which complication as affecting the neonate? hyperglycemia birth trauma macrosomia hypoglycemia

hyperglycemia Gestational diabetes is associated with either neonatal complications such as macrosomia, hypoglycemia, and birth trauma or maternal complications such as preeclampsia and cesarean birth.

The nurse is providing care to a neonate. Review of the maternal history reveals that the mother is suspected of having a heroin use disorder. The nurse would be alert for which finding when assessing the neonate? hypertonicity vigorous sucking easy consolability low, feeble cry

hypertonicity Newborns of mothers with heroin or other opioid use disorder display irritability, hypertonicity, a high-pitched cry, vomiting, diarrhea, respiratory distress, disturbed sleeping, sneezing, diaphoresis, fever, poor sucking, tremors, and seizures.

Cytomegalovirus infection can result in different congenital anomalies. It can also be transmitted via different routes. When discussing this infection with a pregnant woman, the nurse integrates understanding that permanent fetal disability can occur with which type of transmission of CMV? with any transmission after birth transmission in utero transmission during birth transmission

in utero transmission There are three time periods during which mother-to-child transmission can occur; however, permanent disability occurs only in association with in utero infection. Such disability can result from maternal infection during any point in the pregnancy, but more severe disabilities are usually associated with maternal infection during the first trimester.

A pregnant woman diagnosed with cardiac disease 4 years ago is told that her pregnancy is a high-risk pregnancy. The nurse then explains that the danger occurs primarily because of the increase in circulatory volume. The nurse informs the client that the most dangerous time for her is when? in weeks 20 to 28 in weeks 8 to 12 in weeks 28 to 32 in weeks 12 to 20

in weeks 28 to 32 The danger of pregnancy in a woman with cardiac disease occurs primarily because of the increase in circulatory volume. The most dangerous time for a woman is in weeks 28 to 32, just after the blood volume peaks.

A nursing instructor is teaching students about anemia during pregnancy. Which type of anemia does the instructor teach students is most prevalent during pregnancy? folic acid anemia pernicious anemia iron-deficiency anemia sickle-cell anemia

iron-deficiency anemia Iron-deficiency anemia is the most common type in pregnancy. Many woman enter pregnancy with a low iron count because of poor diet, heavy menstrual periods, unwise weight-loss programs, or a combination of these.

A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which important area should the nurse address during assessment of the client? sexual development of the client whether sex was consensual options for birth control in the future knowledge of child development

knowledge of child development The nurse should address the client's knowledge of child development during assessment of the pregnant adolescent client. The nurse need not address the sexual development of the client or whether sex was consensual. This would not be an opportune time to discuss birth control methods to be used after the pregnancy.

Which measure would the nurse include in the plan of care for a woman with prelabor rupture of membranes if her fetus's lungs are mature? reduction in physical activity level observation for signs of infection labor induction administration of corticosteroids

labor induction With prelabor rupture of membranes (PROM) in a woman whose fetus has mature lungs, induction of labor is initiated. Reducing physical activity, observing for signs of infection, and giving corticosteroids may be used for the woman with PROM when the fetal lungs are immature.

The nurse is completing an assessment of a newborn. When auscultating the newborn's heart, the nurse would place the stethoscope at which area to auscultate the point of maximal impulse (PMI)? lateral to the midclavicular line at the fourth intercostal space at the fifth intercostal space at the right midclavicular line at the third intercostal space adjacent to the midclavicular line at the midsternum, just below the suprasternal notch

lateral to the midclavicular line at the fourth intercostal space The point of maximal impulse in a newborn is lateral to the midclavicular line at the fourth intercostal space. A displaced PMI may indicate a tension pneumothorax or cardiomegaly.

Which change in insulin is most likely to occur in a woman during pregnancy? unavailable because it is used by the fetus not released because of pressure on the pancreas less effective than normal enhanced secretion from normal

less effective than normal Somatotropin released by the placenta makes insulin less effective. This is a safeguard against hypoglycemia.

A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply. hemolysis elevated liver enzymes hyperthermia leukocytosis low platelet count

low platelet count hemolysis elevated liver enzymes The HELLP syndrome is a syndrome involving hemolysis (microangiopathic hemolytic anemia), elevated liver enzymes, and a low platelet count. Hyperthermia and leukocytosis are not features of HELLP syndrome.

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? oxytocin ondansetron promethazine methotrexate

methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

A pregnant client has tested positive for cytomegalovirus. What can this cause in the newborn? hypertension microcephaly bicuspid valve stenosis clubbed fingers and toes

microcephaly Signs that are likely to be present in the 10% of newborns who are symptomatic at birth include microcephaly, seizures, IUGR, hepatosplenomegaly, jaundice, and rash.

A pregnant client has a history of asthma. After reviewing the possible medications that may be prescribed during her pregnancy to control her asthma, the nurse determines additional teaching is needed when the client identifies which drug as being used? misoprostol ipratropium albuterol salmeterol

misoprostol Pharmacologic agents used to treat asthma in pregnancy fall into two categories: rescue agents and maintenance agents. Rescue agents provide immediate symptomatic relief by reducing acute bronchospasm. Agents used in this category include albuterol and ipratropium. Maintenance agents, by contrast, reduce the inflammation that leads to bronchospasm. Agents used in this category are inhaled steroids. Common ones prescribed include beclomethasone and salmeterol. Misoprostol is a prostaglandin that is used for treating postpartum hemorrhage but is contraindicated with asthma clients due to the risk of bronchial spasm and bronchoconstriction.

A pregnant client is admitted to a health care facility after their laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. Which assessment finding(s) does the nurse anticipate for this client? Select all that apply. epigastric pain and tenderness generalized edema excessive weight loss nausea and vomiting watery diarrhea

nausea and vomiting generalized edema epigastric pain and tenderness The findings of anemia, elevated liver enzymes, and low platelets are indications of hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome. The symptoms are similar to preeclampsia and can include epigastric or right upper quadrant pain and tenderness, nausea and vomiting, and generalized edema. Watery diarrhea and excessive weight loss are not symptoms of HELLP syndrome. Instead, weight gain may be seen in HELLP syndrome.

A 28-year-old primigravida client with type 2 diabetes comes to the health care clinic for a routine first trimester visit reporting frequent episodes of fasting blood glucose levels being lower than normal, but glucose levels after meals being higher than normal. What should the nurse point out that these episodes are most likely related to? tissue sensitivity to insulin increases using too much insulin at this stage of the pregnancy normal response to the pregnancy insulin resistance is starting to decrease

normal response to the pregnancy This is a normal response to the pregnancy. During pregnancy, tissues become resistant to insulin to provide sufficient levels of glucose for the growing fetus. This can result in three normally occurring responses: blood glucose levels are lower than normal when fasting; blood glucose levels are higher than normal after meals; and insulin levels are increased after meals. The various hormones will prevent the mother from using most of the insulin produced to allow the extra glucose to get to the growing fetus.

A pregnant client diagnosed with hyperemesis gravidarum is prescribed intravenous fluids for rehydration. When preparing to administer this therapy, which solution would the nurse anticipate being prescribed initially? albumin normal saline 0.45% sodium chloride dextrose 5% and water

normal saline For the client with hyperemesis gravidarum, parenteral fluids and drugs are prescribed to rehydrate the client and reduce the symptoms. The first choice for fluid replacement is generally isotonic, such as normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine, or vitamin B6) and electrolytes added. Dextrose 5% and water and 0.45% sodium chloride are hypotonic solutions that would cause the cells to swell and possibly burst. Albumin could lead to fluid overload.

A pregnant client has been diagnosed with gestational diabetes. Which are risk factors for developing gestational diabetes? Select all that apply. hypertension maternal age less than 18 years obesity previous large-for-gestational-age (LGA) infant genitourinary tract abnormalities

obesity hypertension previous large-for-gestational-age (LGA) infant Obesity, hypertension, and a previous infant weighing more than 9 lb (4 kg) are risk factors for developing gestational diabetes. Maternal age less than 18 years and genitourinary tract abnormalities do not increase the risk of developing gestational diabetes.

A woman with an artificial mitral valve develops heart failure at the 20th week of pregnancy. Which measure would the nurse stress with her during the remainder of the pregnancy? beginning a low-impact aerobics program obtaining enough rest maintaining a high fluid intake discontinuing her prepregnancy anticoagulant

obtaining enough rest As the blood volume doubles during pregnancy, heart failure can occur. The pregnant woman needs to obtain adequate rest to prevent overworking the heart. Fluid may need to be restricted.

A pregnant client is reporting of a large amount of malodorous vaginal discharge that is foamy and yellow-green in color, vaginal itching and painful intercourse. When asked, she also reports that urination is somewhat painful. She is diagnosed with trichomoniasis. What treatment would the nurse anticipate the client receiving? oral metronidazole ceftriaxone IM oral erythromycin benzathine penicillin G IM

oral metronidazole : Trichomoniasis is caused by a protozoan infection, which can cause preterm labor, low birth weight, and premature rupture of membranes. Treatment is oral metronidazole because it is more effective in treating the infection than the suppository or creams.

A woman at 35 weeks' gestation with severe polyhydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client? development of gestational trophoblastic disease hemorrhaging preterm rupture of membranes followed by preterm birth development of eclampsia

preterm rupture of membranes followed by preterm birth Even with precautions, in most instances of polyhydramnios, there will be preterm rupture of the membranes because of excessive pressure, followed by preterm birth. The other answers are less concerning than preterm birth in this pregnancy.

The nurse is admitting a G3 P2 client at 38 weeks' gestation who arrived reporting painless bleeding from the vagina leading to the diagnosis of placenta previa. When questioned by the client as to what caused this, which most likely factor should the nurse point out in her answer? maternal age more than 30 years living in coastal areas morbidly obese previous cesarean birth

previous cesarean birth The risk of placenta previa is greatly increased when a woman has had a previous cesarean delivery due to the scarring of the endometrial lining. Maternal age over 35 years, and not just more than 30 years, is considered another risk factor. Placenta previa is more common among those living in high altitudes not among those living in coastal areas. Obesity is not recognized as a potential risk for this condition. Other risk factors can include uterine insult or injury, cocaine use, prior placenta previa, infertility treatment, multiple gestations, previous induced abortion (medical abortion), smoking, previous myomectomy to remove fibroids, short interval between pregnancies, hypertension, or diabetes.

A pregnant client is brought to the health care facility with signs of premature rupture of the membranes (PROM). Which condition(s) and complication(s) are associated with PROM? Select all that apply. spontaneous abortion (miscarriage) placental abruption (abruptio placentae) prolapsed cord preterm labor placenta previa

prolapsed cord placental abruption (abruptio placentae) preterm labor The associated conditions and complications of premature rupture of the membranes are infection, prolapsed cord, placental abruption (abruptio placentae), and preterm labor. Spontaneous abortion (miscarriage) and placenta previa are not associated conditions or complications of premature rupture of the membranes.

During the assessment of a laboring client, the nurse learns that the client has cardiovascular disease (CVD). Which assessment would be priority for the newborn? temperature urine output respiratory function heart rate

respiratory function The nurse should identify respiratory distress syndrome as a major risk that can be faced by the offspring of a client with cardiovascular disease. While the other assessments are important, they are not priority.

A client is diagnosed with peripartum cardiomyopathy (PPCM). Which therapy should the nurse expect to administer to the client? restricted sodium intake monoamine oxidase inhibitors (MAOIs) ginger therapy methadone therapy

restricted sodium intake The client with peripartum cardiomyopathy should be prescribed a restricted sodium intake to control their blood pressure. Monoamine oxidase inhibitors are given to treat depression in pregnancy, not peripartum cardiomyopathy. Methadone is given for the treatment of a substance use disorder during pregnancy. Complementary therapies like ginger therapy help in the alleviation of hyperemesis gravidarum, not peripartum cardiomyopathy.

A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques? second period of reactivity period of decreased responsiveness There is no preferred time. first period of reactivity

second period of reactivity The second period of reactivity is the best time to teach about feeding, positioning for feeding, and diaper-changing techniques. It is also a good time for the parents to interact with the infant as well as examine the infant and ask questions.

A nurse is providing care to a pregnant client hospitalized with preeclampsia. The nurse immediately notifies the health care provider that the client has developed eclampsia based on which finding? proteinuria hyperreflexia blood pressure greater than 160/100 mm Hg seizure activity

seizure activity Although a blood pressure greater than 160/110 mm Hg, hyperreflexia and proteinuria are associated with eclampsia. The onset of seizure activity identifies eclampsia.

When dealing with a pregnant adolescent, the nurse assists the client to integrate the tasks of pregnancy while at the same time fostering development of which trait? autonomy trust self-identity dependence

self-identity The nurse assists the pregnant adolescent to integrate the tasks of pregnancy, bonding, and preparing to care for another with the tasks of developing self-identity and independence. Trust is a developmental task of infancy. Autonomy is a developmental task of toddlerhood. Independence, not dependence, is fostered.

A nurse is conducting a class on the effects of nicotine during pregnancy. Which complication(s) will the nurse include in the teaching? Select all that apply. preterm labor and birth premature rupture of membranes placenta previa spontaneous abortion (miscarriage) tubal ectopic pregnancy

spontaneous abortion (miscarriage) placenta previa preterm labor and birth tubal ectopic pregnancy premature rupture of membranes Smoking during pregnancy increases the risk of spontaneous abortion, preterm labor and birth, hypertension in the pregnant client, placenta previa, and placental abruption (abruptio placentae). It has also been considered an important risk factor for low birth weight, sudden infant death syndrome, and cognitive defects.

The nurse is caring for a pregnant client who is in her 30th week of gestation and has congenital heart disease. Which finding should the nurse recognize as a symptom of cardiac decompensation with this client? swelling of the face dry, rasping cough elevated temperature slow, labored respiration

swelling of the face Swelling of the face is a symptom of cardiac decompensation, along with moist, frequent cough and rapid respirations. Dry, rasping cough; slow, labored respiration; and an elevated temperature are not symptoms of cardiac decompensation.

An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant? hypoglycemia cardiac murmur tachypnea hyperthermia

tachypnea The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur.

The nurse is assessing a primigravida woman who reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. The nurse suspects the woman has contracted which disorder? chlamydia gonorrhea simple yeast infection trichomoniasis

trichomoniasis Trichomoniasis is caused by a one-celled protozoa. The symptoms include large amounts of foamy, yellow-green vaginal discharge. Treatment is with metronidazole, and her partner needs to be treated as well. A yeast infection presents with a cottage cheese-like discharge. Chlamydia often has no symptoms. If the woman does experience symptoms, these may include vaginal discharge, abnormal vaginal bleeding, and abdominal or pelvic pain. Gonorrhea may have symptoms so mild that they go unnoticed in the woman. The woman who contracts gonorrhea may have vaginal bleeding during sexual intercourse, pain and burning while urinating, and a yellow or bloody vaginal discharge.

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? every other day once a week two or three times per week once a day

two or three times per week Bathing two or three times weekly is sufficient for the first year; more frequent bathing may dry the skin.

Which factor would contribute to a high-risk pregnancy? history of allergy to honey bee pollen first pregnancy at age 33 type 1 diabetes blood type O positive

type 1 diabetes A woman with a history of diabetes has an increased risk for perinatal complications, including hypertension, preeclampsia, and neonatal hypoglycemia. The age of 33 without other risk factors does not increase risk, nor does type O-positive blood or environmental allergens.

A pregnant woman at 36 weeks' gestation comes to the care center for a follow-up visit. The woman is to be screened for group B streptococcus (GBS) infection. When describing this screening to the woman, the nurse would explain that a specimen will be taken from which area(s)? Select all that apply. rectum vagina nasal cavity conjunctiva throat

vagina rectum According to Centers for Disease Control and Prevention guidelines, all pregnant women should be screened for GBS at 35 to 37 weeks' gestation and treated. Vaginal and rectal specimens are cultured for the presence of the bacterium. Specimens from the throat, nasal cavity, or conjunctiva are not used.

New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll hold off on feeding him for a while because he might be too full." "We'll turn on the mobile that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly." "We'll swaddle him snuggly to make him feel secure."

"We'll hold off on feeding him for a while because he might be too full." Feeding or burping can be helpful in relieving air or stomach gas, and the parents should be made aware of this. Turning on a mobile above the newborn's head is helpful in calming the newborn. The movement is distracting, and the music is comforting. The newborn's back should be rubbed lightly while the parents speak softly to him. Swaddling the newborn provides security and comfort.

A woman comes to the clinic for her first prenatal visit. As part of the assessment, the woman is screened for rubella antibodies. The nurse determines that a client has immunity against rubella based on which rubella titer? 1:8 1:0 1:6 1:4

1:8 A rubella antibody titer of 1:8 or greater proves evidence of immunity. Women with titers of less than 1:8 should be immunized.

A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider? initial BP 140/85 mm Hg; current BP 130/80 mm Hg initial BP 100/70 mm Hg; current BP 140/90 mm Hg initial BP 110/60 mm Hg; current BP 112/86 mm Hg initial BP 120/80mm Hg; current BP 130/88 mm Hg

initial BP 100/70 mm Hg; current BP 140/90 mm Hg A proteinuria of trace to 1+ and a rise in blood pressure to above 140/90 mm Hg is a concern the client may be developing preeclampsia. The blood pressures noted in the other options are not indicative of developing preeclampsia. The edema would not necessarily be indicative of preeclampsia; however, edema of the face and hands would be a concerning sign for severe preeclampsia.

The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause? Lack of prenatal care The age of the mother Chromosomal abnormality Maternal smoking

Chromosomal abnormality The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done and the mother should feel no fault. The nurse needs to encourage the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother

A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? prevent maternal D antibody formation. prevent fetal Rh blood formation. stimulate maternal D immune antigens. promote maternal D antibody formation.

prevent maternal D antibody formation. Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis sweating and peripheral vasoconstriction radiation, convection, and conduction lack of brown adipose tissue

radiation, convection, and conduction Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? Birth trauma noted on left upper outer thigh. Mottling noted on left upper outer thigh. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. Harlequin sign noted on left upper outer thigh.

Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. A congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spot) is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted.

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success? Use of cameras at all doors Cooperation by the parents with the hospital policies Use of monitor attached to babies Use of pass codes onto the unit

Cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

A pregnant client with sickle cell anemia is admitted in crisis. Which nursing intervention should the nurse prioritize? antibiotics antihypertensive drugs diuretic drugs IV fluids

IV fluids A sickle cell crisis during pregnancy is usually managed by exchange transfusion, oxygen, and IV fluids. Antihypertensive drugs usually aren't necessary. Diuretics would not be used unless fluid overload resulted. The client would be given antibiotics only if there were evidence of an infection.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? Instill 0.5% ophthalmic tetracycline. Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation. Instill 0.5% ophthalmic silver nitrate.

Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

The maternal health nurse is caring for a group of high-risk pregnant clients. Which client condition will the nurse identify as being the highest risk for pregnancy? Loud systolic murmur Secondary hypertension Pulmonary hypertension Repaired atrial septal defect

Pulmonary hypertension Pulmonary hypertension is considered the greatest risk to a pregnancy because of the hypoxia that is associated with the condition. The remaining conditions represent potential cardiac complications that may increase the client's risk in pregnancy; however, these do not present the greatest risk in pregnancy.

The ability of the nurse to identify irregular findings during a physical assessment aids in rapid diagnosis and treatment of possible complications. The nurse assesses a newborn and notes tachycardia. The nurse notifies the health care provider based on the understanding that further assessment is necessary for which condition? drug withdrawal hypothermia anemia infection

drug withdrawal Tachycardia may be found with volume depletion, cardiorespiratory disease, drug withdrawal, and hyperthyroidism.

A client at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse? "It is hard to know why a woman bleeds during early pregnancy." "I can understand your need to find an answer to what caused this. Let's talk about this further." "Your spontaneous bleeding is not work-related." "Something was wrong with the fetus."

"I can understand your need to find an answer to what caused this. Let's talk about this further." Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? " I will change my baby's diapers frequently." "It is not necessary to give my baby a bath daily." "I will give sponge baths until the umbilical cord falls off." "I can use talc powders to prevent diaper rash."

"I can use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct

The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response? "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." "A newborn delivered by cesarean has less sensory stimulation to breathe." "Surfactant may be missing from the lungs depending on the newborn's gestational age." "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery."

"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.

A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best? "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." "I know that it is sad but the pregnancy must be terminated to save your life." "You have experienced an incomplete abortion (miscarriage) and must have the placenta and any other tissues cleaned out." "The choice is up to you but the health care provider is recommending an induced abortion (medical abortion).

"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an abortion (elective termination of pregnancy) or an incomplete miscarriage.

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? "The muscle opening that leads into the stomach is not mature." "He needs to get food orally to make vitamin K." "The newborn's gut is sterile at birth." "His stomach can hold approximately 10 ounces."

"His stomach can hold approximately 10 ounces." A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature.

The parents of a newborn male ask the nurse about circumcision. They are undecided as to what to do. Which response by the nurse is best? "I recommend you discuss the pros and cons of circumcision with the newborn's health care provider." "Circumcision is best because it will prevent the baby from obtaining a sexually transmitted infection." "If you do not circumcise your baby, he will have difficulty maintaining adequate hygiene." "It is best not to circumcise your baby because the procedure is very painful for newborns."

"I recommend you discuss the pros and cons of circumcision with the newborn's health care provider." If the parents decide to have their male newborn circumcised, informed consent is necessary. It is the health care provider's responsibility to obtain informed consent, although the nurse may be responsible for witnessing the parents' signatures to written documentation of that consent. If the parents have unanswered questions, the nurse will notify the health care provider before the procedure is done. Circumcision will decrease the chance of obtaining an STI but will not prevent them in the future. Hygiene can be maintained with proper retraction of the foreskin. The procedure is painful, but all pros and cons should be discussed before making a decision

A pregnant client with a history of asthma since childhood presents for a prenatal visit. What statement by the client alerts the nurse to perform further assessment? "I sometimes get a bit wheezy." "Certain substances make me sneeze." "I sometimes get a feeling of euphoria." "I have trouble getting comfortable in bed."

"I sometimes get a bit wheezy." Wheezing is a classic symptom of asthma. This statement should alert the nurse to the possibility that the client's asthma is not being well-controlled and needs further evaluation and possible intervention. The other statements do not relate to the typical presentation of this disease in pregnancy nor are they cause for concern.

A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best? "Please come in now for an evaluation by your health care provider." "If the bleeding lasts more than 24 hours, call us for an appointment." "Bleeding during pregnancy happens for many reasons, some serious and some harmless." "Lie on your left side and drink lots of water and monitor the bleeding."

"Please come in now for an evaluation by your health care provider." Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "It is best practice to change the diaper every 2 to 4 hours, even during the night." "We will fold down the front of her diaper under the umbilical cord until it falls off." "We should clean the skin with soap and water after each bowel movement."

"We will fold down the front of her diaper under the umbilical cord until it falls off." In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids? 8 to 10 4 to 6 2 to 4 6 to 8

6 to 8 From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 7. 8. 5. 6.

7. The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).

A pregnant client is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. Which sign would indicate a positive test result? An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. A flat, circumscribed area under 10 mm in diameter appears in 6 to 12 hours. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. A flat circumscribed area over 10 mm in diameter appears in 48 to 72 hours.

An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat, circumscribed area.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Reduced risk of penile cancer Lower rate of urinary tract infections Anesthetic may not be effective during the procedure Fewer complications than if done later in life

Anesthetic may not be effective during the procedure The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

A nurse is caring for a pregnant client with sickle cell anemia. What should the nursing care for the client include? Select all that apply. Teach the client meticulous handwashing. Assess serum electrolyte levels of the client at each visit. Instruct the client to consume protein-rich food. Urge the client to drink 8 to 10 glasses of fluid daily. Assess hydration status of the client at each visit.

Assess hydration status of the client at each visit. Urge the client to drink 8 to 10 glasses of fluid daily. Teach the client meticulous handwashing. The nurse caring for a pregnant client with sickle cell anemia should teach the client meticulous handwashing to prevent the risk of infection, assess the hydration status of the client at each visit, and urge the client to drink 8 to 10 glasses of fluid daily. The nurse need not assess serum electrolyte levels of the client at each visit or instruct the client to consume protein-rich food.

A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first? Assess the client's vital signs. Obtain a surgical consent from the client. Administer oxygen to the client. Provide emotional support to the client and significant other.

Assess the client's vital signs. A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature? Monitor the newborn's skin for changes related to fluid loss, such as turgor. Assure the newborn has a cap on the head and is kept covered. Maintain accurate intake and output and monitor for dehydration. Educate the parents to rinse the newborn skin well after using soap.

Assure the newborn has a cap on the head and is kept covered. Newborns have a large surface area to body mass ratio and are particularly susceptible to heat loss. The nurse will assure the newborn wears a cap on the head and is kept covered to avoid heat loss. The nurse would monitor intake and output but not related to temperature regulation. The skin of the newborn should be dried well after any liquid is noted (urine, cleansing wipes, etc.) to prevent temperature loss but not specifically because of the large surface area. The newborn's skin needs to be monitored but not specifically for temperature regulation.

The nurse is caring for a pregnant client who indicates that she is fond of meat, works with children, and has a pet cat. Which instructions should the nurse give this client to prevent toxoplasmosis? Select all that apply. Avoid contact with children when they have a cold. Keep the cat outdoors at all times. Avoid cleaning the cat's litter box. Avoid outdoor activities such as gardening. Eat meat cooked to 160° F (71° C).

Avoid outdoor activities such as gardening. Eat meat cooked to 160° F (71° C). Avoid cleaning the cat's litter box. To minimize risk of toxoplasmosis, the nurse should instruct the client to eat meat that has been cooked to an internal temperature of 160° F (71° C) throughout and to avoid cleaning the cat's litter box or performing activities such as gardening. Avoiding children with colds is unreasonable when working with children, and contact with children with colds is not a cause of toxoplasmosis. The cat should be kept indoors to prevent it from hunting and eating birds or rodents.

The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize? Check blood sugar levels daily. Include iron-enriched foods in the diet. the signs and symptoms of urinary tract infection Take daily iron supplements.

Check blood sugar levels daily. An elevated blood glucose is concerning for diabetes. A fasting blood glucose level of greater than 140 mg/dl (7.77 mmol/L) or random level of greater than 200 mg/dl (11.10 mmol/L) is concerning; this must be followed up to ensure the client is not developing gestational diabetes. The hemoglobin and hematocrit are within normal limits for this client. The values should be hemoglobin greater than 11 g/dl (110 g/L) and hematocrit greater than 33% (0.33). Values lower than that are possible indications of anemia and would necessitate further evaluation. An individual with higher than normal blood glucose levels is at risk for developing urinary tract infection. This will usually happen after the glucose levels are elevated. Anemia can be treated by increasing the consumption of iron-enriched foods and taking a daily iron supplement.

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? Check the name on the baby's identification bracelet. Send a family member to accompany the infant when leaving the room. Provide a list of approved visitors who came spend time with the infant. Check the identification badge of any health care worker before releasing baby from room.

Check the identification badge of any health care worker before releasing baby from room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor? Exposure to chemicals or radiation Advanced maternal age Chromosomal defects in the fetus Faulty implantation

Chromosomal defects in the fetus Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.

What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test? Inform the mother of the results of the hearing test completed on the newborn. Determine if it is time for the mother to breastfeed the newborn and assist as needed. Compare the identification bracelets prior to leaving the newborn with the mother. Explain the procedure completed on the newborn to the mother.

Compare the identification bracelets prior to leaving the newborn with the mother. Accurate infant identification is imperative in hospital protocols. The nurse should always compare the newborn's identification bracelet with that of the mother to ensure that the correct newborn is being given to the correct mother. The nurse will provide the results of the test and assist with breastfeeding; however, these are not priority as the nurse could come back if needed. The nurse should explain a procedure before it is completed

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Convection Conduction Evaporation Radiation

Convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth? Heel but no anterior creases Creases covering one fourth of the foot Creases on two-thirds of the foot Longitudinal but no horizontal creases

Creases on two-thirds of the foot As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel.

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Stimulate the neonate. Inform the charge nurse. Call the primary care provider. Document the data.

Document the data. The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C).

The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex? Turn the head to one side without moving the rest of the body. Place a gloved finger in the newborn's mouth. Gently stroke the newborn's cheek. Startle the newborn by letting the head drop back slightly.

Gently stroke the newborn's cheek. Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex.

The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: thyroid stimulating hormone (TSH) slightly elevated, glucose in the urine, complete blood count (CBC) low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition? Anemia Preeclampsia Gestational diabetes Hyperthyroidism

Gestational diabetes Glycosuria, glucose in the urine, may occur normally during pregnancy; however, if it appears in the urine, the client should be sent for testing to rule out gestational diabetes. Preeclampsia, anemia, and hyperthyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hypothyroidism instead of hyperthyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.

The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: thyroid stimulating hormone (TSH) slightly elevated, glucose in the urine, complete blood count (CBC) low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition? Anemia Hyperthyroidism Gestational diabetes Preeclampsia

Gestational diabetes Glycosuria, glucose in the urine, may occur normally during pregnancy; however, if it appears in the urine, the client should be sent for testing to rule out gestational diabetes. Preeclampsia, anemia, and hyperthyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hypothyroidism instead of hyperthyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.

A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia? Take a low-dose antihypertensive prophylactically. Take one aspirin every day. Monitor the client for headaches or swelling on the body. Have her blood pressure checked at every prenatal visit.

Have her blood pressure checked at every prenatal visit. Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention—nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors.

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family? Place a second stockinette on the baby's head. Help the mother provide skin-to-skin (kangaroo) care. Administer a warm bath with temperature slightly higher than usual. Place the infant under a radiant warmer.

Help the mother provide skin-to-skin (kangaroo) care. The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.

A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Determine the newborn's weight. Administer the medication. Identify the newborn. Assess the newborn for bleeding.

Identify the newborn. The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? Notify the doctor to come suture the site of the bleeding. Clean the cord with soap and water, as oozing of blood is a common finding. Remove the clamp and replace with another one just above the old one. Inspect the clamp to insure that it is tightly closed and applied correctly.

Inspect the clamp to insure that it is tightly closed and applied correctly. Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed.

The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation? Jugular distention Nausea and vomiting Abdominal cramps Urinary retention

Jugular distention A woman who has a cardiac condition is at increased risk in the postpartum period. The most important nursing action is to monitor for signs of cardiac decompensation. The nurse should monitor for and report jugular distention, clubbing, and slow capillary refill time. If an irregular pulse is noted, compare it to the apical pulse. The abdominal cramps may be related to the uterus involution. The nausea and vomiting and urinary retention may be related to the surgical procedure and not necessarily the cardiac issue.

A nurse is teaching a new mother about her neonate and the changes that are occurring as the neonate adapts to life outside the client's uterus. The nurse would incorporate understanding of which change when describing the neonate's current status? Select all that apply. The respiratory system is now fluid filled and under high pressure. The neonate's body temperature is maintained by the extrauterine environment. Right atrial pressure is greater than the left leading to closure of the foramen ovale. Lungs are now responsible for the exchange of oxygen and carbon dioxide. The liver begins functioning as the ductus venosus closes.

Lungs are now responsible for the exchange of oxygen and carbon dioxide. The liver begins functioning as the ductus venosus closes. With the neonate, the lungs are now responsible for gas exchange, and the respiratory system is an air-filled, low-pressure system. Hepatic portal circulation begins with closure of the ductus venosus. The neonate's body temperature is maintained through a flexed posture and brown fat

The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? Monitor the mass with transvaginal ultrasound. Monitor the fetal heart rate (FHR). Monitor the client's beta-hCG level. Monitor the client's vital signs and bleeding.

Monitor the client's vital signs and bleeding. A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending spontaneous abortion (miscarriage). Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. The outside temperature is 55°F (12.8°C). Which action should the nurse prioritize? Check the infant's vital signs. Place another blanket on the infant. Move the infant away from the window. Observe infant's status.

Move the infant away from the window. The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room.

A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client? Switch to feeding breast milk. No action is need; this is normal. Change to a soy-based formula. Increase the newborn's fluid intake.

No action is need; this is normal. The nurse should tell the client not to worry because it is perfectly normal for the stools of a formula-fed newborn to be greenish, loose, pasty, or formed in consistency, with an unpleasant odor. There is no need to change the formula, increase the newborn's fluid intake, or switch from formula to breast milk.

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? Measure fundal height. Palpate the fundus and check fetal heart rate. Obtain a voided urine specimen and determine blood type. Check deep tendon reflexes.

Palpate the fundus and check fetal heart rate. The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? Start an IV to provide intravenous glucose. Perform a heel stick to obtain a blood sample for testing for glucose level. Feed the newborn some formula immediately. Check the client's blood sugar by a venous blood draw.

Perform a heel stick to obtain a blood sample for testing for glucose level. If a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level. After the glucose level is determined, then the nurse will determine what interventions to implement. A venous blood draw is not needed to check the newborn's glucose level.

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? Breastfeeding jaundice. Pathologic jaundice. Bile duct blockage. Physiologic jaundice.

Physiologic jaundice. Physiologic jaundice occurs 48 hours or more after birth. Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Breastfeeding jaundice occurs later within the first week of life. Evidence of bile duct blockage would be more severe and noted at an earlier age.

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between placental abruption (abruptio placentae) and placenta previa. Which statement will the nurse include in the teaching? Placenta previa causes painful, dark red vaginal bleeding during pregnancy. Placenta previa is an abnormally implanted placenta that is too close to the cervix. Placental abruption results in painless, bright red vaginal bleeding during labor. Placental abruption requires "watchful waiting" during labor and birth.

Placenta previa is an abnormally implanted placenta that is too close to the cervix. Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless, bright red bleeding in the third trimester. Placental abruption is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor. Placental abruption can result in concealed or apparent dark red bleeding and is painful. Immediate intervention is required for placental abruption.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? Report the finding to the pediatrician. Since it looks like a milk curd, no action is needed. Rinse the tongue off with sterile water and a cotton swab. Wipe the tongue off vigorously to remove the white patches.

Report the finding to the pediatrician. Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patche

Which statement is true regarding fetal and newborn senses? The rooting reflex is an example that the newborn has a sense of touch. A newborn cannot see until several hours after birth. A newborn cannot experience pain. A fetus is unable to hear in utero. A newborn does not have the ability to discriminate between tastes.

The rooting reflex is an example that the newborn has a sense of touch. The rooting reflex is an example of a newborn's sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The fetus can hear in utero.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn? Toes fan out when sole of foot is stroked. Newborn's toes curl over the nurse's finger. Newborn throws arms outward and flexes knees. Newborn makes stepping motion.

Toes fan out when sole of foot is stroked. The Babinski sign is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger

The clinic nurse teaches a client with pregestational type 1 diabetes that maintaining a constant insulin level is very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use: regular insulin twice a day. an insulin drip. an insulin pump. an insulin pen.

an insulin pump. Because a pregnant client will have some periods of relative hyperglycemia and hypoglycemia no matter how carefully the client maintains diet and balances exercise levels, an effective method to keep serum glucose levels constant is to administer insulin with a continuous pump during pregnancy.

A nurse is teaching a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority? avoidance of infection consumption of a low-fat diet constipation prevention administration of immunoglobulins

avoidance of infection Prevention of crises, if possible, is the focus of treatment for the pregnant woman with sickle cell anemia. Maintaining adequate hydration, avoiding infection, getting adequate rest, and eating a balanced diet are all common-sense strategies that decrease the risk of a crisis. Fat intake does not need to be decreased and immunoglobulins are not normally administered. Constipation is not usually a result of sickle cell anemia.

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice? decreased bilirubin conversion bilirubin hyperexcretion bilirubin overproduction impaired bilirubin excretion

bilirubin hyperexcretion Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirubin conjugation or conversion, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice.

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? heart rate temperature blood sugar Apgar score

blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dl).

A new young mother has tested positive for HIV. When discussing the situation with the client, the nurse should advise the mother that she should avoid which activity? breastfeeding handling the infant with open sores future pregnancies cesarean birth

breastfeeding Breastfeeding is a major contributing factor for mother-to-child transmission of HIV. Cesarean birth before the onset of labor and/or rupture of membranes can greatly reduce the chance of transmitting the infection to the infant. Future pregnancies should be discussed and decided on an individual basis. Proper treatment of any open wounds and education should be provided to the mother to ensure she reduces the chance of transmitting HIV to her infant.

A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to: check her blood sugars frequently and adjust insulin accordingly. limit weight gain to 15 pounds during the pregnancy. begin oral hyperglycemic medications along with the insulin she is currently taking. exercise for 1 to 2 hours each day to keep the blood glucose down.

check her blood sugars frequently and adjust insulin accordingly. The goal for a mother who has type I diabetes mellitus is to keep tight control over her blood sugars throughout the pregnancy. Therefore, she needs to test her blood sugar frequently during the day and make adjustments in the insulin doses she is receiving.

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client? glucagon diet long-acting insulin oral hypoglycemic drugs

diet Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are usually not given during pregnancy and would not be the first option. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.

A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect? gradual onset of symptoms firm, rigid uterus on palpation absence of pain fetal heart rate within normal range

firm, rigid uterus on palpation The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: harlequin sign. erythema toxic. congenital dermal melanocytosis (slate gray nevi). stork bites.

harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots) are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence? prolonged unsuccessful vaginal birth loss of blood volume due to hemorrhage lack of thoracic compressions during birth Inadequate suctioning of the mouth and nose of the newborn

lack of thoracic compressions during birth A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.

Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? ondansetron promethazine methotrexate oxytocin

methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? after the newborn has received the initial feeding on admission to the nursery 24 hours after admission to the nursery 4 hours after admission to the nursery

on admission to the nursery Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.

The nurse explains to a pregnant client that she will need to take iron during her pregnancy after being diagnosed with iron-deficiency anemia. The nurse suggests that absorption of the supplemental iron can be increased by taking it with which substance? orange juice legumes meals high in iron milk

orange juice Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron.

A nurse is observing the interaction between a new mother and the neonate. The nurse notes that the neonate moves the head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response? habituation self-quieting behavior motor maturity orientation

orientation The neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on that stimuli. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves.

A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV? respiratory rate ability to sleep urine protein hemoglobin

respiratory rate A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.

A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as: social behavior. motor maturity. the sleep state. self-quieting ability.

self-quieting ability. Self-quieting ability refers to newborns' ability to quiet and comfort themselves. Assisting parents to identify consoling behaviors also helps. The sleep state is noted as an infant becoming drowsy and less attentive to the parents and his surroundings. Social behaviors are things such as cuddling and snuggling into the arms of the parents when the newborn is held. Motor maturity refers to posture, tone, coordination, and movements of the newborn.

A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time? hypertension premature birth spontaneous abortion (miscarriage) preterm labor

spontaneous abortion (miscarriage) The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for spontaneous abortion (miscarriage). Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.

A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)? no passage of fetal tissue slight vaginal bleeding closed cervical os strong abdominal cramping

strong abdominal cramping Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion

A nurse is performing an assessment on a new client. The woman estimates that she is approximately 16 weeks pregnant. While assessing her, the nurse asks her about apparent scratch marks on her hands, and she tells the nurse that she has three cats at home. What screening would be prescribed for this woman? herpes simplex virus hepatitis C toxoplasmosis cytomegalovirus

toxoplasmosis Toxoplasmosis is an infection caused by the protozoan Toxoplasma gondii, also referred to as T. gondii. Transmission is via undercooked meat and through cat feces. Toxoplasmosis is a common infection in humans and usually produces no symptoms. However, when the infection passes from the woman through the placenta to the fetus, a condition called congenital toxoplasmosis can occur. Approximately 400 to 4,000 cases of congenital toxoplasmosis occur per year in the United States (Williams, 2007). The classic triad of symptoms for congenital toxoplasmosis is chorioretinitis, intracranial calcification, and hydrocephalus in the newborn.

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding? greenish black with a tarry consistency tan in color with a firm consistency yellowy mustard color with seedy appearance brownish black with a mucus-like appearance

yellowy mustard color with seedy appearance The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like.

The heart rate of the newborn in the first few minutes after birth will be in which range? 180 to 220 bpm 80 to 120 bpm 110 to 160 bpm 120 to 130 bpm

110 to 160 bpm During the first few minutes after birth, the newborn's heart rate is approximately 110 to 160 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm.

A pregnant client with type 1 diabetes is in labor. The client's blood glucose levels are being monitored every hour and she has a prescription for an infusion of regular insulin as needed based on the client's blood glucose levels. Her levels are as follows: 1300: 105 mg/dL (5.83 mmol/L) 1400: 100 mg/dL (5.55 mmol/L) 1500: 120 mg/dL (6.66 mmol/L) 1600: 106 mg/dl (5.88 mmol/L) Based on the recorded blood glucose levels, at which time would the nurse likely administer the regular insulin infusion? 1500 1300 1600 1400

1500 For the laboring woman with diabetes, intravenous (IV) saline or lactated Ringer's is given, and blood glucose levels are monitored every 1 to 2 hours. Glucose levels are maintained below 110 mg/dL (6.11 mmol/L) throughout labor to reduce the likelihood of neonatal hypoglycemia. If necessary, an infusion of regular insulin may be given to maintain this level. The insulin infusion would be given at 1500, based on the blood glucose level being higher than 110 mg/dL (6.11 mmol/L).

A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess? painless bright red vaginal bleeding increased fetal movement generalized vasospasm "knife-like" abdominal pain with vaginal bleeding

"knife-like" abdominal pain with vaginal bleeding The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placentae.

What is the expected range for respirations in a newborn? 40 to 80 breaths per minute 10 to 30 breaths per minute 30 to 60 breaths per minute 20 to 40 breaths per minute

30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute.

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? 10% to 15% of their birth weight 20% of their birth weight 5% to 10% of their birth weight 15% to 18% of their birth weight

5% to 10% of their birth weight Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth.

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids? 6 to 8 4 to 6 2 to 4 8 to 10

6 to 8 From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 5 to 9. 1 to 2. 12 to 15. 7 to 10.

7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring

A nurse is assessing a newborn five minutes after birth and notes: HR 110 bpm; a good, strong cry; well flexed extremities; grimacing when slapped on the sole of the foot; and normal pigment in most of the body, with blue hands and feet. What Apgar score will the nurse document for this infant? 9 6 8 7

8 The heart rate of 110 bpm, the strong cry, and the muscles of the extremities being well flexed each indicate a score of 2 in the heart rate, respiratory effort, and muscle tone areas, respectively. The grimace in response to a slap to the sole of the foot and the blue at the extremities each indicate a score of 1 for the reflex irritability and color areas, respectively. Thus, the total Apgar score for this infant is 8 (2 + 2 + 2 + 1 + 1 = 8).

A client is 33 weeks' pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled? 85 mg/dl 120 mg/dl 45 mg/dl 136 mg/dl

85 mg/dl Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dl. A fasting blood glucose level of 45 g/dl is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dl is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dl in a pregnant client indicates hyperglycemia.

A client is 33 weeks' pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled? 45 mg/dl 120 mg/dl 136 mg/dl 85 mg/dl

85 mg/dl Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dl. A fasting blood glucose level of 45 g/dl is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dl is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dl in a pregnant client indicates hyperglycemia.

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Limit the bathing time to 5 minutes. Postpone breastfeeding until after the initial bath. Bathe the baby in water between 90 and 93 degrees. Bathe the baby under a radiant warmer.

Bathe the baby under a radiant warmer. Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.

A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilation (dilatation) to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point? Give birth vaginally Education on causes of cervical insufficiency for the future Bed rest to maintain pregnancy as long as possible Notification of social support for loss of pregnancy

Bed rest to maintain pregnancy as long as possible At 22 weeks' gestation, the fetus is not viable. The woman would be placed on total bed rest with every attempt made to halt any further progression of dilation (dilatation) of the cervix. The nurse would not want this fetus to be born vaginally at this stage of gestation. It is not the nurse's responsibility to notify the client's social support of a possible loss of the pregnancy. It is not appropriate at this time to educate the mother on causes of cervical insufficiency for future pregnancies.

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? Caput succedaneum Molding Harlequin sign Increased intracranial pressure

Caput succedaneum Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? Check blood glucose. Place child in a radiant warmer. Assess the baby's temperature. Assess for pain source.

Check blood glucose. One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting 1cc of medication Using a 21-gauge needle Injecting at a 45-degree angle Injecting the medication into the vastus lateralis

Injecting the medication into the vastus lateralis Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc of medication at a 90-degree angle.

A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole? Dark red, "clumpy" vaginal discharge Painful uterine contractions and nausea Bright red, painless vaginal bleeding Brisk deep tendon reflexes and shoulder pain

Dark red, "clumpy" vaginal discharge Women with hydatidiform mole ("molar pregnancy") often pass blood clots or watery brown/dark red discharge from the vagina in the first trimester. If a complete molar pregnancy continues into the second trimester undetected, other signs and symptoms appear. The woman often presents with complaints of dark to bright red vaginal bleeding and pelvic pain. Infrequently, she will report passage of grapelike vesicles.

A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize? Increase fluids and take more vitamins. Discuss induction of labor with the health care provider. Decrease activity and rest more often. Bed rest and bathroom privileges only until birth.

Decrease activity and rest more often. If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend an increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Report tachypnea. Put warming blanket over infant. Document normal findings. Recheck blood pressure in 15 minutes.

Document normal findings. These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6°F (36.5°C to 37.5°C). Blood pressure should be 60-80/40-45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Identification bands Glucose water Suction equipment Ophthalmoscope Warmer bed

Suction equipment Identification bands Warmer bed In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? orientation to surroundings voluntary movements reflex crying response

reflex The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.