Exam 4 Passpoint

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next?

Administer a prescribed mild analgesic.

After instructing a primiparous client about episiotomy care, which client statement indicates successful teaching?

"I wipe the area from front to back using a blotting motion."

The nurse is gathering data from a female client that states she has had difficulty conceiving. Which statement made by the client would the nurse find most significant related to the difficulty getting pregnant?

"I had gonorrhea that went untreated for about 3 months."

Following postpartum discharge teaching by the nurse, which statement by the client indicates an understanding of how to provide self-care?

"I should contract my buttocks before sitting or rising."

After receiving a change-of-shift report in the normal newborn nursery, the nurse should see which neonate first?

6-hour-old neonate with a blood glucose of 25 mg/dL (1.38 mmol/L)

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation?

Respect the adolescent's wishes and maintain her confidentiality.

When caring for a post partum client, the student nurse correctly recalls which expected progression of lochia?

Rubra, then serosa, then alba

A school nurse is teaching a class about sexually transmitted infections (STIs). Which statement is correct regarding STIs?

STIs are most prevalent among teenagers and young adults.

The nurse is developing a community health education program about sexually transmitted infections. Which information about women who acquire gonorrhea should be included?

Women with gonorrhea are usually asymptomatic.

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate?

adduction and flexion of the extremities with gently rounded shoulders

The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommend to women age 50 and older?

annual mammogram

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine

atony.

A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur?

cervical cancer

A primiparous client who gave birth to a viable term neonate vaginally 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which assessment would be most important?

constipation

When performing an assessment on a one-day old newborn, which finding would be most suggestive of an imperforate anus?

failure to pass a meconium stool

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal?

high-pitched cry

Which finding provides the most evidence that a fetus might have a gastrointestinal tract anomaly?

increased amount of amniotic fluid

While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication?

intracranial hemorrhage

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

lochia rubra

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further?

perineal lacerations

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor?

release of oxytocin during the breastfeeding session

The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication?

retinopathy of prematurity

The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason?

to contract the mother's uterus

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently?

uterine atony

The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low-fat, low-cholesterol diet to lower the risk of heart disease. At what age does the nurse should tell the client to start modifying her child's diet?

age 2 years

A preterm neonate is having frequent blood draws for laboratory specimens. What is most important for the nurse to document about the blood draws?

amount of blood drawn for each specimen

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in:

an arched, side-lying position, avoiding flexion of the neck onto the chest.

A newborn diagnosed with phenylketonuria (PKU) is placed on a low-phenylalanine formula. The mother asks the nurse how long her infant will need to have dietary restriction. Which response would be most appropriate?

"Most likely he will need to follow a low phenylalanine diet for the rest of his life."

A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge? Select all that apply.

"My fertility can return as early as 21 days after my baby's birth." "I have the hospital phone number if I have any questions." "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." "I know if I get fever or chills or change in lochia to call the health care provider." "I will continue my prenatal vitamins until my postpartum checkup or longer."

The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective?

"My menstrual flow should resume in approximately 6 to 10 weeks."

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. What should the nurse should tell the mother?

"Oxygen is drying to the mucous membranes unless it is humidified."

A nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The parents asked the nurse to tell them how their baby will benefit from having phototherapy done. Which statement by the nurse is the most appropriate response about phototherapy?

"Phototherapy decreases the serum unconjugated bilirubin level."

An adolescent with pneumonia shares fears of having contracted human immunodeficiency virus (HIV). The adolescent wants to be tested but does not want parental involvement. What should the nurse say?

"The healthcare provider will run the test confidentially."

A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse?

"We can see you without your parents' consent but have to report any positive results to the public health department."

A newborn weighing 6.5 lb (2,950 g) is to be given naloxone due to respiratory depression as a result of a narcotic given to the mother shortly before birth. The drug is to be given 0.01 mg/kg into the umbilical vein. The vial is marked 0.4 mg/mL. How many milligrams would the newborn receive? Record your answer using two decimal places.

0.03

The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which organ in the neonate?

brain

Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which factor?

control of the growth of pathologic bacteria

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which complications? Select all that apply.

copious frothy mucus episodes of cyanosis distended abdomen

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect?

dizziness

A 49-year-old woman has sought help from her primary care provider because of "intimacy problems." Upon questioning, the woman reveals that she is experiencing sexual desire, but that intercourse causes significant pain. In the absence of sexual activity, the woman states that she does not have any significant vaginal discomfort. What would the clinician recognize that this client is most likely experiencing?

dyspareunia

While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibits which symptom?

dyspnea

Two hours after a vaginal birth under epidural anesthesia, a client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which factor?

edema in the lower urinary tract area

What should the nurse include in a community health program designed to control sexually transmitted infections (STIs)?

education about safe sex practices

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to

enhance bonding by pointing out the neonate's features.

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend?

every 2 to 3 hours for the first 48 hours

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age?

fine, downy hair over the upper arms and back

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time?

firm fundus at the symphysis

A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include which interventions? Select all that apply.

hepatitis B immune globulin at birth series of three hepatitis B vaccinations per recommended schedule standard/routine precautions for mother and infant

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which sexually transmitted infection?

herpes genitalis

A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What documentation should be included on the client's medical record? Select all that apply.

history of unprotected sex (sex without a condom) length of time since symptoms presented history of fever or chills presence of any enlarged lymph nodes on examination allergies to any medications

A septic preterm neonate's IV was removed due to infiltration. The nurse prioritizes restarting the IV to help which complication?

hypoglycemia

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason?

interrupted supply of maternal glucose and continued high neonatal insulin production

A viable neonate born to a 28-year-old multiparous client by cesarean birth because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which factor would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome?

neonate born preterm

Sick and preterm neonates who experience continuity of nursing care directly benefit from

nursing recognition of subtle changes in high-risk neonates' conditions.

The nurse is interviewing a client with newly diagnosed syphilis. In order to prevent the spread of the disease, the focus of the interview should include which approach?

obtaining a list of the client's sexual contacts

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid?

orange juice

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor?

overdistention of the uterus from hydramnios

While caring for several preterm infants in the special care nursery, which action is most important for preventing nosocomial infections in these neonates?

performing thorough handwashing before giving infant care

In developing a plan of care for the client who has just given birth to a 7-lb (3,175-g) baby, the nurse reviews her prenatal, labor, and birth records. Which data in the client's record would alert the nurse to the possibility of a problem?

perineal laceration.

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage?

placenta previa

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?

placing as much of the areola as possible into the baby's mouth

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement?

postpartum "blues"

A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider (HCP) because the mother should be evaluated further for which complication?

postpartum depression

The nurse makes a home visit to a primigravid client on the fourth postpartum day after birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing which condition?

postpartum psychosis

A couple seeks information about natural family planning. Which of the following should the nurse inform the couple about natural family planning? Select all that apply.

requires some period of abstinence uses calculations of menstrual cycles determines ovulation from basal body temperature

A neonate born at 28 weeks' gestation has been receiving 80% to 100% oxygen via mechanical ventilation for the past 2 weeks. The neonate also has received multiple blood transfusions to treat anemia and has experienced several episodes of apnea. The nurse caring for the neonate should anticipate which iatrogenic complication?

retinopathy of prematurity

A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client?

risk for infection

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance?

surfactant

A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period?

taking in

Which group has experienced the greatest rise in the incidence of sexually transmitted diseases (STDs) over the past two decades?

teenagers

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation?

thin, wasted appearance

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason?

to prevent Rh-positive sensitization with the next pregnancy

A young adult woman tells the nurse she has a slight yellow vaginal discharge. The nurse should tell the client to contact her health care provider if she has which additional symptoms? Select all that apply.

vaginal discharge that has a fishy odor abdominal pain a temperature above 101ºF (38.3ºC)

A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?

washing the hands and wearing gloves

In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The client asks, "I've heard recommendations about when to resume intercourse have changed since my last baby. What are they saying now?" When should the nurse instruct the client that she can resume sexual intercourse?

when lochia flow and episiotomy pain have stopped.

A client with gestational diabetes had a cesarean birth because the fetus was determined to be large for gestational age. The nurse should assess for which postsurgical complications? Select all that apply.

wound-edge separation fever after the first 24 hours postpartum lochia odor purulent drainage from incision

A client gave birth to a neonate with spina bifida. The client was informed during her pregnancy that this situation could occur. The nurse giving a report on the client states that the client's decision to continue with the pregnancy was selfish and that the neonate will suffer. How should the nurse proceed in caring for this client and her neonate?

Accept the client's decision and care for her as any other client.

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?

Administer pain medication per prescription.

A client one day post-cesarean birth requests pain medication, stating her pain is 8 out of 10 when the nurse enters the room to perform her shift assessment. Which action by the nurse is most appropriate.

Administer the ordered pain medication, explaining to the patient that she will be back within the hour to examine her.

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho(D) immune globulin I.M. to the mother within 72 hours

Which measure would be most effective in helping the infant with a cleft lip and palate to retain oral feedings?

Burp the infant at frequent intervals.

Which information would the nurse include in a teaching plan about treatments for sexually transmitted infections?

Ceftriaxone sodium may be used to treat Neisseria gonorrhoeae infections.

While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. What should the nurse do?

Continue to monitor the client's vital signs.

The nurse plans the discharge of a newborn diagnosed with torticollis (wry neck). Which action should the nurse take?

Coordinate outpatient physical therapy.

Which practice should a nurse recommend to a client who has had a cesarean birth?

Coughing and deep-breathing exercises

A postmenopausal woman is worried about pain in the upper outer quadrant of her left breast. The nurse's best course of action is to:

Do a breast examination and report the results to the physician.

A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next?

Document these expected behaviors of the taking-in period.

The nurse at the gynecologic clinic is teaching the client about the results of her Papanicolaou test, which demonstrated dysplasia. Which represents the nurse's best intervention?

Explain that results show alteration in the size and shape of cells, which requires follow-up.

The nurse is caring for a client who is 2-hours post-partum and experienced a fourth-degree vaginal laceration. Which intervention should the nurse teach the client is contraindicated at this time?

Frequent Kegel exercises

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains?

G3, P3 client who is breastfeeding her infant

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate?

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first?

Gently massage the fundus.

Immediately after the first oral feeding after corrective surgery for pyloric stenosis, a 4-week-old infant is fussy and restless. What action would be most appropriate at this time?

Give the infant a pacifier to suck on.

The nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage?

Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg

A client plans to travel to a country where hepatitis B is common. What should the nurse advise the client about the most effective way to prevent the disease?

Observe safe sex practices.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma.

A neonate was admitted to the pediatric unit with an unexpected congenital defect. What is the best way to involve the parents in the neonate's care?

Offer the parents opportunities to be involved with the neonate's care while they adjust to his unexpected condition.

Following a cesarean birth, what should the nurse do first?

Palpate the fundus.

The nurse is caring for a client 24 hours postpartum from a normal, vaginal delivery, and identifies which assessment finding and requiring immediate intervention?

Patient reports pain and warmth behild left knee

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98° F (36.6° C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated?

Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures.

Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next?

Provide the client with a warm blanket.

The charge nurse observes that a nurse caring for a very sick infant is making inappropriate remarks and acting bizarrely. What is the first action the charge nurse should take?

Remove this nurse from the client assignment.

While caring for a neonate of a woman with diabetes soon after birth, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate's blood glucose level, and it is 60 mg/dL (3.3 mmol/L), but the neonate continues to exhibit jitteriness and tremors. What should the nurse do first?

Request a prescription for a blood calcium level.

A nurse observes several interactions between a client and her neonate son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply.

Talks and coos to her son. Cuddles her son close to her.

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate?

The client needs application of an ice pack.

One day after a client gives birth, the nurse performs a postpartum assessment. Which finding indicates a need for further evaluation?

The patietn reporting uterine tenderness

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan?

The use of a condom is advised for sexual intercourse.

During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally?

The uterus is descending at the rate of one fingerbreadth per day.

A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the area where the nurse should expect to feel the fundus.

The uterus would be palpable at the level of the umbilicus between 4 and 24 hours after birth. The fundus of the uterus should be palpated for position and firmness.

As part of the postpartum follow-up, a nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information which assessment would the nurse make?

This is expected behavior for a client 3 to 7 days postpartum.

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm moist compress over the painful area.

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed IV fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first?

Verify that the infant has urinated.

The nurse plans care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first?

a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm

The nurse determines that a newborn is experiencing hypoglycemia based on which findings? Select all that apply.

a blood glucose reading of less than 30 mg/dL (1.7 mmol/L) or less at 1 hour irregular respirations, tremors, and hypothermia

The nurse is caring for a primipara who gave birth 12 hours ago. The client says, "Look at all of the beautiful things my family brought for the new baby." The nurse should become concerned if the client has received which gift?

a soft pillow for the neonate's crib

A client is recovering in the labor and delivery area after giving birth to a 6-lb, 3-oz (2,813 g) newborn. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings?

a vaginal laceration

The nurse provides a neonate with an initial feeding. The nurse would suspect a tracheoesophageal fistula if the neonate demonstrated which behavior?

coughing, choking, and cyanosis that occur after several swallows of formula

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. What should the nurse do next?

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Pregnancy should be avoided for 4 weeks after the immunization.

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?

The client will demonstrate self-care and infant care by the end of the shift.

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation?

The increased lochia occurs from lochia pooling in the vaginal vault.

A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires intervention?

Applying a breast binder to support the breasts

A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation?

Limited parent-neonate contact immediately after birth

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease?

Signs of kernicterus

A nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?

Small size for gestational age

The physician orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?

Softening of the stool.

What should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply.

abdominal distension vomiting meconium in the urine

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?

The mother can bring the daughter any foods that she desires.

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

"I should lie on my back as much as possible to relieve the pain."

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do?

Ambulate more often.

The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?

a neonate born at 36 weeks' gestation

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?

hemorrhage

Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium?

rubella counseling and immunization with live rubella virus vaccine

During the fourth stage of labor, the client should be assessed carefully for

uterine atony.

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in the teaching?

"If you have excessive vaginal bleeding, massage your fundus and call the physician."

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period?

2 to 4 days

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy.

The nurse is caring for a client with a diagnosis of early postpartum hemorrhage. Which would not be a priority action at this time?

Assess the number of perineal pads used during the past shift.

The nurse is catheterizing a client who cannot void after a normal birth 8 hours ago. The nurse begins the catheterization process, and the client states, "I forgot to tell the nurse I get hives to betadine." The nurse should take which steps in order of priority from first to last? All options must be used.

Clean povidone-iodine from client's vaginal area. Notify the health care provider (HCP) prescribing catheterization. Document the incident. File an incident report.

A multigravida 30-year-old woman has given cesarean birth to a healthy term neonate due to an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's urinary catheter and observes that the client's urine is slightly red-tinged. What should the nurse do next?

Contact the client's health care provider (HCP) for further orders.

When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant's diagnosis, the nurse should include which action as the priority when the parents visit the infant for the first time?

Emphasize the infant's normal and positive features.

An adolescent presents to a community clinic for treatment of vulvar lesions associated with type 2 herpes simplex. Which intervention is appropriate to do at this time? Select all that apply.

Escort the adolescent to a private examination room. Provide the adolescent with literature about type 2 herpes simplex.

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention?

Massage the fundus.

A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which instructions should the nurse expect to include when developing the teaching plan for the mother about FAS?

Symptoms of withdrawal include tremors, sleeplessness, and seizures.

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate?

Urine output below 1 ml/hour

What conditions would the nurse expect to find in in a preterm neonate suffering from cold stress?

hyperactivity and twitching

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red and moderate.

While the nurse is palpating the breasts of a client who is breastfeeding her 12-hour-old neonate, what is an expected finding?

soft breasts that are not tender to touch

A client with a past history of varicose veins has just given birth to her first neonate. The nurse suspects that the client has developed a pulmonary embolus. Which findings support the nurse's suspicion? Select all that apply.

sudden dyspnea diaphoresis confusion

A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client which finding requires immediate nursing action?

tachycardia and hypotension

The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment?

two perineal pads soaked with blood within 30 minutes

The nurse is caring for a 22-year-old G2, P2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider (HCP)?

urinary output of 25 mL in the past hour

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant's plan of care?

urine toxicology screening