Maternal & Newborn Health - Archer Review (2/2)

Choice B is correct. This client has symptoms of preeclampsia. She has a headache and swelling in her hands/face. These are symptoms of preeclampsia that may get overlooked. Preeclampsia can develop after 20 gestational weeks. Clinical features of preeclampsia include: blood pressure above 140/90 mmHg, proteinuria, and swelling (usually in the hands and face). The nurse should obtain vital signs to determine the client's overall stability and help establish this potential diagnosis. The nurse should report: BP > 140/90, > 1+ proteinuria, weight gain of more than 2 lb./wk., and facial swelling. These are concerning findings for preeclampsia.

The nurse in the antepartum clinic assesses a client at 31 weeks gestation, reporting swelling of the face, hands and a frontal headache. Based on these findings, the nurse should A. determine the fundal height. B. obtain vital signs. C. perform Leopold Maneuvers. D. insert an indwelling urinary catheter.

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Based on the clinical data, the nurse recognizes that the client is in the first stage of labor, specifically, the _____ phase of labor.

Choice D is correct. Nausea and urinary frequency are manifestations associated with presumptive signs of pregnancy.

The nurse is interviewing a client who reports frequent urination and nausea. The client is concerned that she may be pregnant. The nurse understands that these manifestations are A. a possible sign of pregnancy. B. probable sign of pregnancy. C. positive sign of pregnancy. D. presumptive sign of pregnancy.

nonreactive Positive 125 mg/dL

The nurse is reviewing the medical record of a client who is pregnant at 35 gestational weeks Click to highlight the findings in the medical record that require follow-up

Positive pregnancy test Pelvic pain Vaginal bleeding

Which three (3) findings in the nurses' notes require further investigation? Positive pregnancy test Pelvic pain Vaginal bleeding Breast tenderness Frequent urination Nausea

Choice C is correct. Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses.

The nurse is caring for a neonate with a decreased cardiac output. If noted in this client, which of the following is not a sign of decreased cardiac output? A. Oliguria B. Difficulty breastfeeding C. Bradycardia D. Hypotension

Choice D is correct. Frequent urinary tract infections are not associated with maternal above-average body mass index.

The nurse is educating a pregnant woman with an above-average BMI about her risk factors. Which of the following issues does not correlate with an above-normal BMI pre-pregnancy? A. Gestational diabetes B. Preeclampsia C. Swelling D. Frequent UTI

Choice D is correct. Swaddling the newborn can help promote comfort during a heel stick procedure. Swaddling involves wrapping the baby snugly in a blanket or cloth, which can provide a sense of security and comfort. It can also help restrict the infant's movements, making it easier for the nurse to perform the heel stick safely and efficiently. Another pain reduction method includes giving the infant sucrose prior to the heel stick.

The nurse is preparing to perform a heel stick on a newborn. To promote comfort during the procedure, the nurse should A. apply a cool compress to the heel for three to five minutes. B. turn off the lights in the room to minimize stimulation. C. milk the heel once punctured by the lancet. D. swaddle the infant.

Choice C is correct. Neonates born to drug-dependent mothers exhibit jitteriness, hyperactivity, and a shrill cry. These signs usually appear within 24 hours of being delivered.

The nurse is assessing a newborn that was delivered 8 hours ago. The nurse notices hyperactivity, a persistent shrill cry, and jitteriness. The nurse suspects which condition? A. Sepsis B. Hypoglycemia C. Drug dependence D. Hypothermia

Choice B is correct. Fast food is not desired during pregnancy because of the abundance of oils, dressings, and breading that supply a high degree of saturated fats, sodium, and calories. To optimize the client's nutritional intake, if the client insists on fast food, the nurse should recommend a cheeseburger because the cheese will add protein and calcium, both of which are essential during pregnancy.

The nurse is counseling an adolescent who is pregnant and reports frequent eating at fast-food restaurants. The nurse should make which recommendation to help optimize her nutritional intake? A. Choose french fries over a baked potato B. Select a cheeseburger over a regular hamburger C. Pick sandwiches instead of wraps D. Breaded chicken is a better choice than broiled

Choices E and F are correct. Jaundice may be classified as pathologic or physiologic. Jaundice with an onset of less than 24-hours is pathologic and concerning as this may indicate hemolysis. Asymmetrical gluteal folds are not an expected finding because this suggests developmental dysplasia of the hip.

The nurse is performing an assessment on a term newborn four hours after delivery. Which assessment findings require follow-up? Select all that apply. Head circumference of 34 cm Chest is 2 cm smaller than the head Vernix caseosa in the skin folds Positive Babinski reflex Asymmetrical gluteal folds Jaundice noted in the head

Choices A, C, D, and E are correct. Magnesium sulfate relaxes the uterus and may decrease the intensity of uterine contractions. A decrease in intensity will decrease the progression of labor. Often when magnesium sulfate is infused, oxytocin may be used in conjunction. Uterine overdistention is a cause of labor dystocia because when the uterus is stretched, it does not contract properly. Hypoglycemia is a cause of delayed labor progression because of the maternal fatigue it induces. While epidural analgesia provides effective pain control, the decrease in sensation will also decrease the woman's drive to push and interfere with the internal rotation mechanism.

The nurse is planning a staff development conference about the causes of labor dystocia. It would be correct for the nurse to identify which of the following may cause a delayed progression during labor? Select all that apply. Magnesium sulfate infusion Oxytocin infusion Uterine overdistention Hypoglycemia Epidural analgesia

Choice B is correct. The client should be instructed to increase their fluid and fiber intake to prevent constipation because constipation may cause a client to experience significant pain at the episiotomy site during defecation. If the client is still experiencing constipation as they recover from an episiotomy, the primary healthcare provider (PHCP) may prescribe a stool softener.

The nurse is teaching a postpartum client about caring for her episiotomy. Which of the following statement by the client would indicate a correct understanding of the teaching? A. "I can expect to have pain and urgency with urination." B. "I should increase my fluid and fiber intake." C. "I will clean the area with hot, soapy water." D. "I should wipe in a continuous motion using a washcloth."

Choice D is correct. A prolapsed umbilical cord is a serious finding that may lead to fetal hypoxia. The nurse must act quickly if this is suspected. Common fetal heart rate patterns observed during a prolapsed umbilical cord include variable decelerations, sustained bradycardia, or prolonged decelerations. All of these patterns are non-reassuring.

The nurse observes the fetal heart monitor (FHR) tracing showing variable decelerations. Which of the following could cause this FHR pattern? A. Fetal movement B. Fetal head compression C. Compression of the maternal vena cava D. Prolapsed umbilical cord

Choices A and C are correct. Any non-reassuring fetal heart rate will require intervention. The nurse has noted fetal tachycardia. Fetal tachycardia is any increase in fetal heart rate above 160 beats per minute for longer than 10 minutes. Common causes of fetal tachycardia are fetal hypoxia, maternal infection, maternal stimulant use (cocaine use), and fetal acidemia. While awaiting the identification of the cause, the nurse can undertake quick interventions to improve fetal oxygenation. One could remember these interventions with the mnemonic: LION: Lie the mother on her left side Increase IV fluids Oxygen Notify the healthcare provider. In this case, the non-reassuring sign of fetal tachycardia necessitates intervention. Repositioning the client on her left side, administering oxygen, and increasing the rate of IV fluids are all appropriate interventions. The idea is to improve fetal oxygenation.

The nurse is assessing a client in labor and observes a fetal heart rate of 190 beats per minute. The nurse should take which appropriate action? Select all that apply. Place the client in a left side lying positon Decrease the rate of intravenous fluids Administer oxygen Obtain a prescription for intravenous oxytocin Place the client in the Trendelenburg position

Choices B, D, and E are correct. These statements are false and require follow-up. Amniocentesis is an ultrasound-guided test used in the detection of fetal abnormalities. Under ultrasound guidance, a thin needle is inserted into the amniotic sac to remove a sample of amniotic fluid. The fluid is then sent for analysis. Amniocentesis does not require intravenous sedation (choice B). The client will not be given medication to stimulate contractions for the amniocentesis procedure (choice D). Ureterotonic drugs (oxytocin challenge) are administered in a contraction stress test (CST), not amniocentesis. Once again, a CST will determine how the fetus will handle labor, not an amniocentesis (choice E). These statements require follow-up counseling and education to correct the client's understanding.

The nurse is caring for a client scheduled for an amniocentesis. Which of the following statements would require follow-up? Select all that apply. -"This test may tell me the gender of my baby." -"I will receive intravenous (IV) sedation for this test." -"I may have cramping after this procedure." -"I may be given a medicine to stimulate contractions." -"The results will tell me how my baby will handle labor."

was positioned in the front passenger side.; the car seat should be used until the infant is one year old.

The nurse is observing new parents set up a car seat prior to the discharge of an infant. Click to highlight the observations and statements in the nurses' note that requires follow-up. Nurses' Note Discharge teaching completed on car seat safety. The newborn was observed in a rear-facing car seat and was positioned in the front passenger side. The infant was secured in the seat supported with rolled blankets in between the legs. The parents stated that the infant in the car seat should be angled at 45 degrees. The parents finally stated that the car seat should be used until the infant is one year old.

Choice A is correct. Rheumatic fever can cause the formation of valvular lesions, which can lead to cardiac stress during pregnancy.

The nurse is taking the history and physical of a woman who has just discovered that she is pregnant. This nurse knows that the purpose of asking a prenatal client about her history with rheumatic fever has the most to do with: A. Cardiac stress related to a possible valvular lesion. B. Preventing transmission of this teratogenic condition to her infant. C. Preparing to deliver preventative antibiotics during labor and post-birth. D. Monitoring lung sounds for reoccurrence of the disorder.

Choice C is correct. Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her. Women and families have different expectations during childbearing. These expectations are shaped by their experiences, knowledge, belief systems, and social as well as family backgrounds. In most cases, a childbirth companion (or social support during birth) has been found to improve the whole birth experience. Research shows that women who receive good social support during labor and childbirth tend on average to have shorter labors, control their pain better, and often have less need for medical intervention. With these things in mind, the nurse should put forth an effort to help find a support person for the laboring mother. Keep in mind, while nursing staff and non-medical staff can offer support, this is a very emotional time for the mother. Asking the mother's preference regarding who an alternate support person should be would give her the ability to feel like she still has some control over the situation and may prevent worsening stress.

A primigravida patient begins labor and is visibly upset that her family is unavailable. Which is the most appropriate approach for the nurse to take to help meet the client's needs at this time? A. Assure her that the nursing triage team will stay with her at all times. B. Encourage the client regarding her own abilities to cope and maintain a sense of control. C. Ask the client if there is someone else who wants to be her support person. D. Tell the client that they will try to locate her family.

Choices B, C, and D are correct. A normal infant passes meconium within 24 to 48 hours after birth. Failure to pass meconium within 48 hours of life should raise suspicion for meconium ileus (cystic fibrosis), Hirschprung's disease, anorectal malformations, and meconium plug syndrome. Cystic fibrosis is a generalized dysfunction of the exocrine glands leading to increased mucus secretions, particularly in the pancreas and lungs—about 10 to 20% of clients with cystic fibrosis present with meconium ileus. Meconium ileus refers to small bowel obstruction by thickened (inspissated) meconium. Meconium ileus is one of the earliest manifestations of cystic fibrosis, and its symptoms include failure to pass meconium and abdominal distension with or without vomiting. Meconium ileus can be complicated with intestinal perforation, small bowel volvulus, and peritonitis (choice B). Anorectal abnormalities (imperforate anus) can be detected by physical examination at birth. Here, the mechanical obstruction from the structural anomaly results in failure to passage meconium (choice C). Hirschsprung's disease is a congenital anomaly that results in functional obstruction from inadequate motility (perista

The nurse cares for a 48-hour-old newborn who has not yet passed stool since delivery. The nurse understands that the client is at highest risk for which conditions? Select all that apply. Celiac disease Cystic fibrosis Anorectal anomalies Hirschprung's disease Intussusception

Choice B is correct. The client is exhibiting signs of abruptio placentae. Diagnosis of abruptio placentae is predominantly based on clinical findings. The client may exhibit a sudden onset of abdominal pain or back pain. There is a sudden onset of mild to moderate vaginal bleeding in many cases. However, blood may get trapped inside the uterus in some cases, and there may not be any vaginal bleeding despite a severe abruption. Uterine contractions often come one right after another. The uterine tone increases, and therefore, the uterus feels hard/ rigid even in between the contractions. Based on the current international guidelines, the normal fetal baseline heart rate ( FHR) ranges from 110 beats per minute (bpm) to 160 bpm A heart rate of 99 bpm is significantly lower than the normal FHR. The client is showing signs of abruptio placentae and an accompanying decreased fetal heart rate, indicating a fetus in compromise. If unaddressed, this issue will lead to fetal death. The concern for impending fetal demise should be prioritized.

The nurse is assessing a client in the labor and delivery department. She notes that the client's abdomen remains hard between contractions and that the fetal heart rate is 99 beats per minute (bpm). Which nursing diagnosis should take priority? A. Fluid and electrolyte imbalance B. Risk for fetal demise C. Ineffective breathing problem D. Alteration in comfort

Choices A, B, C, D, and E are correct. A is correct. Emphasizing the importance of avoiding alcohol consumption during future pregnancies is crucial for the family to understand. By educating them about the risks of alcohol consumption during pregnancy, they can make informed decisions to prevent FASD in future pregnancies. B is correct. The family needs to be aware of the potential challenges their child may face in the long term. Understanding the developmental and cognitive impacts of FASD can help them provide appropriate support and interventions. C is correct. Behavioral issues are common in children with FASD. Equipping the family with strategies and techniques to manage and address these challenges can enhance their ability to support the child's well-being and development. D is correct. Regular follow-up with a healthcare provider is vital to monitor the child's growth, development, and overall health. It allows for early intervention and timely adjustments to the child's care plan, optimizing outcomes. E is correct. Connecting the family with community resources and support groups can provide them with a network of individuals who understand and can relate to their experiences.

The nurse is caring for a 2-day old infant with fetal alcohol spectrum disorder (FASD) and is preparing the family for discharge. Which of the following educational points are essential to include? Select all that apply. - Emphasize the importance of avoiding alcohol consumption during future pregnancies - Educate the family about the potential long-term developmental and cognitive challenges associated with FASD. - Teach the family strategies for managing behavioral issues that may arise in the child with FASD. - Discuss the need for regular follow-up with a pediatrician or specialist to monitor the child's growth and development. - Provide information on community resources and support groups for families affected by FASD.

Choices B, C, and E are correct. These laboratory values are abnormal and require follow-up. A platelet count of fewer than 150,000 mm3 is concerning for thrombocytopenia and suggests severe preeclampsia. The blood glucose is significantly elevated as the normal fasting blood glucose is 70-100 mg/dL. This client has clinical hyperglycemia and requires follow-up. Finally, the creatinine is quite elevated, suggesting acute kidney injury. This, combined with a low platelet count, is more convincing of severe preeclampsia.

The nurse is caring for a client at 32 gestational weeks. Which laboratory data should be reported to the primary healthcare provider (PHCP)? Select all that apply. Hemoglobin 11.5 g/dL Platelets 90,000 mm3 Fasting blood glucose 254 mg/dL White blood cell 9,500 mm3 Creatinine 3.9 mg/dL

apply pressure to lift the presenting fetal part stay with the client and call for help place the client in the Trendelenburg position administer oxygen via face mask prepare the client for immediate cesarean delivery

The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina. Place the priority actions that should be performed for this client, starting from the highest priority to the lowest priority. stay with the client and call for help apply pressure to lift the presenting fetal part place the client in the Trendelenburg position prepare the client for immediate cesarean delivery administer oxygen via face mask

Choices B, D, and E are correct. Forceps are tools used to help pull on the head of the baby to assist with the delivery. Vacuum-assisted delivery is a method where suction is applied to the head of the baby and pulled while the mother pushes. Episiotomy is a surgical incision in the perineum to widen the vaginal opening and facilitate fetal head delivery. These methods may be used for labor dystocial during the second (pushing stage) stage.

The nurse is caring for a client in the second stage of labor and is experiencing labor dystocia. Which of the following options can the physician perform to facilitate delivery? Select all that apply. Amniotomy Forceps assisted delivery External version Vacuum assisted delivery Episiotomy

The client reports reporting swelling in hands, feet, and face. She reports a frontal headache that started one day ago BP 153/85 mm Hg Urine dipstick reveals +3 proteinuria Endorses a frontal headache

The nurse is caring for a client who is pregnant at 35 gestational weeks. Click to highlight the clinical findings in the nurses' notes that require follow-up. Note: Tap to highlight and select the answer. Nurses' Notes 1300: The client reports reporting swelling in hands, feet, and face. She reports a frontal headache that started one day ago The client also reports frequent urination. She says she has been experiencing 12 fetal movements per hour. Client assessment: BP 153/85 mm Hg HR 89 beats/min Oral temperature 98.8 F (37.1 C) 2+ pitting edema noted in her ankles Urine dipstick reveals +3 proteinuria Endorses a frontal headache

Choice A, C, and D are correct. An ectopic pregnancy is a gynecological emergency. If not treated, a rupture may occur that leads to intraperitoneal bleeding. Classic manifestations of an ectopic pregnancy include: Presumptive pregnancy signs (nausea, breast tenderness) Vaginal bleeding Increased human chorionic gonadotropin (hCG) levels causing a positive pregnancy test Unilateral abdominal pain that may be confined to the pelvic area

The nurse is caring for a client with an ectopic pregnancy. Which findings does the nurse expect? Select all that apply. Pelvic pain Fever Vaginal bleeding Positive pregnancy test Dysuria

Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, which is a severe anemia that results in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility.

The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by A. excessive red blood cell production that requires therapeutic blood donation. B. hemolysis of fetal erythrocytes resulting from incompatibility between maternal and fetal blood C. inability to metabolize amino acid phenylalanine, causing high levels of phenylalanine. D. erythrocytes become shaped like a sickle and sensitive to hypoxia.

Choices A, C, D, and E are correct. Prolonged bed rest can result in deep vein thrombosis (Choice A), alterations in mood due to stress and anxiety (Choice C), and undesirable weight gain (Choice D) due to inactivity. Although bed rest is not ordered often, the nurse must understand that compression stockings and ankle exercises might be requested to prevent DVT. The client should have an opportunity to talk about their feelings related to the bedrest. The nurse should consult the nutritionist to work with the client and obstetrician to ensure a healthy diet that takes into account the decreased activity. Prolonged bed rest can lead to decreased bone density(Choice E), which can increase the risk of osteoporosis.

The nurse is caring for a pregnant client who has an order to be on partial bed rest with bathroom privileges. The nurse understands that the side effects of this order can include: Select all that apply. Deep vein thrombosis Fetal demise Alterations in mood Undesirable weight gain Decreased bone density

Choices B, C, and D are correct. Late decelerations are a non-reassuring fetal heart pattern that requires immediate intervention. The nurse should place the client in a left lateral position, administer oxygen via face mask, and discontinue oxytocin. Repositioning the client will relieve the vena cava compression. Oxygen will correct any maternal hypoxia, and oxytocin should be stopped because uterine contractions decrease uteroplacental blood flow.

The nurse is caring for a pregnant client who is experiencing late decelerations. Which of the following actions should the nurse take? Select all that apply. - Initiate intravenous magnesium sulfate - Reposition the patient on her left side - Administer oxygen via face mask - Discontinue oxytocin infusion - Prepare for an amnioinfusion

Choices B, C, E, and F are correct. B is correct. Dystocia, which is prolonged and painful labor, is a risk factor for postpartum hemorrhage. Prolonged labor, specifically, can dramatically increase the risk of postpartum hemorrhage. C is correct. Placenta previa is a risk factor for postpartum hemorrhage. In placenta previa, the placenta is covering the cervix of the mother rather than sitting in the fundus of the uterus as it should be. This puts the mother at risk for postpartum hemorrhage. E is correct. Maternal obesity is a risk factor for postpartum hemorrhage. Obese women are at increased risk for many pregnancy complications, including gestational diabetes, thromboembolic disorders, preeclampsia, spontaneous abortion, and postpartum hemorrhage. F is correct. Multiparity (having given birth one or more times previously) is a risk factor for postpartum hemorrhage. With each pregnancy, the muscle fibers are stretched and may not contract as effectively after delivery, resulting in uterine atony which can lead to postpartum hemorrhage.

The nurse is caring for a pregnant client. Which of the following conditions would the nurse recognize as increasing this client's risk for postpartum hemorrhage? Select all that apply. Microcephaly. Dystocia. Placenta previa. Singleton pregnancy. Obesity. Multiparity

Choices A, C, and E are correct. A high, pitched cry is an irregular finding in a newborn. It can be a sign of withdrawal in neonatal abstinence syndrome, or a sign of increased ICP if there is birth trauma (Choice A). For the level of consciousness, lethargy is not a normal finding. We expect the newborn to be alert. Lethargic, obtunded, stuporous, or comatose are all abnormal findings (Choice C). A significantly smaller or larger head circumference than expected may indicate a problem with the brain or nervous system (Choice E)

The nurse is completing a newborn assessment and understands that which of the following neurological assessments would be considered abnormal in a newborn. Select all that apply. High pitched cry Pupils are 2mm, equal, round, and react briskly to light. Lethargy Sleeping between each feeding Abnormal head circumference

Choice A is correct. Folic acid (vitamin B9) is essential for developing neural tube development. Neural tube defects are one of the most common congenital disabilities, occurring in approximately one in 1,000 live births in the United States. A neural tube defect is an opening in the spinal cord or brain that occurs very early in human development. The first spinal cord of the embryo begins as a flat region, which rolls into a tube (the neural tube) 28 days after the baby is conceived. A neural tube defect develops when the neural tube does not close completely. Neural tube defects develop before most women know they are even pregnant. Neural tube defects are congenital disabilities of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman knows she is pregnant. The two most common neural tube defects are spina bifida and anencephaly.

The nurse is conducting a prenatal class with a group of clients. Which vitamin should the nurse encourage to prevent neural tube defects in the newborn? A. Folic acid B. Vitamin B12 C. Vitamin E D. Iron

Choice B is correct. These results are typical and should be recorded as such. A drop from pre-pregnancy values is an expected phenomenon if they remain within or close to the normal range. Most women see a decrease in their hemoglobin and hematocrit levels during pregnancy. This phenomenon is known as physiological anemia and occurs as a result of increased plasma volume in the maternal bloodstream. It is essential to confirm that the client is taking prenatal vitamins. Demand for iron increases during pregnancy. Folic acid supplementation is necessary to prevent fetal neural tube defects. Prenatal vitamins will serve to address those needs. Normal hemoglobin in a pregnant client is > 11 g/dL. Normal hematocrit in a pregnant client is > 33%.

The nurse is evaluating the lab test results of one of her prenatal clients. She is eight weeks along and has a hematocrit level of 36% (Male: 42-52% / Female: 37-47%) and hemoglobin of 11.7 gm/dL (Male: 14-18 g/dL / Female: 12-16 g/dL). These numbers are down from her pre-pregnancy H and H levels. The priority action of the nurse would be to: A. Call the client and request that she have her levels redrawn. B. Record these normal findings and confirm that the client is on a prenatal vitamin during her next visit. C. Report this abnormal finding to the doctor immediately. D. Notify the lab that these results are not normal and need to be re-assessed.

Choice D is correct. A newborn who has not passed meconium 48 hours after birth must be assessed for intestinal obstruction or congenital abnormalities. This may be caused by an imperforate anus, meconium ileus, meconium plug syndrome, Hirschprung's disease, or other possibilities. This newborn must be evaluated immediately.

The nurse is on her shift in the nursery. Which of the following newborns would warrant further investigation and intervention from the nurse? A. A 1-hour old newborn with lanugo B. A 6-hour old newborn with a respiratory rate of 50 C. A crying 12-hour old newborn that is turning red D. A 2-day old newborn that has not yet passed meconium

Choices B and F are correct. Urinary frequency and urgency are common during pregnancy because of hormonal changes, increased blood flow to the kidneys, blood volume, and glomerular filtration rate (GFR). Nocturia is also common because sodium and water are retained during the day and excreted overnight. Burning with urination is not expected and may require a prescribed urine analysis (UA) to rule out cystitis. A decrease in appetite is also not expected, as an increase in appetite is common because the caloric requirements of pregnancy significantly increase. The nurse should inquire if the client is experiencing excessive nausea, inhibiting her appetite.

The nurse is performing a health assessment on a client who is pregnant. Which of the following findings would require follow-up? Select all that apply. third (S3) heart sound burning with urination dependent edema absence of menstruation breast tenderness decrease appetite

Choice A is correct. This action requires follow-up because it is incorrect. Only the area that is being washed should be uncovered to prevent the infant from getting cold during a sponge bath. Removing all the clothing articles would expose the infant, lowering their temperature.

The nurse is performing a home visit for the parents of an infant. Which action by the parents while giving the infant a sponge bath requires follow-up by the nurse? A. Removes all of the infant's clothing for the bath B. Uses a mild soap for the bath C. Provides the bath in a warm room D. Washes and dries one part of the baby's body at a time

A. G4-T0-P2-A1-L2 The client has been pregnant 4 times, making her a G4 The client has had no term births (any births 37 weeks or greater), making her a T 0 The client has had two preterm births (any delivery between 20 and 36.6 weeks); the twins count as one birth, and having one stillborn counts as one, making her a P2 The client has had one spontaneous abortion (abortions are countered up to 20 weeks), making her an A1 The client has two living children (each child born is counted individually) L2

The nurse is performing an obstetrics history on a client who is pregnant at 25 gestational weeks. The client reports giving birth to twins at 31 weeks of gestation. She had a stillborn infant at 23 weeks gestation and a spontaneous abortion at 12 weeks gestation. The nurse is correct in documenting her GTPAL as A. G4-T0-P2-A1-L2 B. G4-T0-P1-A2-L2 C. G4-T0-P1-A2-L3 D. G4-T1-P1-A1-L2

Choices A, C, D and E are correct. A is correct. In fetal circulation, the alveoli are filled with fluid. This causes high pressures in the fetal lungs, which shunts blood away from the pulmonary circulation. C is correct. The ductus venosus is a bypass in fetal circulation that shunts blood away from the weak fetal liver and to the brain. This allows the brain to get fresh oxygen first. D is correct. The pressures on the right side of the heart are higher in fetal circulation than on the left side of the heart. E is correct. The foramen ovale and ductus arteriosus normally close shortly after birth, allowing the baby's lungs to take over oxygenation of the blood.

The nurse is preparing a class for antepartum clients on fetal development. Which of the following statements is true regarding fetal circulation? Select all that apply. - There are high pressures in the fetal lungs causing decreased pulmonary circulation. - Blood shunts from left to right in the fetal circulation. - The ductus venosus allows freshly oxygenated blood to go to the fetal brain first. - There are higher pressures in the right atrium in the fetal circulation. - After birth, the fetal circulation system undergoes significant changes as the baby begins to breathe and the lungs become functional.

Choice D is correct. Measuring the fundal height is a painless and noninvasive way to evaluate fetal growth patterns and confirm gestational age. For this assessment, the client should empty their bladder to prevent elevation of the uterus.

The nurse is preparing to measure the fundal height of a client at 16 gestational weeks. The nurse should prepare the client for this assessment by instructing the client to A. lay in a side-lying position with the knees bent. B. prepare for the insertion of an intravenous (IV) catheter. C. not to eat or drink two hours after this assessment. D. empty their bladder

Choice B is correct. This woman should consider a birthing center. Birthing centers are generally drug-free, allow women to roam around the facility to relieve discomfort, and provide a home-like environment.

The nurse is providing a 5-month pregnant woman with her options regarding birthing locations. The nurse would be most correct in suggesting which possibility to a woman who would like freedom of movement with drug-free labor and birth but is not comfortable with a home-birth? A. The nearest hospital to her home B. A birthing center C. She should continue with a home-birth if she is low risk D. A clinician's office with her OB/GYN

Choices A, B, C, and E are correct. Encourage and facilitate skin-to-skin contact between the mother and newborn. This allows for direct warmth transfer from the mother's body to the baby, helping the newborn maintain a stable body temperature. Providing a warm environment also helps prevent heat loss and supports the newborn's ability to maintain a stable body temperature. Swaddling the newborn, when skin-to-skin contact is not taking place, helps keep the baby warm and reduces heat loss by minimizing exposure of the body to the environment. Wrapping the baby snugly in a blanket or using a hat helps preserve body heat. The healthy, full-term infant dressed and under blankets can maintain a stable temperature within a wider range of environmental temperatures. The use of an incubator is one of the three main methods for helping maintain thermoregulation in a newborn.

The nurse is providing care to a postpartum client who delivered a healthy newborn. Which of the following interventions should the nurse include in the plan of care to promote thermoregulation? Select all that apply. Encourage skin-to-skin contact Keep the room warm Swaddle the newborn Place an electric heating pad on the mother Use an incubator when needed, for a newborn that isn't clothed

Choices A, B, and C are correct. Fetal bradycardia, or a decrease in fetal heart rate below 110 bpm, is a non-reassuring sign on a fetal heart rate strip. When the nurse notes this sign, the nurse must intervene by repositioning the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Also, fetal bradycardia is often a result of uterine hyperstimulation. The nurse should discontinue the infusion if the client is on an oxytocin drip. Variable decelerations, or sharp and profound drops in the fetal heart rate unrelated to the time of contractions, are a non-reassuring sign on a fetal heart rate strip. Anytime the nurse notes this sign, intervention is necessary by lying the mother on her left side, increasing IV fluids, administering oxygen, and notifying the healthcare provider quickly. Variable decelerations are often caused by cord compression, such as a prolapsed cord, and would be an emergency requiring quick nursing intervention. Late decelerations, or dips in the fetal heart rate after a contraction, are a non-reassuring sign on a fetal heart rate strip. Anytime the nurse notes late decelerations, the nurse should lay th

The nurse is reviewing nonreassuring fetal heart rate patterns with a group of students. It would indicate effective understanding if the student identifies which pattern as nonreassuring? Select all that apply. fetal bradycardia variable decelerations late decelerations early decelerations accelerations

Choices C, D, and E are correct. A positive contraction stress test means the baby had decelerations in response to contractions and therefore, may not tolerate labor. Therefore, follow-up is needed (Choice C). A nonreactive nonstress test means that the baby did not have two or more 15 by 15 accelerations during the 20 minute test period and is not responding appropriately to movement. Follow-up would be needed for this test result, most likely with a contraction stress test (Choice D). If the mother has Rh-negative blood and the father has Rh-positive blood, further testing and treatment may be needed to prevent complications related to Rh incompatibility. (Choice E)

The nurse is reviewing test results for an antepartum client. Which of the following antepartum test results indicate a need to further follow up? Select all that apply. Contraction stress test - negative Nonstress test - reactive Contraction stress test - positive Nonstress test - nonreactive Rh-negative blood ty

Choice D is correct. This infant has four risk factors for SIDS (preterm; 3 months; male sex; sleeping in a lateral/prone position). SIDS peaks between 2 and 3 months and occurs before 12 months of age. SIDS occurs more in males than females, and the lateral and prone position for sleeping should not be used until 12 months of age. The only mitigating factor for this client is that they are breastfed. This is a mitigating factor because maternal antibodies are passed to the infant.

The nurse is screening clients at risk of sudden infant death syndrome (SIDS). The nurse correctly identifies which client is at the highest risk for SIDS? An infant who is A. a preterm 4-month-old female who sleeps supine and is formula fed. B. a preterm 12-month-old male who sleeps prone and is formula fed. C. a term 6-month-old male who sleeps supine and is formula fed. D. a preterm 3-month-old male who sleeps lateral and is breastfed.

Choice B is correct. Since the nurse has noted a reassuring sign of the fetal heart rate, it is appropriate for her to document the findings and continue to monitor the mother. If the nurse had noticed a non-reassuring sign, other interventions would be necessary.

The nurse is taking the vital signs of a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action? A. Notify the healthcare provider B. Document and continue to monitor C. Place the mother on her left side D. Administer 100% FiO2 via face mask

Choices A, B, C, and D are correct. It is essential to educate mothers with mastitis to continue breastfeeding. The infection will not be passed to their child, and they do not need to worry about adverse effects on their infants. The clogged milk ducts should become unclogged by continuing to breastfeed, and mastitis should improve. The client should be instructed to empty the breast completely at each feeding. Further, the prescribed antibiotic should be continued until it is gone (usually 7-10 days). Wearing a supportive bra but one without an underwire is appropriate educational advice for a mother with mastitis. The support will help with the pain and tenderness in the breasts, but an underwire could cause clogged milk ducts, so it should be avoided.

The nurse is teaching a client who is breastfeeding and has developed mastitis. Which of the following statements by the nurse would be appropriate to make? Select all that apply. - "Continue to breastfeed your child normally." - "Empty each breast at each feeding." - "Complete the entire course of the prescribed antibiotic." - "Wear a supportive bra without an underwire." - "Wean breastfeeding during the infection."

Choice A is correct. These foods are rich in dietary fiber, which can help soften the stool and promote regular bowel movements. Additionally, they provide essential vitamins and minerals that are beneficial during pregnancy. Dietary roughage (or fiber) with sufficient fluids and exercise may help relieve constipation. Constipation in pregnant women is thought to occur due to hormones that relax the intestinal muscles and the pressure of the expanding uterus on the intestines. Relaxation of the intestinal muscle causes food and waste to move slower through your system. Sometimes, iron tablets may contribute to constipation.

The nurse is teaching a client who is pregnant about interventions that may lessen constipation. Which of the following interventions are appropriate to recommend? A. Increasing the consumption of fruits and vegetables B. Taking a mild over-the-counter laxative C. Lying flat on the back when sleeping D. Reduce the consumption of iron by at least ½

Choices A, B, C, D, and E are all correct. A is correct. Lanugo is fine, soft hair that covers the body and limbs. This is a common finding in newborns and is considered normal. B is correct. Milia are small white bumps typically found on the noses and cheeks of newborns. They are very common, considered normal, and usually go away on their own. C is correct. Mongolian spots are usual in newborns. They are a type of birthmark due to the extra pigment in certain parts of the skin. D is correct. Vernix caseosa is the "cheese-like" coating that covers the skin of a newborn immediately after birth. This is a normal finding and should not be removed from the baby until their first bath, as it provides moisture to their skin. E is correct. A pattern of reddish or purplish discoloration on the skin caused by changes in blood flow. It is a common finding in newborns and is often more noticeable when the baby is cold.

The nurse is working in the neonatal nursery. Which of the following integumentary assessments in the newborn are normal? Select all that apply. Lanugo Milia Mongolian spots Vernix caseosa Mottling

Choice B is correct. The nurse should check under the woman's legs, buttocks, and back for lochia drainage by asking the woman to turn on her side. Post-partum hemorrhage (PPH) is not always as dramatic as a gush of blood; a small but constant trickle of blood is just as concerning. The blood may pool under the woman and be missed if the nurse does not request that the client change positions.

The nurse performs a postpartum assessment on a client who delivered a term newborn two hours ago. The nurse suspects that the client has developed postpartum hemorrhage. Which action should the nurse perform to confirm this finding? A. Assess the 24-hour intake and output B. Ask the client to turn to her side C. Assess the pulse for bradycardia D. Obtain orthostatic blood pressure

Choice C is correct. The platelet count is low and requires follow-up and notification to the primary healthcare provider (PHCP). The normal platelet count is 150-400 mm3. Causes of postpartum thrombocytopenia include exposure to certain medications, HELLP syndrome, preeclampsia, or disseminated intravascular coagulopathy.

The nurse reviews clinical data for a client 24 hours postpartum following a vaginal delivery. Which of the following findings would require follow-up by the nurse? A. Hematocrit 46% (37-47%) B. Creatinine 1.0 mg/dL (0.6-1.2 mg/dL) C. Platelets 90,000 mm3 (150,000-400,000 mm3) D. White blood cell 17,000 mm3 (5,000-10,000 mm3)

Choice C is correct. This blood glucose is greater than 250 mg/dL and is clinical hyperglycemia. Regardless if the client has a history of diabetes mellitus, this CBG requires follow-up because it is the only abnormal clinical data.

The nurse reviews clinical data for a client 24 hours postpartum following a vaginal delivery. Which of the following findings would require follow-up by the nurse? A. White blood cell count 14,000 mm3 (5,000-10,000 mm3) B. BUN 18 mg/dL (10-20 mg/dL) C. Capillary blood glucose 258 mg/dL (70-110 mg/dL) D. Urinary output 60 mL/hr

Choice A is correct. Quickening is often described as a flutter sensation in the client's abdomen. This occurs during 16 to 20 weeks of gestation. The client is likely experiencing this sensation as she is at 19 weeks of gestation.

The nurse takes a call at the antepartum clinic from a client who is pregnant at 19 weeks gestation. The client reports feeling a flutter in her abdomen. The nurse understands that this client is likely experiencing A. quickening. B. lightening. C. ballottement. D. ambivalence.

Choices A, B, C, and D are correct. These client statements require follow-up by the nurse because they are not accurate. Hepatitis C is a blood-borne pathogen and is not transmitted in breast milk. It is safe for a woman to breastfeed if she has the hepatitis C virus. If her nipples should crack and start to bleed, breastfeeding should be halted. Vaginal delivery is approved for a client with HCV. Cesarean delivery is not advised because of the increased risk of blood exposure unless indicated for other reasons. Unlike HIV infection, antiviral drugs for HCV are unsafe during pregnancy and must be suspended during the pregnancy. Isolation for an individual with hepatitis C is unnecessary (standard precautions are used).

The nurse teaches a pregnant client with the hepatitis C virus (HCV). Which of the following statements by the client would require follow-up? Select all that apply. - "I will be unable to breastfeed my baby." - "I will have to deliver my baby by cesarean to decrease the risk of transmission." - "I can continue my antiviral drugs while I am pregnant." - "My baby will need to be isolated while in the hospital." - "It may be several months before I know if my baby has hepatitis C."

Choice B is correct. HELLP syndrome stands for Hemolysis, elevated liver enzymes, and low platelets. HELLP syndrome is a condition in which hemolysis of the red blood cells occurs creating elevated liver enzymes and low platelets. Generally, complications are prevented by delivering the fetus as soon as symptoms develop.

The oncoming nurse is receiving a report on a pregnant patient with HELLP syndrome. This nurse knows that HELLP syndrome, a severe progression of preeclampsia stands for: A. Half Eclipsed Lipase Levels and Preeclampsia B. Hemolysis, elevated liver enzymes, and lowered platelets C. Hematocrit elevation, low lipase, and pancreatitis D. Hemoglobin, elevated lipids, and low plasma

Choice B is correct. "Nullipara" refers to a woman who has never given birth (live birth or stillbirth). A nulliparous woman may or may not have been pregnant before. It also includes women who have been previously pregnant but have not given birth because of spontaneous miscarriage or elective abortion before 20 weeks of gestation. A woman who experiences pregnancy loss beyond 20 weeks is not included under "nullipara.

When caring for a client new to the general practice clinic, the nurse notes that the woman is "nulliparous." The nurse knows that the term "nullipara" describes: A. A woman who had one pregnancy loss at 25 weeks and no children are alive. B. A woman who has never given birth to a child. C. A woman who had three prior pregnancies. D. A woman who has never been pregnant.

Choice C is correct. The APGAR score is a systematic method of assessing a newborn's physical condition at birth. It is used to determine the newborn's heart rate, muscle tone, response to stimuli, and color rating by assigning a score of 0 to 2 for each category. The newborn is assessed 1 minute after birth and again at 5 minutes after birth. A score between 7 and 10 indicates that the newborn is adjusting to extrauterine life. A score below 7 indicates that medical or nursing interventions may be needed to improve the newborn's cardiorespiratory status. If the 5 minute APGAR score is below 7, the newborn should be assessed every 5 minutes until the count is 7 or higher.

Which of the following does the Apgar scoring system indicate? A. Heart rate, cyanosis, and edema B. Heart rate, seizure activity, respiratory effort C. Irritability, heart rate, respiratory effort, muscle tone, and color D. Reflex, respiratory rate, and bleeding

Choices C, D, and E are correct. Nasal flaring is a sign of respiratory distress. If the newborn is working hard to breathe, they use extra effort to pull air in through their nose, and their nares flare out with inhalation. This signifies they are struggling to breathe and indicates respiratory distress. Head bobbing is a severe sign of respiratory distress in newborns. As they work harder and harder to breathe, they start using the muscles in their neck to pull their head forward with each inhalation. This signifies they are struggling to breathe and indicates respiratory distress. Finally, grunting is a sign of respiratory distress and may be coupled with the infant developing pallor that may transition to cyanosis.

Which of the following signs are indicative of respiratory distress in the newborn? Select all that apply. Nose breathing Occasional sneezing Nasal flaring Head bobbing Grunting

Choice C is correct. Early decelerations occur when the fetal heart rate decreases at the same time as a contraction. In this question, the nurse noted a decrease from 150 to 120 bpm with the contraction and then a return to baseline. This occurs due to the pressure of the head of the fetus on the pelvis or soft tissue, and no intervention is required by the nurse after an early deceleration.

While assessing a laboring mother during a contraction, the nurse notes a decrease in fetal heart rate from 150 to 120 bpm. The heart rate slows for about 10 seconds and increases back to 150 bpm as the contraction ends. Which of the following correctly classifies this observation? A. Late deceleration B. Moderate variability C. Early deceleration D. Marked variability

Choices B, C, and D are correct. Phenylketonuria, or PKU, is a genetic disorder that results in central nervous system damage from toxic levels of the essential amino acid phenylalanine. The musty odor, urine smell, and hypopigmentation of the hair, skin, and irises are signs of PKU. It is also true that all 50 states require routine screening of newborns for this disorder.

While participating in interdisciplinary rounds on the Mother-Baby floor, the provider mentions that your 2-day old client is at risk for phenylketonuria (PKU). The nurse knows that which of the following statements are true regarding this condition? Select all that apply. - It is a genetic disorder that is autosomal dominant. - Children with phenylketonuria commonly have a musty odor to their urine - Hypopigmentation of the hair, skin, and irises is a prominent sign of the disorder. - All 50 states require routine screening of newborns for phenylketonuria. - Screening for PKU must happen before 24-hours of life

Choices A and C are correct. A fetal heart rate less than 110 beats/minute or greater than 160 beats/minute is nonreassuring (Choice A). Late decelerations are an ominous sign, therefore, immediate interventions should be taken to improve the fetal heart rate; they are characteristic of a nonreassuring heart rate (Choice C).

While reviewing fetal monitoring strips, the labor and delivery nurse notes that the reading is nonreassuring. What features of the fetal monitoring strip does the nurse characterize as nonreassuring? Select all that apply. Fetal heart rate less than 110 beats/minute. Increase in variability. Late decelerations Mild variable decelerations Early accelerations

Choice C is correct. The priority nursing action is to pause the infant's feeds. Next, the nurse should notify the healthcare provider. Infants in the neonatal intensive care unit (NICU) have a high risk of developing necrotizing enterocolitis (NEC). One of the first signs of NEC is the inability of the infant to tolerate feedings. The feeding intolerance is evidenced by abdominal distension and bilious vomiting. This patient is showing potential signs of early necrotizing enterocolitis: hypoactive bowel sounds, increased abdominal girth, and no stool. One of the significant complications of NEC is bowel perforation. If the patient's bowel perforates, it is a medical emergency that can lead to sepsis and death. To reduce this risk, the priority nursing action is to pause the feeds to avoid further damage. Pausing the feeds is an independent nursing action in this urgent scenario, and after that, the nurse can proceed to notify the health care provider.

While working in the neonatal intensive care unit, the nurse assesses the client receiving continuous nasogastric feeding. In the gastrointestinal assessment, the nurse notes: Hypoactive bowel sounds The abdominal girth of 32 cm increased from 30 cm at the previous assessment. Soft abdomen, tender to palpation. No stool x 2 days. What is the priority nursing action? A. Notify the health care provider B. Continue to monitor C. Pause the infant's feeds D. Re-evaluate the abdominal girth at your next assessment

Choice D is correct. Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities.

A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective? A. "At around the time I would normally have my period, I should abstain from intercourse." B. "I should no longer have sex during the last trimester of pregnancy." C. "My sexual desire will remain the same for the entire pregnancy." D. "The best time to enjoy sex is in the second trimester."

Choice B is correct. A serum potassium level of 2.9 mEq/L indicates hypokalemia. During pregnancy, hyperemesis gravidarum (vomiting) results in loss of fluids and electrolytes and is strongly associated with hypokalemia—additionally, loss of stomach acid results in metabolic alkalosis.

A nurse cares for a client in the first trimester of pregnancy and notes that the client's serum potassium level is 2.9 mEq/L(3.5-5 mEq/L). Which of the following assessment findings is likely related to this lab finding? A. Alcohol consumption during pregnancy B. Hyperemesis gravidarum C. Lack of weight gain since the onset of pregnancy D. Food aversions

Choice B is correct. Oxytocin is used to induce labor at or near full-term gestation and to enhance labor when uterine contractions are weak and ineffective. Here, when the nurse notices the client's fundus has been contracting continuously for the past five minutes, and an assessment of fetal heart rate reveals 95 beats per minute, the nurse should immediately recognize these symptoms as evidence of fetal distress. The priority action is for the nurse to stop the oxytocin infusion.

A nurse is caring for a client receiving an intravenous oxytocin infusion for the induction of labor. The nurse notes the client's fundus has been contracting continuously for the past five minutes. An assessment of the fetal heart rate reveals 95 beats per minute. Which of the following should be the nurse's initial action? A. Place the client in a Trendelenburg position B. Stop the oxytocin infusion C. Administer oxygen via facemask D. Administer intravenous fluids at a high rate

Choice A is correct. Pregnancy increases a woman's risk of developing gingivitis and cavities. The patient has gingivitis and it appears like her dentist recommended tooth extraction for her. There is some concern regarding undergoing dental extractions during pregnancy. However, there is no evidence that a pregnant woman will need to delay dental removal. Delaying dental care could be harmful to the mother and fetus. Emergency treatment can be done at any time during pregnancy. However, elective dental surgery should be deferred until the second trimester (weeks 14 through 20). By the second trimester, fetal organogenesis is complete, and the risk of adverse effects from procedure/medications is lower. The consequences of not treating a dental infection during pregnancy outweigh the possible risks of the medications. The patient has gingivitis that needs to be addressed soon. Also, the blood volume of the pregnant woman significantly increases in 3rd trimester and remains elevated until delivery. Although there is no risk to the fetus during this trimester, the pregnant woman may experience increased discomfort. There is also a risk of hypotension in the supine position, so, short denta

A prenatal client with gingivitis at her fourth-month clinic visit mentions that she has a tooth extraction planned for the following month and is wondering whether or not she can continue with the procedure. What information will you provide the prenatal client? A. The second trimester is the safest period for dental extractions. B. She will need to wait until after delivery to have the procedure performed. C. She should wait until the third trimester to have the procedure performed. D. She should take anti-viral medications before the procedure to prevent illness

hypoglycemia, hyperglycemia

The neonate is at highest risk for ______ related to the client's ______

Choices A, D, and F are correct. A is correct. A boggy uterus is a sign of subinvolution. This refers to a womb that is not firm and contracting as expected to in the postpartum stage. The uterus should contract to clamp down and prevent bleeding, but in subinvolution, it does not do so. D is correct. Increased bleeding is a sign of subinvolution. When the uterus is not contracting and clamping down, it is not preventing postpartum bleeding. A healthy postpartum uterus would be contracting firmly, but this does not occur with subinvolution, so the mother is at risk for increased bleeding. F is correct. Persistent/prolonged lochial discharge is a sign of subinvolution. Lochia describes vaginal discharge after childbirth and is made up of blood, mucus, and uterine tissue. Normally, the rate of flow will be highest right after delivery and will gradually lessen.

The nurse is assessing a client in the immediate postpartum period. Which of the following signs or symptoms would indicate the client is experiencing subinvolution? Select all that apply. Boggy uterus. Board-like abdomen. Decreased fundal height. Increased bleeding. Hyporeflexia. Persistent lochial discharge.

Choice A is correct. Jaundice is a yellow color of skin and sclerae caused by bilirubin buildup in the baby's blood. In dark-skinned babies, jaundice may not be visible upon skin assessment, even with high blood bilirubin levels. The correct technique when assessing an infant (or an adult) with dark skin for jaundice would be to examine the mucous membranes in the mouth, the hard palate, or the sclera.

The nurse is assessing an infant with dark skin for jaundice. The nurse plans on assessing this client's A. hard palate of the mouth. B. lower back and sacrum. C. lower legs right below the knee. D. nail beds.

Choices A, B, and D are correct. During pregnancy, there is an increased demand for oxygen to supply both the mother and the developing fetus. Iron deficiency anemia occurs as a result of insufficient amounts of iron (needed to make hemoglobin) to meet oxygen demand. Iron deficiency anemia is associated with an increased risk for low birth weight, preterm delivery, and perinatal mortality.

The nurse is caring for a 30-year-old client who has developed iron-deficiency anemia during pregnancy. Which complication would this client be at an increased risk for due to iron deficiency anemia? Select all that apply. Low birth weight Preterm delivery Gestational diabetes Perinatal mortality Placenta previa

Choices A, C, D, and E, are correct. Prolonged labor with hypotonic contractions is classified as labor dystocia. Labor dystocia is a broad term that indicates that labor is not progressing. Key interventions for a client experiencing labor dystocia include encouraging the client to void frequently (when she feels the urge) because a full bladder will impede uterine contractions. A potential infusion of oxytocin to augment uterine contractions is a plausible prescription to be anticipated from the primary healthcare provider (PHCP). Frequent maternal repositioning is a key and noninvasive intervention that helps with fetal descent and effective contractions. The nurse should keep the client upright and encourage frequent repositioning. Fluid and electrolyte imbalances may be a cause of stunted labor. The nurse should be prepared to administer parenteral fluids because fluid and electrolyte abnormalities may cause labor dystocia.

The nurse is caring for a client experiencing prolonged labor with hypotonic contractions. Which of the following actions should the nurse take? Select all that apply. Encourage frequent voiding Maintain strict bedrest Prepare for a prescribed infusion of oxytocin Encourage frequent repositioning Prepare for an infusion of intravenous (IV) fluids

Choices A, B, D, and E are correct. Nausea and vomiting are common during the first trimester because of increased human chorionic gonadotropin and decreased gastric motility. Non-pharmacological measures include instructing the client to eat dry crackers before getting out of bed in the morning, consume fluids at least 30 minutes before or after solid food, brush their teeth immediately after a meal to decrease the aftertaste of food, and avoid overfilling the stomach which can be irritating and trigger nausea and vomiting.

The nurse is caring for a client who is experiencing nausea associated with her pregnancy. The nurse should recommend that the client Select all that apply. - eat dry crackers before getting out of bed in the morning. - consume fluids at least 30 minutes before or after solid food. - lie down soon after eating. - brush their teeth immediately after a meal. - avoid overfilling your stomach.

Respiratory rate 68 breaths per minute Apical Pulse 187 Axillary Temperature 95.7°F (35.3°C) Extremities Unequal thigh and gluteal creases

The nurse is completing a physical assessment of a newborn immediately following birth Click to highlight the findings in the nursing assessment that require follow-up Nursing Assessment Respiratory rate 68 breaths per minute Apical Pulse 187 Axillary Temperature 95.7°F (35.3°C) Head Symmetrical Mouth Small, white, hard cysts on the hard palate Neck Raises head from side to side while prone Cry Vigorous Respiratory Clear lung fields Extremities Unequal thigh and gluteal creases Skin Bluish-gray marks on the sacrum

The nurse should educate the antepartum client about which of the following physiological changes during pregnancy? Select all that apply. Increase in heart size Increase in gastric motility Reduced renal threshold for glucose Decreased basal metabolic rate Decreased esophageal sphincter tone

The nurse should educate the antepartum client about which of the following physiological changes during pregnancy? Select all that apply. - Increase in heart size - Increase in gastric motility - Reduced renal threshold for glucose - Decreased basal metabolic rate - Decreased esophageal sphincter tone

Choice B is correct. Physiological anemia of pregnancy occurs when there is an increase in plasma in the blood, thus "outweighing" the number of otherwise normal red blood cell levels. Physiological anemia is normocytic (normal red cell size), whereas anemia caused by iron deficiency would be "microcytic."

Upon gathering the lab results from your prenatal client's recent blood draw, the nurse notes that the patient's red blood cell levels have decreased since before pregnancy. The nurse believes that physiological anemia of pregnancy is likely occurring. This results from which of the following? A. Decrease in circulating red blood cells B. Increase in plasma C. Increase in iron demands from the body D. Decrease in heart size

Choice C is correct. Coarctation of the aorta is a narrowing of the aorta near the ductus arteriosus. Because of this narrowing, there is increased blood flow to the upper extremities and decreased blood flow to the lower extremities. That causes the symptoms described in the question: bounding upper pulses, faint lower pulses, and overall better perfusion to the upper extremities.

While assessing a newborn infant in the nursery, you observe bounding 3+ radial pulses and faint 1+ pedal pulses. You also notice that the feet are cold and pale, while the hands are warm and pink. Which cardiac defect do you suspect this infant has? A. Tetralogy of Fallot (TOF) B. Hypoplastic left heart syndrome C. Coarctation of the aorta (COA) D. Transposition of the great arteries

Based on the most recent clinical data, the nurse is most concerned about the client's heart rate. activity. respiratory rate. skin characteristics.

activity

The client will need a ____ as evidenced by ____ and ____

glucose tolerance test; advanced maternal age; BMI of 30

Choice C is correct. Preeclampsia is a dangerous complication in pregnancy that is characterized by high blood pressure and protein in the urine. A history of frequent urinary tract infections would not put this client at increased risk for developing preeclampsia.

The nurse is collecting the health history of a pregnant client. Which of the following conditions would not put this client at an increased risk of developing preeclampsia? A. Obesity B. Chronic hypertension C. Frequent urinary tract infections D. Multifetal gestation

Choice B is correct. Caffeine intake should be less than 200 mg/day. Excessive caffeine intake has been linked to miscarriage or preterm birth. An 8-oz (240 mL) cup of brewed coffee contains approximately 137 mg of caffeine.

The nurse is preparing a prenatal class focused on nutrition. Which of the following statements should the nurse make? A. "Raw sushi is okay to consume during pregnancy because of its high protein level." B. "Caffeine intake should be limited during pregnancy to less than 200 mg/day." C. "To increase your iron intake, choose citrus fruits or strawberries." D. "Sodium intake is restricted to 1 gram per day during all three trimesters."

Choice B is correct. Linea nigra refers to the linear hyperpigmentation of the midline of the abdomen (from sternal notch to pubis). This is a frequent change that occurs during the 2nd trimester.

A primigravida patient in her 2nd trimester calls the OB office to report a dark line on her skin in the middle of her abdomen. The phone triage nurse would recognize this as which of the following? A. Chloasma B. Linea nigra C. Goodell Sign D. Striae gravidarum

Choice B is correct. The Hepatitis B vaccine is given in three doses; the first dose is administered at the time of birth, the second dose at two months, and the third dose at six months of age. The Centers for Disease Control and Prevention (CDC) makes recommendations for vaccines and reviews special situations in vaccinations.

You are a nurse in the L&D department of the local hospital. You are caring for a newborn born at term with APGAR scores of 8 and 10. Before discharge from the hospital, you should ensure that the newborn has received: A. Hep A (hepatitis A) vaccine B. Hep B (hepatitis B) vaccine C. RV (Rotavirus) vaccine D. DTaP (diphtheria, tetanus, and pertussis) vaccine

Choice A is correct. Chadwick's sign presents as a blue to purple hue of the cervix and is considered a "probable" sign of pregnancy.

Chadwick's sign is a prenatal assessment performed at the initial visit to verify pregnancy. The obstetric nurse knows that Chadwick's sign presents with: A. A blue to purplish hue of the cervix B. Softness to the uterine fundus felt through the abdomen C. A thinning and lengthening of the cervix D. The absence of menstruation at day 28 in a woman's cycle

Choice D is correct. Photographing all visitors and requiring visitors to sign in is fundamental to preventing infant abduction. This creates a record of the visitor, and the photograph is helpful if an abduction should occur.

The nurse participates in a committee reviewing the hospital security plan regarding infant abduction. Which of the following recommendations should the nurse make to the committee? A. Rearrange rooms so that the crib is near the door. B. Carry infants in the hallway instead of using the bassinet. C. Issue staff identification badges without a photo. D. Take photographs of all visitors.

Choice C is correct. The incidence of domestic violence intensifies while a woman is pregnant. Signs of domestic violence while pregnant include the late onset of prenatal care, unexplained bruising, and depression. Other symptoms include problems adhering to prenatal care, missed appointments, and drug or alcohol abuse.

The maternal health nurse is taking the history and physical for a pregnant woman in her second trimester. She has several mysterious bruises on her arms and appears isolative. The nurse would provide vigilant surveillance for which common occurrence in pregnancy? A. Chronic depression B. Physiological anemia C. Domestic violence D. Acute insomnia

Choice B is correct. Nifedipine is a calcium channel blocker indicated as a tocolytic in preterm labor. This medication relaxes smooth muscle and reduces uterine contractions.

The nurse cares for a client at 30 weeks gestation at risk of delivering preterm. Which of the following medication would the nurse anticipate the primary healthcare provider (PHCP) to prescribe? A. Penicillin G B. Nifedipine C. Oxytocin D. Misoprostol

Choice D is correct. At five minutes after birth, the expected SpO2 is in the 80-85% range. Regardless of the cyanosis, if the oxygen saturation is within this range, the infant probably does not need supplemental oxygen at this point. The American Heart Association and American Academy of Pediatrics suggest the following table for Target Pre-ductal Oxygen Saturation levels following birth.

You are caring for a newborn born at term. On your assessment. You note that central cyanosis is present and persistent at five minutes after birth. You attach a pulse oximeter to the newborn. When determining whether or not the infant requires supplemental oxygen, you know that the expected oxygen saturation at 5 minutes after birth is: A. 65-70% B. 70-75% C. 75-80% D. 80-85%

Choice C is correct. Rubella is a maternal infection that is known to increase the risk that the fetus will have a congenital heart defect. All mothers should be tested for rubella, and if found to be positive, should have a fetal echocardiogram performed to evaluate the fetus' heart more closely.

Which of the following maternal infections may increase the risk of developing congenital heart defects in the fetus? A. Parainfluenza B. Adenovirus C. Rubella D. Measles

Choice D is correct. The term "Small for Gestational Age (SGA)" is used when the infants are smaller than normal for the number of weeks of pregnancy (gestational age). When an infant's weight is below the 10th percentile for the gestational age, it is considered small for gestational age. By definition, about 10 percent of all newborns are labeled as SGA. Not all "Low Birth Weight" babies are SGA. Infants may be of low birth weight but may still fall above the 10th percentile for gestational age. It is important to distinguish SGA from other related terms, "Low Birth Weight (LBW)", "Very Low Birth Weight (VLBW), and "Extremely Low Birth Weight (ELBW)." These definitions are based on the infant's weight at the time of birth. These are not percentile scores and are defined on the absolute weight limit. An LBW infant is defined as an infant with a weight of less than 2500 grams (5 lb. and 8 ounces), regardless of gestational age at the time of birth. A VLBW infant is defined as one with a weight less than 1500 grams at the time of birth. An ELBW infant is less than 1000 grams at the time of birth.

While working in the Neonatal Intensive Care Unit (NICU), you are notified that a "small for gestational age" infant is being brought to the unit. Being a NICU nurse, you understand that this means which of the following? A. The infant's weight is less than 2500 grams. B. The infant's weight is below the 20th percentile. C. The infant's weight is less than 1500 grams. D. The infant's weight is below the 10th percentile.

Choice D is correct. A spontaneous abortion or miscarriage occurs before 20 weeks.

The nurse is caring for a prenatal client with some vaginal bleeding. The nurse knows that this client could be experiencing a spontaneous abortion or miscarriage if it is occurring before ________ weeks of gestation. A. 14 B. 16 C. 18 D. 20

Choice C is correct. Oxytocin should always be administered intravenously as a piggyback infusion. Intravenous infusion is the only acceptable method of parenteral administration of oxytocin for the induction or stimulation of labor. Accurate control of the infusion rate is essential and is best accomplished by an infusion pump. The current FDA recommendation is "to piggyback the Pitocin (oxytocin) infusion on a physiologic electrolyte solution, permitting the Pitocin (oxytocin) infusion to be stopped abruptly without interrupting the electrolyte infusion."

A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions. After you get the client situated in a labor, delivery, and recovery room, you notice the client's health care provider (HCP) enter the room to evaluate the client. Following the evaluation, the HCP exits the room, and shortly thereafter, you enter. During your discussion, the client states the HCP "went to order oxytocin." In anticipation of that order, you understand this client's oxytocin will be administered via which route of administration? A. Intramuscular administration B. Intravenous administration via mainline infusion using an infusion pump C. Intravenous administration via piggyback using an infusion pump D. Oral administration

Choice D is correct. The first sign of threatened abortion is vaginal bleeding, which is relatively common during early pregnancy. Approximately 25% of pregnant women experience "spotting" or bleeding in early pregnancy, and up to 50% of these pregnancies end in spontaneous abortion. Vaginal bleeding, which may be brief or last for weeks, may be accompanied by uterine cramping, persistent backache, or feelings of pelvic pressure. These added symptoms are more likely to be associated with loss of pregnancy.

A nurse in a gynecology clinic is assessing a first-time client (G1P0) who is eight weeks pregnant. Which assessment finding would alert the nurse of a high-risk pregnancy? A. The client reports nausea and vomiting four to five mornings per week. B. The client expresses her ambivalence toward the pregnancy to the nurse. C. The client reports intermittent constipation since learning she was pregnant. D. The client reports intermittent vaginal spotting and abdominal cramping.

Choice C is correct. The rupture of membranes causes the amniotic fluid to be expelled in large amounts. If the fetus has not engaged, the umbilical cord may prolapse along with the fluid; this poses a danger to both the fetus and the mother. The mother should then promptly arrive at the labor and delivery unit.

A woman in her 37th week of gestation is wary about complications and labor signs. She asks the nurse, how would she know if it was time to go to the labor and delivery unit. The best response is: A. "When the mucus plug is out." B. "When you feel a heaviness in your bladder." C. "When you see a large gush of fluid coming out of your vagina." D. "When you feel nauseated and vomit altogether."

Choices A, C, and E are correct. The quad screen, or quadruple marker test, is done in the second trimester of pregnancy and includes measuring levels of AFP, HCG, estriol, and inhibin A. The clinician uses this test to evaluate the chance of carrying a baby with genetic abnormalities such as Down syndrome (choice A), trisomy 18, and spina bifida (choice C). Gastroschisis or omphalocele are birth defects that affect the abdominal wall (choice E). A quad screen test can also diagnose these abdominal conditions if an ultrasound during the first trimester was not performed or is inconclusive. As DNA screening improves, that diagnostic method might be used instead of the quad screen.

The nurse explains the quad screen test to her prenatal client in the second trimester. Which of the following conditions can be detected by the quad screen test? Select all that apply. Down syndrome Tay-Sachs disease Spina bifida Cystic fibrosis Abdominal wall defects

Choice D is correct. In the presence of vaginal bleeding, an internal vaginal examination is contraindicated unless performed inside an environment prepared to perform an emergent vaginal delivery or cesarean section (i.e., such as a labor and delivery unit). Additionally, this emergency room nurse is likely not permitted under hospital or emergency department policy to perform an internal vaginal examination on a full-term pregnant woman with vaginal bleeding and severe abdominal pain. Additionally, this emergency department nurse is likely not trained to perform an internal vaginal examination on a full-term pregnant woman, as this skill is not routinely performed or practiced in an emergency department.

A pregnant client is brought into an emergency department by her husband. The client reports she is currently at 37 weeks gestation and began experiencing severe abdominal pain and bright red vaginal bleeding which "runs down my legs" thirty minutes prior to arrival. She currently rates her abdominal pain 10/10. Based on this information, which assessment method should the emergency room nurse refrain from performing? A. External fetal heart rate monitoring B. Abdominal palpation C. Measurement of vital signs D. Internal vaginal examination

Choice B is correct. Epidural analgesia may cause bladder distention. Bladder distention may cause pain that remains after initiation of the block and may interfere with fetal descent in labor.

The nurse is caring for a client in labor who just received epidural analgesia. The nurse should monitor the client for which adverse effects? A. Hypertension B. Bladder distention C. Hypothermia D. Precipitous labor

Choice C is correct. It is widely accepted that a finding of a single transverse palmar crease on the palm - often referred to as a simian line or simian crease - is often observed in a wide range of chromosomal defects, including, but not limited to, Down syndrome, congenital limb deficiency, trisomy 13/18/21, 4p, 18q, etc. Although this finding does not in and of itself render a diagnosis of a chromosomal disorder, this finding by the nurse would necessitate the need to alert the newborn's primary health care provider (HCP), as genetic and chromosomal testing will likely need to be performed.

While working in the nursery, a nurse assesses a newborn born less than two hours ago. Which of the following findings by the nurse would necessitate further investigation? A. A diamond-shaped soft area present at the top of the newborn's head B. Greasy, white substance that resembles cheese on the newborn's neck, back, and thighs C. A single crease on the palm D. Acrocyanosis

Choice B is correct. Rh immune globulin (RhoGAM) is administered to the unsensitized Rh-negative woman at 28 weeks of gestation to prevent sensitization, which may occur from small leaks of fetal blood across the placenta. Rh immune globulin (RhoGAM), a commercial preparation of passive antibodies against Rh factor, is repeated after birth if the woman delivers an Rh-positive infant.

A 28-week pregnant client is advised by her physician to receive an Rh immune globulin (RhoGAM) injection. The client asks the nurse the reason for the medication. Which of the following is the most appropriate response from the nurse? A. "Rh immune globulin (RhoGAM) prevents measles during pregnancy." B. "This injection prevents you from forming antibodies against your baby." C. "Rh immune globulin (RhoGAM) prevents jaundice in your baby." D. "This type of injection prevents autosomal abnormalities."

Choice C is correct. The fetus is experiencing variable decelerations of heart rate in the setting of ruptured membranes. Amnioinfusion refers to the infusion of a warmed isotonic solution into the uterine cavity through the IUPC. It is mostly used as a treatment to correct fetal heart rate changes caused by umbilical cord compression, indicated by variable decelerations seen on cardiotocography. It can help cushion the cord and relieve pressure when the membranes have ruptured.

A woman was admitted to the obstetric unit in active labor and has had a frank rupture of membranes. A fetal scalp electrode and intrauterine pressure catheter were inserted promptly. The woman had progressed to 8-cm dilation when the nurse noticed abrupt decreases in the fetal heart rate of 15-20 bpm that quickly returned to baseline. The changes in fetal heart rate occurred with and without contractions. At this point, the nurse should prepare to initiate a client teaching about the possibility of which procedure? A. High forceps delivery B. Oxytocin induction C. Amnioinfusion D. Cesarean birth

Choices B and C are correct. A positive Babinski sign is when the toes splay outward after stroking the plantar surface of the foot. It is normal in the newborn but pathologic in the adult population (choice B). When a baby is startled and responds by suddenly stretching out his arms, this is the Moro reflex(choice C).

During a newborn assessment, the nurse performs a variety of reflex assessments to evaluate the newborn's nervous system and overall health. Which of the following statements about reflexes in the newborn is true? Select all that apply. -The Babinski reflex is also known as the startle reflex. -A positive Babinski sign is normal in the newborn. -The Moro reflex is demonstrated when the infant is startled and stretches out their arms in response. -The Moro reflex is pathologic in the newborn. -The tonic neck reflex is present at birth and is essential for sucking

Choices A, B, and D are correct. Hyperreflexia, headache, and epigastric pain are typical symptoms of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Hyperreflexia is a common finding and may occur with ankle clonus. These findings arise because of neuromuscular irritability. Other findings associated with preeclampsia include hypertension, facial swelling, and proteinuria.

The nurse is assessing a client with severe preeclampsia. Which clinical findings should the nurse anticipate? Select all that apply. hyperreflexia headache uncontrolled vomiting epigastric pain glycosuria

Choice A is correct. An early sign of illness involves an increase in the client's heart rate. Tachycardia is a rapid response to hypovolemia. A heart rate change from 80 to 125 bpm warrants further investigation into a possible illness.

The postpartum nurse is monitoring a new mother for signs of illness following vaginal delivery of a newborn infant. Which of the following is an early sign of excessive blood loss? A. Heart rate change from 80 to 125 bpm B. Blood pressure change from 125/90 to 119/82 mmHg C. A decrease in respiratory rate from 22 to 16 breaths per minute D. Reports of perineal soreness