Evolve Maternity

By how much should the nurse instruct a pregnant client to increase her daily protein intake?

10 g

A primigravida in her seventh week of gestation asks the nurse when she can expect to feel her baby move. The nurse replies that quickening usually occurs in the:

20th week

A mother is breastfeeding her newborn. She asks when she may switch the baby to a cup. The nurse concludes that the mother understands the teaching about feeding when she says she will start to introduce a cup after the baby reaches:

6 months

A female client came to the clinic with suspected primary syphilis. What sign of primary syphilis does the nurse expect the client to exhibit?

An indurated painless nodule on the vulva that is draining

While observing a newborn with a diaphragmatic hernia, what does the nurse expect to identify?

Barrel-shaped chest

In childbirth classes the nurse is teaching paced breathing techniques for use during labor. In which order should the breathing techniques be used as labor progresses?

Cleansing breaths Slow, deep breaths Modified-paced breathing Pant-blow breathing Slow, exhalation pushing

A nurse is caring for a client in labor who is receiving epidural anesthesia. For which common side effect of this route of anesthesia should the client be monitored?

Hypotensive episodes

A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem?

Inborn error of metabolism

What nursing care is most important for a newborn with respiratory distress syndrome (RDS)?

Keeping the infant in a warm environment

A nurse is caring for a client in labor whose cervix is dilated 6 cm. The client is receiving epidural analgesia. What common response to regional anesthesia does the nurse anticipate?

Lightheadedness

Why is it important for the nurse to know the infant's gestational age and how it compares with the birthweight?

Potential problems may be identified.

A nurse is testing a newborn's heel blood for the level of glucose. Which newborn does the nurse anticipate will experience hypoglycemia? (Select all that apply.)

Preterm infant Small-for-gestational-age infant Large-for-gestational-age infant

A new father tells the nurse that he is anxious about not feeling like a father. What is the priority nursing action to meet this father's needs?

Providing time for the father to be alone with and get to know the baby

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? (Select all that apply.)

Reflex irritability: cry Respiratory rate: good cry Heart rate: 110 beats/min

A nurse at a women's health clinic confirms that client teaching regarding the use of an oral contraceptive is understood when the client states, "I:

Will put a baby's picture on my bathroom mirror so I'll see it every morning"

A primigravida is admitted with a ruptured fallopian tube resulting from a tubal pregnancy and surgery is performed to remove the fallopian tube. What should postoperative nursing care include?

Explaining that the client may still be capable of becoming pregnant

A newborn experiences a hypothermic period while being bathed and having clothing changed. Once the hypothermic episode has been identified and treated, what is the next nursing action?

Feeding the infant

A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?

Identifying the infant, assessing respirations, and keeping him warm

A newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. What should the nurse explain to the mother about the purpose of PKU testing?

It is used to measure protein metabolism.

A client with a large fetus is to have a pudendal block during the second stage of labor. What does the nurse plan to instruct the client about the effectiveness of the block? (Select all that apply.)

Perineal pain will not be felt. The bearing-down reflex will be diminished.

Which statements by a client with hyperemesis gravidarum would confirm that the client needs further teaching? (Select all that apply.)

"I'll start limiting my carbohydrates." "I'll lie down for at least 2 hours after I eat."

After 18 months of unsuccessful attempts at conception by a client, primary infertility related to anovulatory cycles is diagnosed. Clomiphene citrate (Clomid) is prescribed. The nurse concludes that the client understands the teaching about the correct time to take the clomiphene when the she states:

"I'll start the pills on the fifth day of my cycle."

A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out!" Examination reveals that her cervix is dilated 9 cm. What should the nurse say while trying to calm the client?

"Medication may interfere with the baby's first breaths; keep breathing."

A couple arrives at the newborn nursery asking to take their newborn grandson to his mother's room. What is the best response by the nurse?

"Please go on to see your daughter. I'll bring the baby to her room."

The nurse concludes that a couple with a newborn with Erb's palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion?

"Recovery usually occurs in about 3 months."

A mother is inspecting her newborn girl for the first time. The infant's breasts are edematous, and she has a pink vaginal discharge. How should the nurse respond when the mother asks what is wrong?

"The swelling and discharge are expected. They're a response to your hormones."

During a childbirth class, several participants have questions about the elective induction of labor. One participant states that it is more convenient for a woman with a busy schedule. What evidenced-based information should the nurse provide to the participant?

"The widespread use of elective induction increases the risk of unfavorable outcomes."

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?

"We'll have to have the baby fitted with prosthetic devices before he'll be able to walk."

Four weeks after giving birth, a client is agitated and tells the clinic nurse, "The baby cries all the time, and I don't know what to do." What question should the nurse ask before planning nursing care?

"What is the baby's daily schedule?"

A nurse takes into consideration that the effect PKU has on the infant's development will depend on:

Adherence to a corrective diet instituted early

Twenty-four hours after an uncomplicated labor and birth a client's complete blood count reveals a white blood cell (WBC) count of 17,000/mm3. How should the nurse interpret this WBC count?

An expected response to the process of labor and birth

At her first prenatal clinic visit a primigravida has blood drawn for a rubella antibody screening test, and the results are positive. What intervention is important when the nurse discusses this finding with the client?

Asking her whether she has had German measles and when she had the disease

After reading that nutrition during pregnancy is important for optimal growth and development of a baby, a pregnant woman asks the nurse what foods she should be eating. The nurse begins the teaching/learning process by:

Asking the client what she usually eats at each meal

The fetus of a woman in labor is at +1 station. At what place in the pelvic area does the nurse conclude that the presenting part is located?

Below the ischial spines

A nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. What is the action of this therapy?

Breaks down the bilirubin into a conjugated form

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?

Breathe into her cupped hands

What should the nurse teach a client about performing breast self-examination?

Compress the nipples to check for discharge.

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is used to:

Estimate fetal age

Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent?

Evaporation

A nurse is discussing informed consent with a client who is scheduled for a hysterectomy. What should the informed consent include? (Select all that apply.)

Explanation of available alternative treatments Answers to questions and concerns about the procedure Complete description of the possible dangers and discomforts

During their first visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed?

Family history of genetic abnormalities

A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea, but no vomiting, throughout the day. What should the nurse recommend? (Select all that apply.)

Focus on and repeat a rhythmic chant. Eat small, frequent meals and eat dry crackers in between.

Absence or weakness of which of the following reflexes during the newborn assessment should the nurse report to the health care provider?

Gag

A nurse expects signs of respiratory distress syndrome (RDS) in a neonate whose mother:

Has type 1 diabetes

Because of the high discomfort level during the transition phase of labor, nursing care should be directed toward:

Helping the client maintain control

Three days after birth, a breastfeeding newborn becomes jaundiced. The parents bring the infant to the clinic and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL. The nurse explains that what the infant has is physiological jaundice, a benign condition, caused by:

Immature liver function

A client who wishes to postpone having children until she and her husband are financially sound tells the nurse she has been taking oral contraceptive pills for several years. What finding indicates a potential risk in regard to continued use of birth control pills?

Increased blood pressure

A thin older adult client is found to have osteoporosis. What should the nurse include in the discharge plan for this client?

Instructions relative to diet and exercise

Which statement is true regarding caput succedaneum in newborns?

It is swelling consisting of serum, blood, or both.

A client starting her second trimester asks a nurse in the prenatal clinic whether she can safely take an over-the-counter (OTC) medicine now that she is past the first 3 months of pregnancy. The nurse explains why she should consult with her health care provider before taking any oral medications. What physiological alteration associated with pregnancy may change the client's response to medication?

Longer gastrointestinal emptying time

The nurse is obtaining a health history from a client with endometriosis. What consequences can occur as a result of this disorder? (Select all that apply.)

Metrorrhagia Bowel strictures Voiding difficulties

What should the nurse tell a new mother will be delayed until her newborn is 36 to 48 hours old?

Screening for phenylketonuria

A client states that she wishes to use the calendar method of birth control. The nurse concludes that the client understands how to calculate the beginning of the fertile period when she states, "I will:

Subtract 18 days from the length of my shortest cycle"

A client has a cesarean birth. The nurse monitors the newborn's respiration because infants subjected to cesarean birth are more prone to atelectasis. Why does this occur?

The ribcage is not compressed, then released during birth.

A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client?

Urine retention

At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?

Uteroplacental insufficiency

The nurse has completed a prenatal class for women who are expecting their first babies. Which statement by a pregnant woman indicates the need for additional teaching?

"During pregnancy it's safe for me to use my regular herbal remedies."

An older female client tells the nurse in the clinic that she has a cystocele that was diagnosed a year ago. She has urinary frequency and burning on urination. The client asks, "The doctor wanted me to have surgery for the cystocele last year, but I can manage with peripads. It won't hurt not to have surgery, will it?" How should the nurse respond?

"Yes, you're risking kidney damage."

A 20-year-old woman is known to be heterozygous for the cystic fibrosis (CF) gene. Her husband's genotype is unknown at present and the couple is expecting their first child. What should the nurse tell the couple about the probability of their baby's having CF?

25% or less

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 mg/dL. What should the nurse do?

Continue to monitor the blood glucose level per policy.

A nurse is teaching a childbirth preparation class about the discomfort of labor. What is the greatest influence on the perception of pain for a woman in labor?

tension on the client

Where is the best area for the nurse to determine adequate tissue oxygenation in a neonate born of black parents?

Mucous membranes of the mouth

A client at 36 weeks' gestation arrives at the prenatal clinic for a routine examination. The nurse determines that the client's blood pressure has increased from 102/60 to 134/88 mm Hg and becomes concerned she may be experiencing mild preeclampsia. What other sign of mild preeclampsia does the nurse anticipate?

Proteinuria of 1+

Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity?

Verifying oxygen saturation frequently to adjust flow on the basis of need

During a routine visit to the prenatal clinic a client listens to the fetal heartbeat for the first time. The client, commenting on how rapid it is, appears frightened and asks whether this is normal. The nurse should explain:

"The heart rate is usually rapid, and this one is in the expected range."

A mother asks the neonatal nurse why her infant must be monitored for hypoglycemia when her type 1 diabetes was in excellent control during her pregnancy. How should the nurse respond?

"Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mothers during pregnancy, so the glucose level may drop."

A nurse is caring for several pregnant clients in the prenatal clinic. Which client causes the most concern because of her predisposition to placenta previa?

30 years old, gravida 6, para 5

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? (Select all that apply.)

Long nails Wrinkled skin

A multipara is admitted to the birthing room in active labor. Her temperature is 98° F (36.7° C), pulse 70 beats/min, respirations 18 breaths/min, and blood pressure 126/76 mm Hg. A vaginal examination reveals a cervix that is 90% effaced and 7 cm dilated with the vertex presenting at 2+ station. The client is complaining of pain and asks for medication. Which medication should be avoided because it may cause respiratory depression in the newborn?

Meperidine (Demerol)

The parents of a newborn with phenylketonuria (PKU) ask a nurse how to prevent future problems. What must the nurse consider before responding?

Most important is the institution of a corrective formula soon after birth.

Which characteristics should alert the nurse to conclude that a male newborn is a preterm infant? (Select all that apply.)

Small breast buds Wrinkled thin skin Pinnae that remain flat when folded

The nurse reads the history of a neonate admitted to the nursery and discovers that the infant's mother was listed as gravida 1 para 1 before the baby was born. How should the nurse use these data to gather more information?

To consider that someone recorded the gravida and para incorrectly

The health care provider hands a neonate to a nurse immediately after birth. What should the nurse do next for the newborn?

Dry and provide skin-to-skin contact with the mother

A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? (Select all that apply.)

Foramen ovale Ductus arteriosus

A newborn whose mother has type 1 diabetes is receiving a continuous infusion of fluids with glucose. What should the nurse do when preparing to discontinue the IV?

Decrease the rate slowly

A preterm infant with respiratory distress syndrome (RDS) has blood drawn for an arterial blood gas analysis. What test result should the nurse anticipate for this infant?

Decreased blood pH

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?

Document the stool in the infant's record

A nurse evaluates that a client who is taking oral contraceptives understands the related dietary teaching when the client states, "While I'm taking birth control pills I should increase my intake of foods containing:

Folic acid."

A primigravida, unsure of the date of her last menstrual period, is told by the nurse that she appears to be at 22 weeks' gestation. What data support this conclusion?

Fundus at the umbilicus

On her first prenatal visit a client says to the nurse, "I guess I'll be having an internal examination today." What is the nurse's best response?

"Have you ever had an internal examination done before?"

A nurse is instructing a client to cough and deep-breathe after an emergency cesarean birth. The client says, "Get out of here. Can't you see that I'm in pain?" Which response will be the most effective?

"If you can't cough, try taking six very deep breaths."

A pregnant client has a positive group B Streptoccus (GBS) test at 36 weeks' gestation. What is the priority instruction that the nurse will include in the client's teaching plan?

"This information will be in your prenatal record, but please remind your labor and delivery nurse of this finding."

As the nurse helps a postpartum client change her perineal pad, the client comments, "I wish you didn't have to look at the pad it's embarrassing for me." What is the best nursing response?

"This seems to be uncomfortable for you, but I have to estimate the amount of blood loss to prevent any problems."

During the postpartum period a client with heart disease and type 2 diabetes asks a nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How should the nurse respond?

"You should use foam with a condom to prevent pregnancy — this is the safest method for women with your illnesses."

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? (Select all that apply.)

Cardiac output increases. Blood pressure decreases. The heart is displaced upward

What type of respirations does the nurse expect to identify in a healthy newborn?

Abdominal and irregular

During a male newborn's first encounter with his mother the nurse encourages her to undress him. The mother strokes him with her whole hand and while looking at him intently says, "He feels so velvety, and he is going to be just as good looking as his daddy." The baby is alert and responsive while gazing at his mother. What is the nurse's assessment of this first mother-infant encounter?

Early parenting behavior

The nurse should explain to the newly pregnant primigravida that the fetal heartbeat will first be heard with:

Electronic Doppler ultrasonography at 10 to 12 weeks

A multigravida of Asian descent weighs 104 lb, having gained 14 pounds during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do?

Encourage the family to bring in special foods preferred in their culture

The husband of a woman who had her fourth child 3 weeks ago states she has been irritable and crying frequently since bringing her newborn home. He asks the nurse whether this is normal. The nurse tries to help him understand the situation by stating that:

Having four children is tiring and assistance may be needed.

A nurse is caring for the newborn of a drug-addicted mother with suspected cytomegalovirus disease. What does the nurse suspect was the cause of the disease?

Having sex with many partners

Shortly after birth a newborn is found to have Erb's palsy. What condition does the nurse suspect caused this problem?

Injury to brachial plexus during birth

A woman is admitted for a hysterectomy and bilateral salpingo-oophorectomy. The nurse reviews the client's gynecological history. What condition does the client have that causes the nurse to anticipate an abdominal, rather than a vaginal, hysterectomy?

Large uterine fibroids

A client who is in the first trimester is being discharged after a week of hospitalization for hyperemesis gravidarum. She is to be maintained at home with rehydration infusion therapy. What is the priority nursing activity for the home health nurse?

Monitoring the client for signs of electrolyte imbalances

A nurse is planning a childbirth education class about maternal psychological and physiological changes as pregnancy nears term. Which problems and concerns should the nurse include in the presentation? (Select all that apply.)

Nesting needs increase. Anxiety about childbirth increases. Gastrointestinal motility decreases.

A 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply?

Open neural tube defects

The nurse presents a program on breast self-examination. After a return demonstration the nurse concludes that she needs to review certain aspects of the teaching program. Which behavior by one of the students supports this conclusion?

Palpating each breast while in the sitting position

Before the administration of Rho(D) immune globulin (RhoGAM) the nurse reviews the laboratory data of a pregnant client. Which blood type and Coombs test result must a pregnant woman have to receive RhoGAM after giving birth?

Rh-negative and Coombs negative

A newborn has an Apgar score of 3 at 1 minute after birth. What is the immediate nursing action in response to this Apgar score?

Start resuscitation

The parents of a newborn are concerned about red pinpoint dots on their infant's face and neck. How should the nurse explain the finding?

The cause is an increased intravascular pressure during birth.

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data?

These findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately.

A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first?

Turn the oxytocin infusion off

A client with osteoporosis has been receiving dietary information from the nurse. Which food selection by the client indicates that the nurse's dietary instruction was effective?

Turnip greens

A client with endometriosis asks the nurse what side effects to expect from leuprolide (Lupron). What should the nurse include in the response?

Weight gain

What should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder?

Protecting the skin surrounding the exposed bladder

What does a nurse expect to find when checking the vital signs of a client in the early postpartum period?

Bradycardia with no change in respirations

A 63-year-old woman with the diagnosis of estrogen-receptor positive cancer of the breast undergoes lumpectomy and radiation therapy, and tamoxifen (Nolvadex) is prescribed. The client asks the nurse how long she will have to take the medication. The nurse responds:

"You'll need to take it for 5 years, after which it will be discontinued."

During prenatal classes the nurse teaches the difference between true labor and false labor. How does the nurse explain the difference?

Cervix effaces and dilates during true labor.

A woman has made the decision to have breast augmentation surgery, and the procedure is to be performed on an outpatient basis. As part of the preoperative protocol, the nurse provides teaching regarding the discharge instructions. Which instructions apply to this type of surgery? (Select all that apply.)

Avoid taking aspirin or NSAIDs (e.g., ibuprofen [Advil]) for pain relief. Sleep with your head and torso elevated for at least 1 week. Take your temperature daily and notify the clinic if it goes above 99.6° F.

A nurse is estimating a newborn's gestational age. What parameters should the nurse evaluate? (Select all that apply.)

Breast size Genital development

Which factor in a client's history increases the risk for osteoporosis?

Prolonged immobility

In the second hour after a client gives birth, her uterus is found to be firm, above the level of the umbilicus, and to the right of midline. What is the appropriate nursing intervention at this time?

Assisting the client to the bathroom to empty her bladder

A newborn male is admitted to the nursery. He weighs 10 lb 2 oz, which is 2 lb more than the birthweight of any of his siblings. What should the nurse do in relation to the baby's weight?

Perform serial glucose readings

What antidote to the side effects of terbutaline (Brethine) should a nurse have available?

Propranolol (Inderal)

A nurse helps a client to the bathroom to void several times during the first stage of labor. This is done because a full bladder:

May inhibit the progress of labor

What characteristics cause the nurse to suspect that a newborn has Down syndrome? (Select all that apply.)

Protruding tongue Epicanthal eye folds One transverse palmar crease

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? (Select all that apply.)

Thin upper lip Small upturned nose Smooth vertical ridge in the upper lip

A client is scheduled for a laparoscopic bilateral tubal ligation. What should the nurse include in preoperative teaching?

"You will be admitted as an outpatient for same-day surgery."

A client is scheduled for a vacuum aspiration abortion to terminate an unwanted pregnancy. What information should the nurse's teaching plan include?

A temperature of 100.4° F (38° C) or higher should be reported immediately.

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. Eleven hours after birth, the infant's skin appears yellow. What is the most likely cause?

ABO incompatibility

An estrogen-progestin oral contraceptive is prescribed for a client. Which adverse effects should the nurse teach the client to report to the health care provider? (Select all that apply.)

Chest pain Breast soreness Calf tenderness

What factor identified by the nurse in a client's history places the client at increased risk for breast cancer?

Late beginning of childbearing

A nurse is teaching a client to care for her episiotomy after discharge. What priority instruction should the nurse include?

Perform perineal care after toileting until healing occurs.

A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. (Select all that apply.)

Sleep needs increase. Fluid retention increases. Calcium requirements increase.

The transmission of which microorganism that causes maternal mastitis is minimized by frequent handwashing by nursing staff members?

Staphylococcus aureus

A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant?

"Give him brief rest periods and frequent burpings during feedings so he can get rid of swallowed air."

A woman who was discharged recently from the hospital after undergoing a hysterectomy calls the clinic and states that she has tenderness, redness, and swelling in her right calf. What should the nurse instruct the client to do?

Call an ambulance to go to the emergency department.

At 6 weeks' gestation a client is found to have gonorrhea. What medication does a nurse expect the health care provider to prescribe?

Ceftriaxone (Rocephin)

A primigravida at term is admitted to the birthing room in active labor. Later, when the client is dilated 8 cm, she tells the nurse that she has the urge to push. The nurse instructs her to pant-blow at this time because pushing can cause which of the following?

Cervical edema

One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry; moves all extremities well; and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score?

8

A nurse assesses a newborn 1 minute after birth. The body is pink with blue extremities; the heart rate is 122 beats/min; the legs are withdrawn when the soles are flicked, respiration is easy, with no evidence of distress; and the arms and legs are flexed and moving vigorously. What Apgar score should the nurse document in the newborn's medical record?

9

Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements?

Enlarged head

An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication should the nurse instruct the parents to report if it occurs at home?

Fever accompanied by decreased responsiveness

A client who is pregnant for the first time and carrying twins is scheduled for a cesarean birth. What should preoperative teaching include?

Frequent ambulation is begun within 24 hours.

After 2 weeks of radiation therapy for cancer of the breast a client experiences some erythema over the area being radiated. The area is sensitive but not painful. She states that she has been using tepid water and a soft washcloth when cleansing the area and applying an ice pack three times a day. What does the nurse conclude from this information?

Further teaching on skin care is necessary.

A nurse is caring for a client who is receiving internal radiation for cancer of the cervix. For which adverse reactions to the radiotherapy should the client be monitored? (Select all that apply.)

Hemorrhage Increased temperature

A couple, married for 5 years, want to start a family. When talking with the nurse the husband says, "Well, I guess we're going to have to jump into bed three or four times a day, every day, until it works." What is the nurse's best response?

Instructing them in the frequency and timing of intercourse to promote conception

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection because:

It contains exposed tissue and blood

During discharge teaching a client who just had a hysterectomy states, "After this surgery, I don't expect to be interested in sex anymore." What should the nurse consider before responding?

Many women incorrectly equate hysterectomy with loss of libido.

When calculating an Apgar score for a newborn, what is given a score in addition to the heart rate?

Muscle tone

A nurse is evaluating the rate of involution of a client's uterus on the second postpartum day. Where does the nurse expect the fundus to be located?

One or two fingerbreadths below the umbilicus

A nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first visit to the prenatal clinic. What information should the nurse consider including that the client will understand with regard to active immunity?

Protein substances are formed by the body to destroy or neutralize antigens.

In her 36th week of gestation, a client with type 1 diabetes has a 9-lb 10-oz infant in a cesarean birth. For which condition should the nurse monitor this infant of a diabetic mother?

Respiratory distress syndrome

A client who is taking an oral contraceptive calls the nurse with concerns about side effects of the medication. Which adverse effect of this medication should alert the nurse to inform the client to immediately stop the contraceptive and contact the health care provider? (Select all that apply.)

Visual disturbances Persistent headaches

A 35-year-old client is scheduled for a vaginal hysterectomy. She asks the nurse about the changes she should expect after surgery. How should the nurse respond?

surgical induced menopause

A 36-year-old primigravida, accompanied by her husband, is admitted to the birthing unit at 39 weeks' gestation. External fetal monitoring is instituted. What should the nurse consider when a fetus is being monitored?

The machinery may be frightening to a laboring couple.

A client is admitted with a diagnosis of stage 0 cervical cancer (carcinoma in situ). What does the nurse emphasize while helping the client understand her diagnosis and prognosis?

Five-year survival rates for this cancer are nearly 100% with early treatment.

A client comes to the fertility clinic for hysterosalpingography using radiopaque contrast material to determine whether her fallopian tubes are patent. When preparing for the test, the nurse explains to the client that she:

May have some persistent shoulder pain for 14 hours after the test

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. What should the nurse consider before responding?

These accelerations are a sign of fetal well-being.