exit h (2)
The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that:
Crosses the suture line
What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? Select all that apply.
Smoker Twin gestation
A nurse is assessing clients on the postpartum unit for pain. The client who will have more severe afterbirth pains is one who:
Is a grand multipara
During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. What should the nurse do?
Rewarm gradually.
During a prenatal visit a client who is at 36 weeks' gestation states that she is having uncomfortable irregular contractions. How should the nurse respond?
Walk around until they subside."
A nurse is assessing a newborn in the birthing room. What finding indicates that a newborn has failed to make the appropriate adaptation to extrauterine life?
Central cyanosis
During the second reactive period a newborn becomes more alert and responsive and there is an increase in mucus production and gagging. What should the nurse do first?
Remove secretions from the pharynx.
A priority intervention for the infant undergoing phototherapy is:
Exposing as much skin as possible by turning the infant every 2 hours
After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond?
I'll get you some warm blankets to help make the chill go away."
A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is in labor. What does the nurse do to verify that the client is in true labor?
Interprets findings of the pelvic examination
As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. What does the nurse conclude about this occurrence?
It is a common finding in 2-day-old neonate.
What should the nurse recommend to a new mother when teaching her about the care of the umbilical cord area?
Leave the area untouched or clean with soap and water, then pat it dry
A laboring client is to have a pudendal block. What should a nurse teach the client about the effects of the pudendal block?
She will not feel an episiotomy.
When is it most important for a female client to know that a fetus may be structurally damaged by the ingestion of drugs?
When she is planning to become pregnant
Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the laboratory report reveals:
An increased Paco2 of 55 mm Hg
A plan of care is created for a term small-for-gestational-age (SGA) neonate who has been admitted to the neonatal intensive care unit (NICU). The goal is for the newborn to reach 5 lb by a specified date. On the specified date the infant weighs 4 lb 2 oz. What should the nurse do next?
Evaluate the problem before altering the plan.
A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus:
Even with the umbilicus
A nurse in the newborn nursery receives a call from the emergency department saying that a woman with active herpes virus lesions gave birth in a taxicab while coming to the hospital. What does the nurse consider about the transmission of the herpes virus?
It can be acquired during a vaginal birth.
A nurse is trying to determine whether a pregnant woman's membranes have ruptured. What findings support the conclusion that they have ruptured? Select all that apply. Nitrazine paper turns blue on contact with the fluid.
Microscopic examination of the fluid reveals kerning.
The nurse observes that 12 hours after birth the neonate is hyperactive and jittery, sneezes frequently, has a high-pitched cry, and is having difficulty suckling. Further assessment reveals increased deep tendon reflexes and a diminished Moro reflex. What problem does the nurse suspect?
Opioid drug withdrawal
A 7-lb newborn is admitted to the nursery with a prescription for intramuscular phytonadione (vitamin K, AquaMEPHYTON) 1 mg. The nurse explains to the parents that this vitamin is administered to:
Promote clotting of the blood
Two days after giving birth a client's temperature is 101° F (38.3° C). A nurse notifies the health care provider and receives a variety of prescriptions. In what order should they be implemented?
Send a lochia specimen for culture
The parents of a newborn who is undergoing phototherapy ask a nurse why their baby's eyes are covered with eye patches. What information should the nurse remember before responding?
They prevent injury to the conjunctiva and retina.
A client in active labor is considering combined spinal-epidural analgesia (CSE). She states that she is concerned about her ability to walk after receiving this type of analgesia. What is the most accurate response by the nurse?
This analgesia gives you pain relief without compromising your ability to ambulate.
After her baby's birth a client wishes to begin breastfeeding. How can the nurse assist the client at this time?
Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
When a client's legs are being placed in stirrups for birth, the nurse ensures that the left and right legs are positioned simultaneously to help prevent:
Trauma to the uterine ligaments
On a 6-week postpartum visit a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for:
Vitamin C and iron
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
During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat?
Cheese and broccoli
A new mother asks a nurse why medicine is being put in her baby's eyes. What infection should the nurse tell the mother it is given to prevent?
Chlamydia
A nurse in the clinic determines that a 4-day-old neonate who was born at home has a purulent discharge from the eyes. What condition does the nurse suspect?
Chlamydia trachomatis infection
List the mechanisms of labor in the correct sequence.
Engagement Descent Flexion Internal rotation Extension Restitution External rotation Expulsion
A pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How does the nurse, using the GTPAL format, document the client's obstetric history?
G5 T2 P1 A1 L4
How should a nurse direct care for a client in the transition phase of the first stage of labor?
Helping the client maintain control
During a routine prenatal visit, a client tells a nurse that she gets leg cramps. What condition does the nurse suspect, and what suggestion is made to correct the problem?
Hypocalcemia; increase her intake of milk.
During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond?
Let's talk about why you don't want the medicine to be put into your baby's eyes."
A vaginal examination reveals that a client's cervix is 90% effaced and dilated 6 cm. The fetus's head is at station 0 and the fetus is in an ROA position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor?
Midway through first stage of labor
What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?
Moderate serosa
A client attending a class in preparation for childbirth states, "I am sick and tired of wearing these same old clothes. I just wish all this would be over and done with." What is the nurse's most therapeutic response?
Most women feel the same way you do at this time."
Organize the steps in infant cardiopulmonary resuscitation (CPR) in the correct sequence.
Note the infant's color and tap or gently shake the shoulders. Position the infant supine on a firm, flat surface. Open the airway with the head tilt-chin lift method and listen for exhalation. Initiate rescue breathing at a rate of 40 to 60 breaths/min. Check the pulse at the brachial artery. Initiate chest compressions in a 30:2 ratio
After being shown to the parents, a preterm male newborn weighing 3 lb 15 oz (1500 g) is moved to the neonatal intensive care unit. What should the nurse's plan for parental visits include?
Taking them to visit their son as soon as possible
A client in labor is receiving an oxytocin (Pitocin) infusion. For which adverse reaction resulting from prolonged administration should the nurse monitor the client?
Water intoxication
A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. A licensed practical nurse/licensed vocational nurse (LPN/LVN) and aide are also working on the unit. Which nursing action is best delegated to the LPN/LVN?
Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10
After an emergency cesarean birth, a neonate born at 35 weeks' gestation is admitted to the neonatal intensive care unit. The neonate has a Silverman-Anderson score of 6. What nursing intervention is needed?
Administration of respiratory support and observation
An infant born in a birthing center is being transferred to a regional neonatal intensive care unit because of respiratory distress. Which nursing action best promotes parent-infant attachment?
Allowing the parents to hold their infant before departure
A client expresses a desire to breastfeed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breastfeed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request?
By supporting the client's decision and explaining that the infant may lie close to her breast for nippling as desired
A 37-year-old woman agrees to have a prenatal test done to diagnose fetal defects. There is a history of Down syndrome in her family, and this is her first pregnancy. Which invasive prenatal test provides the earliest diagnosis and rapid test results?
Chorionic villus sampling
A client gives birth to an 8-lb baby. Ten minutes after the birth, the placenta has not yet separated. What is the next nursing intervention?
Continuing to assess the client for signs of separation
What is the nurse's priority assessment for a client in the fourth stage of labor?
Distention of the bladder
At 9 pm visiting hours are officially over, but the sister of a newly admitted postpartum client remains at the bedside. What is the most appropriate nursing intervention?
Encouraging the sister to participate in care as much as the client wishes
An infant is born precipitously in the emergency department. What should the nurse do first?
Establish an airway for the newborn.
A newborn has just begun to breastfeed. Although the neonate has latched on to the mother's nipple, soon after beginning to suck the infant begins to choke, has an excessive quantity of frothy secretions, and exhibits unexplained episodes of cyanosis. How should the nurse intervene?
Halt the feeding and notify the health care provider to evaluate the infant for a tracheoesophageal fistula.
A nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant:
Has a limited supply of brown fat available to provide heat
Nursing assessment of a client in labor reveals that she is entering the transition phase of the first stage of labor. Which clinical manifestations support this conclusion?
Increased bloody show, irritability, and shaking
A nurse who is caring for a mother and her newborn infant reviews their record. In light of the data the record contains, what nursing intervention is required?
Maternal rubella vaccination
A client is admitted to the birthing unit in active labor. Cervical dilation has progressed from 2 to 3 cm over the previous 8 hours. The health care provider determines that the client has hypotonic dystocia, and an infusion of oxytocin (Pitocin) is prescribed to augment her contractions. What is the most important nursing action at this time?
Monitoring the duration and intensity of the contractions
When calculating an Apgar score for a newborn, what does the nurse assess in addition to the heart rate?
Muscle tone
A client at 37 weeks' gestation is in active labor. Her contractions are now 2 to 3 minutes apart and lasting approximately 60 seconds. The fetal heart rate (FHR) averages around 100 beats/min between contractions. What should the nurse do next?
Notify the primary health care provider.
What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply.
Pain management with oral analgesics Assessment of the site every 15 minutes Application of an ice pack for 20-minute intervals
A client is admitted to the birthing room in active labor. She is gravida IV, para III. When she is at 8 cm of dilation, her membranes rupture spontaneously. What should the nurse do after assessing fetal well-being?
Perform a vaginal exam.
Early in the ninth month of pregnancy a client experiences painless vaginal bleeding and is admitted to the hospital. What should the client's plan of care include?
Placing the client in the semi-Fowler position to increase cervical pressure
At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client?
Planning nursing care activities that provide time for the client to rest and sleep
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.
During labor the nurse encourages the client to void periodically. The nurse knows that an overdistended urinary bladder during labor can:
Predispose the client to uterine hemorrhage after birth
A new mother refuses to look at her newborn, who has a severe birth defect. What is the most therapeutic approach by the nurse?
Reinforcing the explanation of the defect and giving her time to discuss her fears
The most appropriate method for a nurse to evaluate the effects of the maternal blood glucose level in the infant of a diabetic mother (IDM) is by performing a heel stick blood test on the newborn. What does this test determine?
Serum glucose level
Which finding indicates the development of a complication resulting from the presence of bilateral cephalhematomas?
Skin color
A nurse determines that the husband of a client in the early phase of labor understands the teaching from childbirth classes when he helps his wife use the breathing pattern of:
Slow-chest
A client at 10 weeks' gestation complains of frequent urination. Before explaining this phenomenon to the client in language that she will understand, the nurse remembers that:
Softening and compressibility of the lower uterine segment results in uterine anteflexion.
A health care provider tells a mother that her newborn has multiple visible birth defects. The mother seems composed and asks to see her baby. What nursing action will be most helpful in easing the mother's stress when she sees her child for the first time?
Staying with her after bringing the infant to help her verbalize her feelings
At the beginning of the first formula feeding a newborn begins to cough and choke, and the lips become cyanotic. What does the nurse do first in response?
Suctions and then oxygenates the newborn
A client participated in caring for her infant in the neonatal intensive care unit for several days in preparation for the infant's discharge. On the day of discharge she arrives at the unit with an alcohol odor on her breath and slurred speech. What is the most appropriate action by the nurse?
Talking with her about her condition while assessing her willingness to participate in an alternate plan for discharge
How should a nurse screen the newborn of a diabetic mother for hypoglycemia?
Testing heel blood with the use of a glucose-oxidase strip
After a client has been in labor for 6 hours at home, she is admitted to the birthing room. The client is dilated 5 cm and at −1 station. In the next hour her contractions gradually become irregular and are more uncomfortable. Which possibility should the nurse consider first?
The client has a full bladder
On the third postpartum day a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged?
The lymphatic system in the breasts is congested.
The nurse is helping a mother breastfeed her newborn. What is the best indication that the newborn has achieved an effective attachment to the breast?
The mouth covers most of the areolar surface.
A nurse is caring for a primigravida during labor. What does the nurse note that indicates that birth is about to take place?
The perineum has begun to bulge with each contraction.
A client who is 28 weeks into her second pregnancy is experiencing increasing edema in the lower extremities. The nurse advises rest with the legs elevated and provides dietary instructions. What other advice should the nurse provide?
The selected foods do not need to have a low salt content
A contraction stress test (CST) is performed on a client at 40 weeks' gestation. The findings are interpreted as negative. What does the nurse conclude from this interpretation?
There will be weekly retesting because, at this time, the fetus has oxygen reserves.
A client is receiving an epidural anesthetic during labor. For which side effect should the nurse monitor the client?
Urine retention
A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do and, anyway, holding babies during feedings spoils them. What is the nurse's best response?
You seem concerned about time. Let's talk about it."
The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies of
parent-child attachment
A negative home pregnancy test may result if the woman performs the test:
10 days after intercourse took place
What is the priority nursing action during a client's second stage of labor?
Assessing the perineum for bulging
Ten minutes after administering nalbuphine (Nubain) via IV piggyback to a primigravida in active labor, the nurse notes a fetal heart rate of 132 with minimal variability. The client states that the pain is more tolerable and she is able to use her breathing techniques more effectively. Contractions continue every 2 to 3 minutes and are of 60 seconds' duration. What is the nurse's next action?
Document the findings, including the stable fetal heart rate variability after administering the opioid infusion.
A nurse determines that a 1-day-old newborn has a heart rate of 138 beats/min. What is the best nursing action at this time?
Documenting the heart rate
A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has:
Drunk a glass of orange juice and timed 10 fetal movements,,,
After being transported to the hospital by the ambulance, a pregnant woman is brought into the emergency department on a stretcher. During the assessment the nurse notes that the fetus's head has emerged. How should the nurse assist the mother in the birth of the fetus' anterior shoulder?
Gently guiding the head downward
A nurse assesses the process of involution by measuring the location of the client's fundus during the postpartum period. Click the location the fundus is expected to be 1 day after birth in a client whose bladder is not distended.
-Place the dot right on the umbilicus
How should the nurse assess a newborn's grasp reflex?
By pressing the examining fingers against the palms of the newborn's hands
A client and her partner are working together during the woman's labor. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that will alleviate the client's discomfort during contractions?
Deep-breathe slowly.
While a mother is inspecting her newborn she expresses concern that her baby's eyes are crossed. How should the nurse respond?
This is expected. Your baby is trying to focus."
A new mother exclaims to the nurse, "My baby looks like a Conehead!" How should the nurse respond?
This often happens as the baby's head moves down the birth canal—the bones move for easier passage."
During labor a client who is receiving epidural anesthesia has an episode of severe nausea, and her skin becomes pale and clammy. What is the immediate nursing action?
Elevating the legs
A nurse is planning a prenatal class about the changes that occur during pregnancy and the necessity of routine health care throughout pregnancy. Which cardiovascular compensatory mechanisms should the nurse explain will occur? Select all that apply.
- Increased blood volume - Increased cardiac output - Enlargement of the heart
A primipara is admitted to the birthing room in active labor. The fetus's head is engaged and the cervix is dilated 9 cm when there is a gush of fluid from the vagina. Place the nursing actions in order of priority.
1. Monitor the fetal heart rate for signs of compromise. Test the fluid's pH with Nitrazine paper. Perform a vaginal examination to ascertain the progression of labor. Notify the practitioner
A 24-year-old client who has been told that she is pregnant is at her first prenatal visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding her daily caloric intake include?
340 more calories during the second trimester
To determine the presence of respiratory alkalosis in the laboring client, the nurse should assess her for:
A tingling sensation in the hands
A nurse is assessing a multipara who had a spontaneous vaginal birth 2 hours ago after 6 hours of labor. What should the nurse do first after reviewing the vital signs, performing a physical assessment, and transcribing the practitioner's prescriptions?
Assist the client to the bathroom
Sickle cell screening α-Fetoprotein (AFP) testing for neural tube defects Serum glucose for gestational diabetes Fetal movement test Group B Streptococcus culture
Birth of the fetus within a day
A pregnant woman tells a nurse in the prenatal clinic that she knows that folic acid is very important during pregnancy and that she is taking a prescribed supplement. She asks the nurse what foods contain folic acid (folate) so she may add them to her diet in its natural form. Which foods should the nurse recommend? Select all that apply.
Black and pinto beans Enriched bread and pasta
A local anesthetic (pudendal block) is administered to a client as second-stage labor begins. For what side effect does the nurse monitor for the client?
Decreased blood pressure
What findings occur with supine hypotensive syndrome? Select all that apply.
Feeling of faintness Increased venous pressure Decreased systolic pressure
A client is concerned about gaining weight during pregnancy. What should the nurse tell the client is the cause of the greatest weight gain during pregnancy?
Fetal growth
Which of the following variables are scored on a biophysical profile? Select all that apply.
Fetal tone Fetal movement Amniotic fluid index Fetal breathing movements
During a newborn assessment a nurse reports a sign of respiratory distress. What clinical manifestation has the nurse identified?
Flaring nares
The nurse manager receives report on the following laboring clients. Which client should the nurse see first?
G6 P5 with intact membranes at 5 cm of dilation
During a home visit the nurse obtains information about a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply.
Lethargy Ambivalence Emotional lability
During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented?
Mongolian spots
A postpartum client intends to breastfeed her infant for the first time. How should the nurse assist the client?
Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
What is the most appropriate time for the nurse to administer an intravenous opioid analgesic to a client in active labor?
When a contraction starts
A client is receiving an intravenous piggyback infusion of oxytocin (Pitocin) to augment labor. The nurse identifies three contractions lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is followed in response to this observation. List in order of priority the nursing actions that should be taken.
- .Stop the piggyback infusion. - Check the fetal heart rate (FHR). - Determine whether the contractions have diminished. - Notify the health care provider - Administer oxygen by way of facemask - Document the responses of the client and fetus
A woman at 40 weeks' gestation is admitted in active labor. After appropriate progress of her labor, the woman asks for and receives epidural analgesia. Once the epidural catheter has been inserted, which nursing assessments and interventions should be performed? Select all that apply.
- Maintaining intravenous fluid administration - Having oxygen available in case of hypotension - Checking the bladder for distention every 2 hours - Monitoring fetal heart rate and labor progress per hospital protocol
Epidural anesthesia was initiated 30 minutes ago for a client in labor. The nurse determines that the fetus is experiencing late decelerations. List the following nursing actions in order of priority.
- Reposition client on her side. - Increase intravenous fluids. - Reassess the fetal heart rate (FHR) pattern. - Notify the health care provider if late decelerations persist. - Document interventions and related maternal/fetal responses.
A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a course on several tests during pregnancy. Place the tests in the order in which they should be performed during pregnancy.
- Sickle cell screening - α-Fetoprotein (AFP) testing for neural tube defects - Serum glucose for gestational diabetes - Fetal movement test - Group B Streptococcus culture
A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? Select all that apply.
- Sitting - Lateral - Knee-chest
A pregnant woman at 6 weeks' gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement that has been approved by the Food and Drug Administration. What should the nurse recommend to the client? Select all that apply.
- Stop taking the supplement immediately. - Discuss the use of the supplement with the practitioner. - Discuss the use of any over-the-counter products with the practitioner.
A primigravida at 34 weeks' gestation tells the nurse that she is beginning to experience some lower back pain. What should the nurse recommend that the client do? Select all that apply.
- Wear low-heeled shoes. - Perform pelvic tilt exercises several times a day.
An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the infant. Which dosage and route will the nurse use?
0.5 to 1.0 mg given intramuscularly
A pregnant woman reports nausea and vomiting during the first trimester of pregnancy. The nurse explains that an increase in which hormone is the precipitating cause of the nausea and vomiting?
Chorionic gonadotropin
The nurse is caring for a client in transitioning labor and notes an early deceleration on the fetal heart monitor. Which intervention would be appropriate for the nurse to implement?
Continuing to monitor fetal heart rate (FHR) tracing
Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer?
Continuous infusion of heparin
A client at 36 weeks' gestation exhibits oligohydramnios. What newborn complication should the nurse anticipate?
Intrauterine growth restriction (IUGR)
A nurse is caring for a client in labor. What assessment finding reveals that the transition phase of labor has probably begun?
The client begins to perspire and has a flushed face.
The nurse is providing care to a multiparous client in active labor. The client is requesting something for the pain. What is the nurse's next action?
Examining the client's cervix for dilation and effacement
Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time?
Helping the client change her position
