Maternal Newborn "Hard"

A nurse is caring for a client who is scheduled to undergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an O-positive blood type. Which of the following interventions should the nurse perform? A. Apply an external fetal monitor to the client B. Instruct the client to drink fluids and not to void prior to the procedure C. Administer Rho(D) immunoglobulin after the procedure D. Instruct the client to take a deep breath and hold it during the procedure

A. Apply an external fetal monitor to the client The nurse should assess fetal heart tones and uterine tone prior to and throughout the procedure to establish a baseline and monitor for changes. - B: Clients should be instructed to void immediately prior to the procedure to decrease the risk of accidentally puncturing the bladder during the amniocentesis. - C: Rho(D) immunoglobulin would only need to be administered if the client had an Rh-negative blood type to help ensure maternal antibodies do not form against fetal cells. - D: The client should stay relaxed and breathe normally during the introduction of the needle. The act of taking a deep breath and holding it will lower the diaphragm and shift the uterine contents. This will increase the risk of inadvertently puncturing the placenta or fetus.

A nurse is teaching a client who is pregnant and has presentational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? A. Carbohydrates should make up 55% of your diet B. Protein should make up 70% of your diet C. Fats should make up 45% of your diet D. Fiber should make up 10% of your diet

A. Carbohydrates should make up 55% of your diet For clients who have presentational diabetes, intake of simple carbohydrates should be limited. The ideal diet is composed of 55% carbohydrates, 20% protein (B), 25% fat (C), and less than 10% saturated fat. - D: There is no limitation on the amount of fiber a client who has presentational diabetes should consume. Fiber should be recommended to clients to decrease constipation, which can be an effect of pregnancy.

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take? A. Encourage the client to frequently change positions B. Instruct the client to take breaths and hold them for 10 seconds while pushing C. Assess maternal vital signs every 1 hour D. Assist the client to the restroom

A. Encourage the client to frequently change positions During the second stage, frequent position changes can promote the descent of the fetus through the birth canal. The nurse should assist the client in finding optimal positions of comfort which allow the client to rest between contractions but also enhances expulsive efforts. - B: Having the client hold her breath while pushing increases intrathoracic and cardiovascular pressure and decreases the amount of oxygen that reaches the fetus. - C: The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the second stage of labor. - D: The client should remain on bedrest during this stage of labor due to impending delivery.

A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth

A. Gestational diabetes Gestational diabetes increases the risk of postpartum depression. - Other risk factors include infertility treatment, pregnancy complications, preterm birth, and a history of mood disorder. - B: An unplanned pregnancy increases the risk of postpartum depression. Significant life events such as job loss also increase the risk. - C: Being married is a protective factor against postpartum depression. Being unmarried increases the risk of experiencing postpartum depression. - D: Preterm birth increases the risk of postpartum depression. Having an ill newborn also increases this risk.

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. I should stop swaddling my baby once she is able to roll over by herself B. My baby's legs should be extended straight out when I swaddle her C. I should be able to slide just 1 finger between my baby's chest and the swaddled blanket D. After swaddling, I should place my baby on her side in her crib or bassinet

A. I should stop swaddling my baby once she is able to roll over by herself The parent should discontinue swaddling the baby once the baby is able to roll over, which occurs around 2 months of age. - Rolling over can tighten the swaddle and keep the baby from breathing properly. - B: The parent should avoid swaddling the newborn with the legs extended, as this can cause hip dislocation. The parent should swaddle the newborn with the hips slightly flexed and enough room in the blanket for the newborn to move the knees. - C: The parent should be able to fit 2 to 3 fingers between the newborn's chest and the swaddled blanket. A swaddle that is too tight can interfere with respiration or cause the newborn to overheat. - D: The parent should lay the newborn on her back after swaddling to reduce the risk of sudden infant death syndrome (SIDS).

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor B. Maternal drug use C. Hyaline membrane disease D. Meconium aspiration

A. IV narcotics administered to the mother during labor The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor. - B: The use of naloxone in a newborn who has been exposed to narcotics during pregnancy could result in immediate withdrawal symptoms. - C & D: Naloxone has no effect on hyaline membrane disease or meconium aspiration respiratory distress.

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

A. Intraventricular hemorrhage When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile. Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure. Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent neurological damage. - B: A premature infant has an increased risk of hypoglycemia due to decreased glycogen stores and increased metabolic needs. These infant are typically unable to meet nutritional needs with oral intake. - C: Due to limited subcutaneous and brown fat stores and an inability to maintain a flexed position, a premature infant has a greatly increased risk of hypothermia. - D: Meconium aspiration syndrome is typically a complication of post-term infants. Insufficient gas exchange from an aging placenta can lead to hypoxic episodes during which the fetus releases meconium into the amniotic sac.

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner? A. Lightly stroke the upper thighs B. Steadily apply pressure to the sacrum C. Gently massage the mid-abdominal area D. Firmly squeeze both hips

A. Lightly stroke the upper thighs Effleurage involves lightly stoking or massaging the abdomen in rhythm with breathing to help relieve labor pain. However, when a monitor belt is in use, the sides of the abdomen, chest, or upper thighs are alternative locations for massage. - B: This technique is known as counter-pressure and is used to help decrease lower back pain by relieving occiput pressure on the spinal nerves. - C: Gently massaging the abdomen is therapeutic for pain relief; however, massage of the mid-abdominal area is not possible for this client due to the positioning of the monitor belt. - D: This is a method of counter-pressure and is used to help relieve lower back pain by placing pressure on the hips.

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? A. Losing 2.2 pounds each month would be acceptable B. Losing 4.4 pounds each month would be acceptable C. Losing 5.5 pounds each month would be acceptable D. Losing 6.6 pounds each month would be acceptable

A. Losing 2.2 pounds each month would be acceptable An important postpartum goal is for the client to lose the weight gained during pregnancy. An acceptable amount of weight loss for a client who is lactating is 1 kg (2.2 lb) per month. - B, C, & D: Clients who are NOT lactating should lose approximately 0.5 to 0.9 kg (1.1 to 2 lb) per week.

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include? A. Notify your provider if you notice cracking on your nipples B. Notify your provider if you have not had a bowel movement within 5 days C. Notify your provider if your breasts leak when you shower D. Notify your provider if your vaginal discharge is a brownish-red color

A. Notify your provider if you notice cracking on your nipples The client should notify the provider of cracking, bleeding, or blistered nipples since this increases the client's risk of infection. - B: The client should notify the provider if she does not have a bowel movement within 3 days. - C: The client should expect the breasts to leak when stimulated such as when showering or hearing a baby cry. - D: The client should expect her lochia to turn a brownish-red or pink color approximately 3 days after birth and to remain that color for up to a week. The lochia will then turn a yellowish-white color for a few days before stopping.

A nurse is providing care for a client who is in the second stage of labor. The fetal heart tracing indicates multiple variable decelerations. Which of the following actions should the nurse take? A. Prepare an amnioinfusion B. Place the client in a supine position C. Administer oxygen 2 L/min via nasal cannula D. Give a glucocorticoid

A. Prepare an amnioinfusion The nurse should prepare an amnioinfusion to decrease cord compression. - B: The nurse should assist the client into a side-lying or knee-to-chest position to decrease umbilical cord compression. - C: The nurse should administer 8 to 10 L/min of oxygen by non-rebreather face mask to enhance oxygen saturation. - D: The nurse should administer a glucocorticoid for a client who is experiencing preterm labor to accelerate fetal lung maturity in fetuses between 24 and 34 weeks. It is not given to clients who are having variable decelerations.

A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should notify the provider about which of the following assessment findings? A. The client reports a frequent cough B. The client reports that none of her shoes fit anymore C. The client reports a weight gain of 2 lb in a 2-week period D. The client reports leg cramps in the evening

A. The client reports a frequent cough A frequent cough could be an indication of cardiac decompensation and should be reported to the provider. - B: Edema of the lower extremities is a common occurrence in pregnancy and does not warrant provider notification. Generalized edema should be reported. - C: This weight gain is within the expected range during the second or third trimester of pregnancy for a client of average pre-pregnant weight. It does not warrant notification of the provider. Excessive weight gain could be a sign of cardiac decompensation and should be reported. - D: Leg cramps are a frequent occurrence during pregnancy due to compression of lower-extremity nerves from the enlarging uterus. This finding does not warrant notification of the provider.

A nurse is teaching a client about squatting exercises during pregnancy. Which of the following statements should the nurse include? A. These exercises should be done for 15 minutes each day to strengthen the perineal muscles B. Squatting exercises can tone your abdomen, helping you lose weight faster following delivery C. Practicing squatting exercises during pregnancy will reduce lower back pain during labor D. Doing squatting exercises 3 times per week will improve your overall fitness

A. These exercises should be done for 15 minutes each day to strengthen the perineal muscles Squatting exercises help stretch the perineum, allowing stretching during delivery and improving functional efficiency after delivery. - B: Squatting exercises are done during pregnancy. Weight loss after delivery is affected by exercise and diet. - C: Pelvic rocking exercises can help reduce back pain during pregnancy and in early labor. - D: Prenatal yoga performed during pregnancy can improve the client's overall fitness.

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. You should slightly increase your exposure to sunlight B. You will need extensive dermatological treatment for this condition after you deliver your baby C. Your provider will schedule weekly lab testing to monitor your liver function D. Your provider will prescribe isotretinoin cream

A. You should slightly increase your exposure to sunlight Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching. - B: Pruritus gravidarum will resolve without extensive treatment after delivery. - C: Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no effect on the liver. Therefore, the client will not require weekly liver function studies. - D: Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant due to its teratogenic effects on the fetus.

A nurse is caring for a client who is pregnant with a male child and expresses concern to the nurse about the possibility of the child having hemophilia. The client is a carrier of the gene mutation for this condition. Which of the following percentages represents the chance that the child will have this disorder? A. 25% B. 50% C. 75% D. 100%

B. 50% Hemophilia A is an X-linked recessive inheritance disorder, which means that female clients who are carriers have a 50% chance of passing the gene mutation to their children. - If the child is female, she will be a carrier. If the child is male, he will have the disorder. - This is because male children inherit an X chromosome from their biological mothers and a Y chromosome from their biological fathers. If the male child has the gene mutation on 1 of his X chromosomes, it will cause the disorder even though it is on a copy of the gene. - A: In the usual pattern of inheritance, the biological mother does not have the disorder, possessing a normal allele and a mutant allele. A male may or may not inherit the gene mutation, so there are no 25% possibilities in this scenario. The male child inherits a Y chromosome from his biological father, which is not relevant for the inheritance pattern of hemophilia A. - C: A male may or may not inherit the gene mutation, so there are no 75% possibilities in this scenario. - D: There are no 100% possibilities in this scenario.

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care for the infant D. Collect a cord blood specimen to test for the presence of HIV

B. Administer the hepatitis B vaccine prior to discharge Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected with HIV can receive all inactivated vaccinations. - A: In the United States and Canada, breastfeeding should be avoided in mothers who are HIV-positive. - C: The nurse should use standard precautions when caring for a newborn who has been exposed to HIV. - D: To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained. Maternal antibodies will be present in the cord blood and can affect the test results.

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability

B. Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. The nurse must assess the newborn's blood glucose level within the firs hour following birth and frequently thereafter until blood glucose levels are stable. - A: Betamethasone does not affect the newborn's ability to maintain body temperature. Hyperthermia is not an adverse effect of betamethasone. - C: Betamethasone administered to an antepartum client does not affect the newborn's vital signs. If the newborn has a rapid apical pulse, it is related to another cause like prematurity or respiratory insufficiency. - D: Irritability is not an adverse effect of betamethasone.

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age B. Discard opened cans of formula after 48 hr refrigeration C. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet D. Bottles and nipples can be hand-washed in hot, soapy water

B. Discard opened cans of formula after 48 hr refrigeration Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination. - A: Infants should not be left alone when feeding. Infants who fall asleep with a bottle in their mouth are prone to choking and tooth decay. - C: Tap water needs to be sterilized prior to reconstituting formula. The tap water needs to be boiled for 2 minutes, cooled, and used within 30 minutes to mix the formula. - D: Bottles, nipples, nipple rings, and caps must be boiled for 5 minutes prior to the first use. After that, the feeding equipment can be placed in the dishwasher for cleaning. If no dishwasher is available, the feeding equipment must be boiled between uses.

A nurse is assessing a client who is pregnant and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort? A. Relaxin B. Estrogen C. Progesterone D. Human chorionic somatomammotropin (HCS)

B. Estrogen Estrogen increases vascularity and connective tissue growth. Nasal stuffiness, a common discomfort in pregnancy, results from the increased vascularity of the mucus membranes within the nasal passages. - A: Relaxin causes loosening of the ligaments, making the pelvic joints more flexible to facilitate the birthing process. - C: Progesterone has a relaxant effect on smooth muscle, which helps the uterus remain relaxed and maintain the pregnancy. The effects of this hormone also contribute to the occurrence of constipation and heartburn during pregnancy. - D: HCS is produced by the placenta and stimulates the maternal metabolism to supply nutrients for fetal growth. This hormone is additionally responsible for lactation development of the maternal breasts.

A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include? A. Position the client on her hands and knees while in bed B. Flex the client's legs apart and raise her knees to her abdomen C. Apply gentle pressure on the client's funds while she is lying supine D. Push the fetus's anterior shoulder under the symphysis pubis externally

B. Flex the client's legs apart and raise her knees to her abdomen The McRoberts maneuver includes helping the client flex her knees apart, which rotates the pubic bone anteriorly. - This movement releases the anterior shoulder, but the nurse should not apply pressure directly to the anterior shoulder during this maneuver. - This maneuver can be used for clients with or without epidural anesthesia. - A: This positioning is part of the Gaskin maneuver, which includes positioning the client on her hands and knees to release the anterior shoulder of the fetus. - C: Using fundal pressure will not release the anterior shoulder of the fetus and is associated with neonatal neurological complications. This intervention should be avoided. - D: When the nurse applies suprapubic pressure, the anterior shoulder of the fetus is pushed underneath the symphysis pubis. This dislodges the anterior shoulder and allows the fetus to rotate, but it is not the McRoberts maneuver.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Overlapping suture lines B. Generalized petechiae C. Acrocyanosis D. Transient strabismus

B. Generalized petechiae The nurse should report generalized petechiae to the provider. - This manifestation can be associated with an infection or a clotting-factor deficiency. - A: Overlapping suture lines are an expected variation for a newborn, as the newborn's head mold during the second phase of labor to ease delivery from the vagina. - C: Acrocyanosis is an expected manifestation for newborns during the first 24 hours following birth. - D: Transient strabismus is an expected manifestation until the newborn is 3 to 4 months old.

A nurse is providing education for a pregnant client about symptoms that should be reported immediately to the provider. Which of the following client responses indicates an understanding of the teaching? A. I should call my provider if I develop melasma B. If I notice that my eyes are puffy, I should call my provider C. I should call my provider if I notice that my feet and ankles are swollen D. If I notice periodic numbness and tingling in my fingers, I should call my provider

B. If I notice that my eyes are puffy, I should call my provider Puffy eyes are associated with facial edema, which is a sign of pregnancy-induced hypertension. This should be reported immediately. - A: Melasma, a blotchy pigmentation of the skin on the face, is an expected finding during pregnancy. - C: Dependent or physiological edema during pregnancy requires no treatment. If the client also has swelling of the face or hands, reporting is warranted. - D: These symptoms are caused by drooping of the shoulders during pregnancy, which causes traction on the brachial plexus nerves. This is a common occurrence during pregnancy. Maintaining good posture will help diminish the sensation.

A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Increase the rate of the primary IV infusion C. Position the client in a semi-Fowler's position D. Provide glucose via oral hydration or IV

B. Increase the rate of the primary IV infusion Late decelerations can be caused by uteroplacental insufficiency. The fetal heart tracing shows a gradual decrease in fetal heart rate with a return to baseline on uterine contractions. - This could be related to maternal hypotension, which can be corrected with increased IV fluids to increase maternal blood volume. This improves uterine and cardiac perfusion as well. - A: A client who has received epidural analgesia should not be assisted out of bed to the toilet or a bedside commode due to inhibited muscle control and the increased risk of falling. - C: Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client in a lateral or Trendelenburg position improves maternal circulation. - D: Hypotension is a function of low blood pressure rather than low blood glucose. The nurse should address low blood pressure through positioning and bolus Iv fluids.

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic disease

B. Menorrhagia An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or a history of ectopic pregnancy. - A: An IUD is an appropriate method of contraception for women who have hypertension. It is a good alternative to the estrogen-based oral contraceptives that cannot be taken by women who have hypertension. - C: A history of multiple gestations is not a contraindication for an IUD. - D: An IUD is an appropriate method of contraception for women who have a history of thromboembolic disease because an IUD is not associated with clotting problems and is a good alternative to oral contraceptives, which are contraindicated for women who have a history of thromboembolic disease.

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? A. Administer the oxytocin with manual IV tubing B. Monitor the fetal heart rate every 15 minutes initially C. Begin the infusion at 10 milliunits/min D. Titrate the dosage until the client has 1 contraction every minute

B. Monitor the fetal heart rate every 15 minutes initially The nurse should plan to monitor the fetal heart rate (FHR) every 15 minutes through the first stage of labor and then every 5 minutes during the second stage. Additionally, the nurse should document the FHR with every change of the oxytocin dosage. - A: The nurse should administer oxytocin with an infusion pump to ensure accurate flow rate delivery. - C: The nurse should begin the infusion at 1 milliunit/min and should increase the infusion slowly every 30 to 60 minutes by no more than 1 to 2 milliunits/min until the desired response is achieved. - D: The nurse should titrate the dosage until the client has 1 contraction every 2 to 3 minutes. One contraction every minute is an indication of uterine tachysystole.

A nurse is teaching a prenatal class about non pharmacological comfort measures during labor. Which of the following statements should the nurse identify as an indication that the instructions have been understood? A. I can have my partner apply counter pressure to my upper abdomen B. My baby will be monitored with a Doppler device during hydrotherapy C. I can have the nurse apply acupressure to my lower abdomen D. My TENS unit will not help with lower back pain during early labor

B. My baby will be monitored with a Doppler device during hydrotherapy During hydrotherapy, the nurse should monitor the fetal heart rate with a fetoscope, a Doppler device, or a wireless external fetal monitor. - A: The client's partner should apply counter pressure to her lower back, not her abdomen, to help relive pain in that area. - C: Acupressure can help relieve pain, but the sites for applying pressure are the lower back, hips, neck, shoulders, wrists, ankles, soles of the feet, small toes, and just below the kneecaps, not the abdomen. - D: Trancutaneous electrical nerve stimulation (TENS) delivers electrical impulses on either side of the spine. This noninvasive method of pain management can help relieve back pain during the early part of the first stage of labor.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A. Perform a vaginal examination to determine cervical dilation B. Obtain blood samples for baseline laboratory values C. Place a spiral electrode on the fetal presenting part D. Prepare the client for a transvaginal ultrasound

B. Obtain blood samples for baseline laboratory values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels. - A: The nurse should not perform a vaginal examination on a client who is experiencing vaginal bleeding. A vaginal examination can lead to hemorrhage if the client has placenta previa. - C: The nurse should not perform a vaginal examination on a client who is experiencing vaginal bleeding. A spiral electrode can be placed only when the client's membranes are ruptured, the cervix is sufficiently dilated, and placenta previa is ruled out to avoid hemorrhage. - D: The client should be on strict pelvic rest because she is experiencing bright red vaginal bleeding.

A nurse in a labor and delivery unit is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include? A. Count the fetal heart rate for 15 seconds after contractions B. Palpate and count the maternal radial pulse while listening to the fetal heart rate C. Place the listening device over the fetal chest to hear the fetal heart rate D. Percuss the maternal abdomen to verify the position of the fetus

B. Palpate and count the maternal radial pulse while listening to the fetal heart rate The nurse should palpate and count the maternal pulse while listening to the fetal heart rate to validate findings and distinguish the maternal pulse from the fetal heart. - A: When assessing fetal wellbeing with intermittent auscultation, the nurse will establish the baseline fetal heart rate by counting for 30 to 60 seconds after each contraction. This will identify any discrepancies in the baseline of the fetal heart rate. - C: The listening device should be placed over the fetal back to hear the fetal heart rate. This area has the clearest and loudest sounds. - D: Percussing the abdomen does not allow verification of fetal positioning. The nurse should palpate the abdomen to verify the position of the fetus.

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%

B. Platelet count 135,000/mm^3 The nurse should notify the provider of this result because it is an indication of thrombocytopenia. A low platelet count is a manifestation of preeclampsia or HELLP syndrome and requires further evaluation. - A: The nurse should notify the provider if the client's Hgb is below 11 g/dL because this is an indication of anemia. - C: The nurse should notify the provider if the client's WBC count is greater than 15,000mm^3 because this is an indication of infection. - D: The nurse should notify the provider if the client's Hct is under 33% because this is an indication of anemia.

A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth

B. Preterm labor Progesterone maintains the lining of the uterus, which maintains the pregnancy. It also reduces uterine contractility. A client who has a low progesterone level is at risk for preterm labor. - A: Glucose metabolism and pact-genesis are influenced by human placental lactose (HPL). HPL causes insulin resistance, which may lead to gestational diabetes. - C: Lactogenesis is influenced by HPL. - D: Estrogen stimulates uterine growth and mammary gland development.

A nurse is planning care for a client in active labor whose fetus is in an occipital brow presentation. Which of the following complications should the nurse anticipate as a result of this fetal presentation? A. Precipitous labor B. Prolonged labor C. Hypertonic uterine dysfunction D. Umbilical cord prolapse

B. Prolonged labor An occipital brow presentation increases the diameter of the presenting part, which may prevent the fetal head from descending into the pelvis. This can result in prolonged labor, forceps- or vacuum-assisted birth, or a cesarean delivery. - A: Precipitous labor proceeds abnormally fast, progressing from the onset of labor to delivery in less than 3 hours. An occipital brow presentation is not a contributing factor in precipitous labor. - C: Hypertonic uterine dysfunction commonly occurs in the latent, not the active, phase of the first stage of labor. An occipital brow presentation is not a contributing factor to this labor pattern. - D: A cord prolapse occurs when the umbilical cord precedes the fetal presenting part. Risk factors for cord prolapse include an abnormally long cord, breech or shoulder presentation, polyhydramnios, a small fetus, or an unengaged presenting part. An occipital brow presentation is not a contributing factor.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

B. Renal agenesis Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios. - A, C, & D: Fetal cardiac anomalies, fetal neural tube defects, and fetal hydrocephalus do not affect the volume of amniotic fluid.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis (NEC)

B. Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. - In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness. - A & C: Oxygen therapy does not cause atelectasis or interstitial emphysema but can be used for clients who have atelectasis or interstitial emphysema. - D: Oxygen therapy does not cause NEC, a severe disease of premature newborns. In NEC, the lining of the intestinal wall dies, and the tissue sloughs off. The cause of this disorder is unknown. Decreased blood flow to the bowel may keep the bowel from producing the normal protective mucus. Bacteria in the intestine may also contribute to this condition.

A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention? A. Withhold analgesics to prevent urinary retention B. Run water in the sink while the client sits on the toilet C. Perform Crede's maneuver every 4 hours D. Restrict oral hydration

B. Run water in the sink while the client sits on the toilet Running water in the sink, placing the client's hand in warm water, and using a squeeze bottle to run water over the client's perineum can assist with spontaneous voiding. - A: The nurse should administer analgesics as needed to decrease the client's pain during voiding. - C: Crede's maneuver is used for clients who are not expected to regain voluntary bladder control. - D: Clients who are postpartum will have increased urine output and are at risk for bladder distention. Restricting oral hydration will not prevent bladder distention.

A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take? A. Ensure the client has a full bladder B. Stand at the client's right side if the nurse is right-handed C. Assist the client onto her back with knees extended D. Palpate the outline of the fetus's head with the palms of the hands

B. Stand at the client's right side if the nurse is right-handed The nurse should stand facing the client on the side that correlates with the nurse's dominant hand; therefore, if the nurse is right-handed, the nurse should stand at the client's right side. - A: The nurse should assist the client to empty her bladder prior to performing Leopold maneuvers. - C: Placing the client in a supine position increases the risk of supine hypotension; therefore, the nurse should place a pillow under the client's head and a rolled towel under her hip with the knees flexed. - D: The nurse should palpate the outline of the fetus's head with the fingertips.

A nurse is performing a non stress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide? A. This test will determine if you are likely to deliver within the next week B. This test will help determine if your baby is healthy C. This test can see how your baby responds when you have contractions D. This test will determine if your baby's lungs are mature

B. This test will help determine if your baby is healthy This NST is used as a prenatal fetal assessment. It tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress. - A: The NST does not evaluate uterine relaxation. It measures certain expected patterns that occur with fetal movement. - C: A contraction stress test is used to assess the fetal response to uterine contractions. - D: Fetal lung maturity is assessed by performing an amniocentesis.

A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? A. Bilirubin level 5 mg/dL B. Weight loss 12% of birth weight C. Loose, green stools D. Axillary temperature of 36.6C (97.9F)

B. Weight loss 12% of birth weight An acceptable weight loss over the first 3 to 5 days is 10%. The nurse should report this finding to the provider. - A: This bilirubin level indicates that the newborn no longer needs phototherapy. The provider should discontinue the treatment. - C: Loose stools are a common finding in newborns receiving phototherapy. Green stools are also common before they transition to yellow. - D: This temperature is within the expected reference range for axillary temperatures of newborns, which is 36.5-37.5c (97.7-99.5f)

A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. Your provider will insert a hand into your uterus and turn your baby around B. You will receive a medication to relax your uterus prior to the procedure C. This procedure will be performed in the clinic at your next visit D. Your baby's heartbeat will be monitored occasionally throughout the procedure

B. You will receive a medication to relax your uterus prior to the procedure A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the provider. - A: This action is appropriate for internal version. With external version, the provider attempts to turn the fetus around externally, not internally. - C: External version is a high-risk procedure that is performed in a hospital setting in the event of an emergency. - D: During the external version, the fetal heart-rate pattern is monitored continuously because the fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart rate for at least 60 minutes following the procedure.

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

C. Baker's yeast An allergy to baker's yeast is a contraindication to receiving the hepatitis B vaccine. The nurse should notify the client's provider. - A: Clients who have an allergy to shellfish should not receive IV contrast dye, which contains iodine. Therefore, this client can receive the hepatitis B vaccine. - B: Clients who have an allergy to gelatin should not receive the MMR vaccine. Therefore, this client can receive the hepatitis B vaccine. - D: Clients who have an allergy to eggs should not receive the influenza vaccine. Therefore, this client can receive the hepatitis B vaccine.

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching? A. Drop by the clinic any day this week so we can count your baby's kicks B. Count fetal kicks once a day for a total of 30 minutes C. Before bedtime is a good time to start counting the kicks D. Wear loose clothing when performing the kick count

C. Before bedtime is a good time to start counting the kicks Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC), before bedtime or after meals for 2 hours, or until 10 movements are counted. - Alternatively, the client can count all fetal movements in a 12-hour period each day until at least 10 movements are counted. - A: The kick count is performed at home and is noninvasive. The client does not need to come to the clinic for this diagnostic test. - B: The kick count can be performed only once a day, but should be counted for a total of 60 minutes if done once per day. - D: When performing a kick count, the client does not have to wear loose clothing. The kicks come from inside the body, and clothing does not obstruct fetal movement or make counting difficult.

A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Soy-based formula is recommended to decrease colic B. Amino acid formula is recommended to increase the newborn's protein intake C. Cow's milk-based formula is recommended for healthy newborns D. Low-iron formula is recommended to prevent excess iron intake

C. Cow's milk-based formula is recommended for healthy newborns The nurse should identify that cow's milk-based formulas are similar to human breast milk and are recommended for newborns and infants unless prescribed otherwise by the provider. - Certain conditions that might indicate a need to switch to an alternate formula include galactosemia, a congenital lactase deficiency, and immunoglobulin E allergies. - A: The nurse should identify that soy-based formula is not known to decrease the manifestations of colic. - B: The nurse should identify that amino acid formulas are recommended for newborns and infants who have a protein intolerance. - D: The nurse should identify that iron-fortified formulas are recommended since they meet the newborn's daily iron requirements.

A nurse is caring for a client at 35 weeks gestation who has severe preeclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? A. Blood pressure B. Intake and output C. Daily weight D. Severity of edema

C. Daily weight Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status. - A: The nurse should assess the client's blood pressure to evaluate circulatory status, but another assessment provides more accurate information. - B & D: The nurse should assess the client's intake and output and the severity of the client's edema to evaluate fluid status, but another assessment provides more accurate information.

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30 degree angle D. Place the client in a semi-Fowler's position

C. Elevate the client's legs to a 30 degree angle The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30-degree angle. This improves blood flow and reduces manifestations of hypotension. - A: A client who is experiencing postpartum hypovolemic shock requires IV fluid replacement and potentially a blood transfusion. The nurse should maintain running IV access and possible increase the IV fluid rate. - B: Oxygen supplementation is important for a client who is experiencing postpartum hypovolemic shock. Oxygen should be administered at 10 L/min via facemark to increase oxygenation and perfusion to the tissues. - D: The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30-degree angle, not in a semi-Fowler's position.

A nurse is providing care to a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the nurse? A. Intense contractions lasting less than 30 seconds B. Rest periods between contractions lasting longer than 90 seconds C. Fetal heart rate decreased by 15/min D. Maternal temperature of 37.8c (100f) after ruptured membranes

C. Fetal heart rate decreased by 15/min A FHR of 15/min is known as variable decelerations and requires intervention by the nurse due to cord compression. The cord can prolapse after the rupture of membranes, compromising the fetus. The fetal heart rate and pattern should be monitored for several minutes after the rupture of membranes to assess the wellbeing of the fetus. - A: Contractions lasting less than 30 seconds are an expected finding. Contractions lasting longer than 90 seconds can be a risk with or without membrane rupture. - B: Rest periods lasting longer than 90 seconds allow the fetus to recover. Rest periods lasting less than 30 seconds can be a risk for the fetus because of the shortened recovery period. - D: A temperature of 100f or less would be an expected finding. A temperature greater than 100f after membranes are ruptured could indicate the potential for infection.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 52/min B. Weight gain 2500 grams (5.5 lb) C. Head circumference 28 cm (11 in) D. Blood glucose 48 mg/dL

C. Head circumference 28 cm (11 in) A head circumference of 28 cm (known as microcephaly) is below the expected reference range of 32 to 36.8 cm for a newborn. - Microcephaly can indicate fused cranial sutures or prenatal infection with rubella, toxoplasmosis, or cytomegalovirus. The nurse should report this finding to the provider. - A: A respiratory rate of 52/min is within the expected reference range of 30 to 60/min for a newborn. - B: A weight of 2,500 grams is within the expected reference range of 2,500 to 4,000 grams for a newborn. - D: A blood glucose level of 48 mg/dL is within the expected reference range of greater than 45 mg/dL for a newborn.

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? A. I should clean my diaphragm with alcohol each time I use it B. I should leave the diaphragm in place for 4 hours after intercourse C. I should replace my diaphragm every 2 years D. I should use a vaginal lubricant to insert my diaphragm

C. I should replace my diaphragm every 2 years A diaphragm is a flexible rubber cup that is filled with spermicide and inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by a provider and should be replaced every 2 years. - A: A diaphragm should be cleaned with mild soap and water and dried gently. Alcohol can dry out the diaphragm and can weaken the rubber, which will reduce its effectiveness for birth control. - B: A diaphragm should remain in place for at least 6 hours after intercourse. - D: A diaphragm should be rinsed with water, and contraceptive jelly should be applied prior to placing the device into the vagina. Vaginal lubricants, mineral oil, and baby oil should not be used on the diaphragm because they can weaken the rubber.

A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? A. Nitrous oxide could make my baby sleepy when he is born B. I should inhale the nitrous oxide between contractions C. I will feel the effects of the nitrous oxide almost immediately D. Nitrous oxide can make me feel disoriented

C. I will feel the effects of the nitrous oxide almost immediately The effects of nitrous oxide are felt within 1 minute of inhalation. - A: Nitrous oxide does not appear to cause neonatal sedation or a difference in Apgar scores. - B: The client should inhale nitrous oxide through a face mask as the contraction begins and use it during the contraction. - D: Nitrous oxide induces a feeling of relaxation and decreases the client's perception of pain. It does not cause feelings of disorientation.

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability

C. Impaired placental perfusion Maternal hypotension can occur in 10% to 30% of women who receive epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impair the deliver of oxygen to the fetus. - A: Respiratory depression in the newborn may occur if narcotic agonist-antagonist analgesics are administered to the mother within 1 to 4 hours of birth. - B: The use of diazepam in labor can disrupt newborn thermoregulation and result in hypothermia. - D: Minimal or absent FHR variability is a side effect of administering opioids to a laboring client.

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns. - A, B, & D: Placenta previa, multiple gestation, and anemia are not potential risk factors for hyperbilirubinemia in newborns.

A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O negative. Which of the following actions should the nurse take? A. Administer a dose of Rho(D) immune globulin B. Request a prescription for an antibiotic until delivery C. Instruct the client to obtain a rubella immunization after delivery D. Inform the client that she will need to deliver via cesarean birth

C. Instruct the client to obtain a rubella immunization after delivery This client is not immune to rubella and should receive this immunization after delivery. - A: This client has Rh-negative blood and should have received Rho(D) immune globulin at 28 weeks gestation. She should receive it again within 72 hours if the newborn is Rh-positive. - B: The client will receive IV antibiotic therapy during labor to prevent the transmission of group B beta-hemolytic streptococcus to the newborn. - D: The client has no laboratory findings that warrant delivery by cesarean birth.

A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take? A. Assess fetal heart rate and contraction pattern every 15 min after insertion B. Thaw the frozen gel in a warm water bath prior to insertion C. Maintain the client in a side-lying position for 30 min after insertion D. Initiate an oxytocin infusion for induction 1 hr after gel insertion

C. Maintain the client in a side-lying position for 30 min after insertion The client should maintain a side-lying or supine position with a lateral tilt for 30 to 40 minutes after the insertion of the medication to allow the gel to stay in contact with the cervix. - A: Fetal heart rate and contractions should be assessed continuously because prostaglandin E2 gel can cause tachysystole and fetal distress. - B: Using a warm-water bath or microwave to accelerate the warming of the gel can inactivate the ingredients. The gel should be allowed to thaw at room temperature. - D: Initiation of an oxytocin infusion should be delayed for 6 to 12 hours after the last instillation of prostaglandin E2 gel.

A nurse is assessing a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client to perform a site bath

C. Notify the provider Excessive vaginal bleeding in the presence of a contracted uterus is a sign of a vaginal or cervical laceration. The provider must be notified so the laceration can be repaired. - A: Massaging the uterus would be appropriate if the fundus were not contracted. The fundus is reported as first and contracted; therefore, the excessive bleeding is not coming from the uterus. - B: The uterus is reported as firm and contracted; therefore, the excessive bleeding is not coming from the uterus. Emptying the bladder will have no effect on the vaginal bleeding. - D: A sitz bath is used to promote comfort. This intervention will not address the issue of excessive vaginal bleeding.

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take? A. Encourage the client to bear down with contractions B. Request a prescription to initiate oxytocin C. Offer the client hydrotherapy D. Assist the client with ambulation

C. Offer the client hydrotherapy Therapeutic rest measures should be initiated for a client who has hypertonic uterine dysfunction. Therapeutic rest can include hydrotherapy and analgesia to relieve pain. - Decreasing uterine contractions and helping the client relax and sleep will help prevent early exhaustion. - A: Pushing is indicated during the second stage of labor once the client reaches full cervical dilation, which is 10 cm. - B & D: Oxytocin and ambulation are indicated for the management of hypotonic uterine dysfunction rather than hypertonic uterine dysfunction

A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take? A. Increase the rate of intravenous fluid infusion B. Discontinue the infusion of oxytocin C. Re-evaluate the FHR tracing in 15 minutes D. Request a prescription for an amnioinfusion

C. Re-evaluate the FHR tracing in 15 minutes Early decelerations are a result of the compression of the fetal head during contractions. They are benign and require no specific intervention. The nurse should reassess the FHR and contraction pattern in 15 minutes due to the infusion of oxytocin. - A: Oxytocin is given by starting a primary IV infusion and administering the medication through a secondary line. The rate of IV fluids should be increased to improve uteroplacental perfusion if the client is experiencing late decelerations or uterine tachysystole. - B: The nurse should discontinue the oxytocin infusion in the presence of tachysystole, late decelerations, or variable decelerations. This action is not appropriate for the presence of early decelerations. - D: An amnioinfusion is utilized to relieve intermittent umbilical cord compression that results in variable decelerations.

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes

C. Respiratory distress syndrome Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia. - A: Preterm birth is a risk factor for NEC. Approximately 90% of cases of NEC occur in preterm newborns. - B: Low birth weight and intrauterine growth restriction are risk factors for NEC. - D: Maternal gestational diabetes is not a risk factor for NEC. Risk factors include asphyxia, gastrointestinal infection, and polycythemia.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? A. Continuous loch flow and a flaccid uterus B. Report of increasing pain and pressure in the perineal area C. Slow trickle of bright vaginal bleeding and a firm fundus D. Gush of rubra lochia when the uterus is massaged

C. Slow trickle of bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration. - A: The nurse should monitor for excessive vaginal bleeding in the presence of a flaccid uterus to identify that the blood is coming from the uterus. The most common cause of this occurrence is a full bladder or retained placental fragments. - B: The nurse should monitor for a report of increasing pain and pressure in the perineal area to identify a vulvar hematoma. - D: When the nurse massages the uterus, it will contract and help move pooled blood in the uterus to the vaginal opening.

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? A. Breast engorgement B. Hypothermia C. Urinary retention D. Rupture of membranes

C. Urinary retention After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors. - A: Breast engorgement does not generally become problematic until 3 to 5 days after birth. - B: Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the client's temperature at this time, then every 4 hours for the first 8 hours, and then at least every 8 hours after that. The client might feel chilly during this stage; if so, the nurse should provide a warmed blanket. - D: Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of labor.

A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. You will not get pregnant while you are breastfeeding, so you will not need any birth control B. A birth control pill that only contains estrogen is available for use while you are breastfeeding C. Condoms are the only method of contraception that is appropriate while you are breastfeeding D. A progestin-only pill or injection is available for use while you are breastfeeding

D. A progestin-only pill or injection is available for use while you are breastfeeding Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication. - A: Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and effective means of birth control. The client may experience an unplanned pregnancy if she waits until her periods resume before considering birth control options. - B: Estrogen-containing birth control pills, implants, patches, and vaginal rings are not recommended for clients who are breastfeeding due to the risk of inhibiting breast milk production and supply. - C: Condoms and other non-hormonal birth control methods are appropriate for clients who are breastfeeding; however, there are other methods that are also appropriate.

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication? A. Prolonged rupture of membranes at 38 weeks gestation B. Intrauterine growth restriction C. Post-term pregnancy D. Active genital herpes

D. Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection while passing through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection. - A, B, & C: Clients with prolonged rupture of membranes, intrauterine growth restriction, or have a post-term pregnancy should receive oxytocin to induce labor.

A nurse is creating a plan of care for a client who is in the active stage of labor and expresses a desire to use non pharmacological methods of pain relief. Which of the following interventions should the nurse include? A. Encourage the client to listen to music B. Instruct the client how to use informational biofeedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower

D. Assist the client into a warm shower Assisting the client into a warm shower is a non-pharmacological method used to decrease labor pain. This method stimulates the release of endorphins and increases circulation. Research supports the use of hydrotherapy as an effective method of labor pain management. - A: Music can provide distraction and relaxation while a client is in early labor, but evidence does not support the effectiveness of music as a method of pain relief during active labor. - B: Informational biofeedback can be an effective method of increasing relaxation; however, this method must be taught and practiced during the prenatal period to be effective during labor. - C: Asking the client to reconsider using regional anesthetics such as epidural or spinal anesthetics does not support the client's wishes to utilize non-pharmacological methods of pain control.

A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. Distended abdomen B. Increased blood pressure C. Generalized petechiae D. Barrel-shaped chest

D. Barrel-shaped chest The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a barrel-shaped chest as the abdominal organs have shifted into the chest cavity. - A: The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a scaphoid abdomen as abdominal contents have shifted into the chest cavity. - B: The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit decreased blood pressure and cyanosis. - C: The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit cyanosis and respiratory distress, not petechiae.

A nurse is providing teaching to the parents of a newborn about bottle-feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula if the newborn is gaining weight too quickly B. Prop the bottle with a blanket for the last feeding of the day C. Discard unused refrigerated formula after 72 hr D. Boil water for powdered formula for 1-2 min

D. Boil water for powdered formula for 1-2 min The parents should run tap water for 2 minutes and then boil it for 1-2 minutes before mixing it with the formula to decrease the risk of contamination. - A: The parents should not dilute ready-to-feed formula because the newborn will get full before consuming the appropriate amount of calories and nutrients. - B: The parents should always hold the bottle when feeding the newborn to prevent aspiration and the development of caries. - C: The parents should only keep unused prepared formula for 48 hours to decrease the risk of contamination.

A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take? A. Teach the client to lie on her side B. Request a prescription for an opioid analgesic C. Offer a site bath to the client D. Encourage the client to interact with the newborn

D. Encourage the client to interact with the newborn Interacting with the baby can help provide a distraction and decrease the discomfort of uterine contractions. - While it is important to let the parent know that afterpains are more intense during and after breastfeeding, it is also necessary to encourage the planning of methods that provide the most effective and timely relief. - Other non pharmacological interventions can include distraction, therapeutic touch, imagery, hydrotherapy, acupressure, aromatherapy, music therapy, massage therapy, and transcutaneous electrical nerve stimulation (TENS). - A: The nurse should recommend a prone position to help reduce the discomfort of uterine contractions. Side-lying is helpful in decreasing the discomfort of perineal lacerations and an episiotomy. - B: For relieving the pain of the client's uterine contractions, the nurse should request a prescription for ibuprofen or acetaminophen, not an opioid. - C: A sitz bath is recommended to decrease perineal discomfort. Relaxation techniques can be used to help reduce postpartum discomfort caused by uterine contractions.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. Extended periods of sleep B. Poor muscle tone C. Respiratory rate 50/min D. Exaggerated reflexes

D. Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability. - A: Extended periods of sleep indicate CNS depression, not hyperactivity. - B: A newborn with NAS has increased muscle tone. Hypotonia is not an expected finding for a newborn who has narcotic withdrawal. - C: Newborns who have NAS often experience respiratory distress, which is manifested by respirations >60/min. A RR of 50/min is within the expected reference range.

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? A. Fundal height of 34 cm (13.4 in) B. Total pregnancy weight gain of 3.6 kg (8 lb) C. Gestational hypertension D. Fetal gastrointestinal anomaly

D. Fetal gastrointestinal anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurological disorders are expected findings for a fetus experiencing the effects of polyhydramnios. - A: Polyhydramnios will result in a fundal height greater than expected for gestational age. - B: Polyhydramnios will result in an increase in weight gain, not decrease. - C: Gestational hypertension causes oligohydramnios, which is a decrease in the amount of amniotic fluid surrounding the fetus

A nurse is providing nutritional teaching for a pregnant client who had a pre-pregnancy body mass index (BMI) of 38. Which of the following statements by the client demonstrates an understanding of the teaching about her recommended weight gain during pregnancy? A. I should plan to gain 12.7 to 18.1 kg during my pregnancy B. I should plan to gain 11.3 to 15.9 kg during my pregnancy C. I should plan to gain 6.8 to 11.3 kg during my pregnancy D. I should plan to gain 5 to 9.1 kg during my pregnancy

D. I should plan to gain 5 to 9.1 kg during my pregnancy Clients with a pre-pregnancy BMI of greater than 30 are considered to be obese and should plan to limit their weight gain to 5 to 9.1 kg (11 to 20 lb) during pregnancy. - A: Clients with a pre-pregnancy BMI of less than 18.5 are considered underweight and should plan to gain between 12.7 to 18.1 kg (28 to 40 lb) during pregnancy. - B: Clients with a pre-pregnancy BMI of 18.5 to 24.9 are considered to be of normal weight and should plan to limit their weight gain to 11.3 to 15.9 kg (25 to 35 lb) during pregnancy. - C: Clients with a pre-pregnancy BMI of 25 to 29.9 are considered to be overweight and should plan to limit their weight gain to 6.8 to 11.3 kg (15 to 25 lb) during pregnancy.

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. I will limit breastfeeding to 5 minutes per breast B. I will not breastfeed if I start to have flu-like symptoms C. I will shop for an underwire nursing bra today D. I will avoid any of my family members who are ill

D. I will avoid any of my family members who are ill The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis. - A: Adequate emptying of the breasts reduces the risk of developing mastitis. - B: Flu-like symptoms could indicate maternal illness or early mastitis. However, the client should continue to breastfeed in order to promote adequate breast emptying. - C: Underwire nursing bras can prevent adequate breast emptying and can predispose the client to mastitis.

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? A. My baby's head will be cone-shaped for about 2 months B. My doctor performed this procedure because I didn't dilate past 6 centimeters C. The doctor performed this procedure because my hemoglobin was low D. My baby has a higher risk of developing jaundice

D. My baby has a higher risk of developing jaundice A vacuum-assisted birth increases the risk of jaundice as the bruises caused by the device dissipate. - A: The procedure will result in caput succedaneum, which is a swelling on the scalp that generally resolves without treatment in 3 to 4 days. - B: Providers choose vacuum-assisted birth when a client has a prolonged second stage of labor or when the fetus is in distress. The client must be fully dilated before undergoing a vaginal birth. - C: Providers choose vacuum-assisted birth when a client has a prolonged second stage of labor or when the fetus is in distress, not because of a low Hgb level.

A nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client to home B. Administer betamethasone C. Perform an amnioinfusion D. Prepare for delivery of the infant

D. Prepare for delivery of the infant Delivery is considered when a biophysical profile score of 6 or lower is obtained at or after 36 weeks of gestation or with a score of 4 or lower at any gestational age. - A: A biophysical score of 4 indicates possible chronic fetal asphyxia. It would not be appropriate to discharge the client to home. - B: Betamethasone is administered to promote fetal lung development and to decrease the risk of respiratory distress syndrome if delivery is anticipated between 24 and 34 weeks of gestation. - C: An amnioinfusion is performed during labor to relieve transient fetal hypoxia caused by umbilical cord compression.

A nurse is caring for a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart race tracing. Which of the following actions should the nurse take? A. Discontinue oxytocin infusion and apply oxygen B. Increase oxytocin infusion rate by 2 mu/min C. Administer terbutaline 0.25 mg subcutaneously D. Reposition the client in a side-lying position and continue to monitor

D. Reposition the client in a side-lying position and continue to monitor A Category 1 fetal heart rate tracing is an expected finding and does not represent fetal distress. - The nurse should reposition the client in a side-lying position to optimize uteroplacental perfusion and continue to monitor the tracing for another 10 minutes to determine if tachysystole resolves. - A: The nurse should discontinue the oxytocin infusion and apply oxygen for a Category 2 (intermediate) or Category 3 (abnormal) fetal heart rate tracing. - B: The nurse should not increase the oxytocin infusion when the client is experiencing tachysystole because tachysystole can cause fetal distress. - C: The nurse should administer terbutaline 0.25 mg subcutaneously for a Category 2 or Category 3 fetal heart rate tracing if discontinuing the oxytocin does not resolve the tachysystole.

While assessing a client who is in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention? A. The funds is at midline B. The funds is below the umbilicus C. The bladder is resonant with percussion D. The bladder fluctuates with palpation

D. The bladder fluctuates with palpation In bladder distention, the bladder is suprapubic, round, bulging, and is dull to percussion and will fluctuate like a balloon filled with water. - The uterus is usually displaced to the right, boggy, and located well above the umbilicus. - A: In bladder distention, the uterus is displaced to the right. - B: In bladder distention, the uterus is above the umbilicus. - C: In bladder distention, the bladder sounds dull with percussion.

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. This is an attempt by your body to retain the fluid gained during pregnancy B. This is caused by an increase in your estrogen hormonal levels C. This is caused by the increased pressure on your veins in your lower legs D. This is a source of your fluid loss after delivery

D. This is a source of your fluid loss after delivery Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tissue fluid begins within 12 hours after birth. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period. - A: Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased venous pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in blood volume. - B: Postpartum diuresis is caused by decreased estrogen levels. - C: Postpartum diuresis is caused, in part, by the removal of increased venous pressure in the lower extremities. Urine output can exceed 3,000 mL/day during the first 2 to 3 days postpartum.

A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? A. This medication can cause your blood pressure to rise B. This medication can cause dry mouth C. This medication can cause you to urinate excessively D. This medication can make you sleepy

D. This medication can make you sleepy Meperidine hydrochloride is an opioid analgesic used for moderate to severe pain during labor. It binds to the brain's opioid receptors and alters the client's response to pain. The client should be informed of the possible adverse effects of this medication such as hypotension, confusion, sedation, headaches, respiratory depression, constipation, and urinary retention. - A, B, & C: These are not manifestations of this medication.

A nurse is caring for a client in labor whose cervix is dilated to 9 cm. She is experiencing strong contractions every 2 min lasting 75 sec. The nurse should recognize that the client is in which of the following phases or stages of labor? A. Latent phase of first stage B. Active phase of first stage C. Second stage D. Transition phase of first stage

D. Transition phase of first stage These findings indicate the transition phase of the first stage of labor. - The first stage ends with the transition phase in which the cervix dilates to 8 to 10 cm. Uterine contractions are strong, occurring every 2 to 3 minutes and lasting 45 to 90 seconds. - A: The latent phase is characterized by some cervical effacement and dilation from 0 to 3 cm, with little progress in the descent of the presenting part. - B: The active phase is characterized by cervical dilation from 4 to 7 cm and significant descent of the presenting part. In this phase, the client has moderate to strong uterine contractions every 3 to 5 min that last 40 to 70 seconds. - C: The second stage begins with complete cervical dilation and ends with the birth of the newborn.

A nurse is providing teaching about exercise to a client who is pregnant. Which of the following pieces of information should the nurse include? A. You can continue participating in whatever sports or activities you did prior to becoming pregnant B. Intermittent exercise is a great way to stay healthy during pregnancy C. You should limit your exercise to walking if you did not exercise prior to becoming pregnant D. Vigorous exercise should be limited and should not be performed in hot, humid weather

D. Vigorous exercise should be limited and should not be performed in hot, humid weather Vigorous or strenuous activities should be limited to no longer than 20 minutes. Hot, humid weather and vigorous exercise can prompt dehydration or cause the fetus to develop hyperthermia. - A: The nurse should caution the client to restrict activities that are considered contact sports like soccer, touch football, or roller derby. - B: The nurse should encourage the client to maintain a scheduled exercise routine about 3 times per week for 30 minutes rather than engage in intermittent activity. - C: A client who was sedentary before pregnancy should begin with low-intensity physical activity. Then, the client can advance her activity level gradually to more than just walking.

A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed. Which of the following nutrients should the client increase during lactation? A. Calcium B. Iron C. Vitamin D D. Vitamin C

D. Vitamin C The nurse should recommend that the client increase her vitamin C intake during lactation to 115-120 mg per day. - A: The calcium requirements for clients who are breastfeeding are the same as for clients who are not pregnant (1,000 to 3,000 mg per day). Food choices that are high in calcium include milk, yogurt, green leafy vegetables, and cheese. - B: The client's iron requirements decrease during lactation from 27 mg to 9 to 10 mg per day. - C: The vitamin D requirements for clients who are breastfeeding are the same as for clients who are not pregnant (600 IU per day).

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 to the provider because it is below the expected reference range of 14 to 24 g/dL. - B: The expected reference range for a newborn's platelet count is 150,000 to 300,000/mm^3. - C: The expected reference range for a this newborn's total bilirubin level is 2 to 6 mg/dL. - D: The expected reference range for serum glucose for this newborn is 40 to 60 mg/dL.

A nurse is teaching a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include? A. Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions B. You will learn how to prevent pain during labor by focusing your mind to control your breathing C. During labor, you will be encouraged to disassociate by using an internal focal point D. During labor, you will use conscious relaxation and levels of progressive breathing

B. You will learn how to prevent pain during labor by focusing your mind to control your breathing The Lamaze philosophy is based on prophylaxis by using the mind. The method is based on the theory that through stimulus-response conditioning, clients can learn to use controlled breathing to reduce pain during labor. - A: This response is representative of the Dick-Read method of managing pain during childbirth because it focuses on reducing fear. Fear is reduced through education prior to labor. - C: This response is representative of the Bradley or partner-coached method. This method is based on the premise that pregnancy and childbirth are joyful, natural processes and that a woman's partner should play an active role during pregnancy, labor, and the early newborn period. - D: The psychosexual method includes a program of conscious relaxation and levels of progressive breathing that encourage a woman to flow with, rather than struggle against, contractions.

A nurse is perfomring a physical assessment of a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

A & B A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward A "C" formation of the thumb and forefinger and an extension of the legs before pulling upward are expected components of the Moro reflex. - This response is present at birth and absent by 6 months of age in neurologically intact infants. - C: Full-term newborns who have an intact Moro reflex abduct their arms and legs, not adduct. - D: The arms of full-term newborns who have an intact Moro reflex form a complete embrace after startling and return to flexion and movement. Preterm infants lack the neurological maturity to complete the embrace, and their arms fall backward as a result of weakness. - E: This is an expected component of the tonic neck reflex, not the Moro reflex.

A nurse is caring for a postpartum client 8 hr after deliver. Which of the following factors places the client at risk of uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn

A, B, D A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor - Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. - After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. - A distended bladder displaces the uterus and can prevent adequate contraction of the uterus. - Also, prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting. - C: Oxytocin promotes uterine contractions. - E: A large fetus and multifetal gestation can lead to over-stretching of the uterus and prevent uterine contractions.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. This will resolve in 3 to 6 weeks without treatment B. This will resolve on its own within 3 to 4 days C. The provider might gain this area with a syringe D. This appearance is expected at birth, so you don't need to worry

A. This will resolve in 3 to 6 weeks without treatment This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks. - B: A caput succedaneum is present at birth and extends across suture lines. It is edema of the scalp and will resolve in 3 to 4 days. - C: The provider will not aspirate the fluid due to the risk of infection when puncturing the skin. - D: This finding is not expected in most newborns.

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? A. Uterine tone B. Fetal heart rate C. Blood pressure D. Amount of bleeding

A. Uterine tone The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain. - B & C: Fetal distress and hypotension may be present in both abruptio placenta and placenta previa. - D: The amount of blood loss is not diagnostic of the cause of bleeding.

A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? (All options must be used.) A. Position a hand around the top of the client's fundus B. Ask the client to lie on her back with her knees flexed C. Use slight downward pressure to compress the client's fundus D. Place a hand just above the client's symphysis pubis E. Rotate the upper hand to massage the client's uterus

B, D, A, E, C The nurse should gently massage the fundus to restore the muscle tone of the client's uterus. - Step 1: The nurse should place the client on her back with her knees flexed. - Step 2: The nurse should place a hand just above the symphysis pubis. - Step 3: Position the other hand around the top of the client's fundus. - Step 4: The nurse should then rotate the upper hand to massage the client's uterus. - Step 5: Use slight downward pressure to compress the client's fundus.

A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus

C. 3 cm below the umbilicus The client's fundus should descend about 1 to 2 cm every 24 hours; therefore, at 2 days postpartum, the client's fundus should be located 3 cm below the umbilicus. - A: About 1 hour after giving birth, the client's fundus rises to about 1 cm above the umbilicus and then gradually descends over the next several days. - B: The client's fundus should be located 1 cm above the umbilicus sometime within the first 24 hours after birth. - D: The client's fundus should be located 1 cm below the umbilicus in between 1 and 2 days postpartum.

A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? A. Swaddle the infant with arms and legs extended B. Administer naloxone IM C. Avoid eye contact during feedings D. Discourage the mother from handling the infant during the withdrawal phase

C. Avoid eye contact during feedings The nurse should avoid eye contact and talking during feedings. Infants with NAS have difficulty processing multiple forms of stimulation and can quickly become frustrated. - A: The infant should be tightly swaddled with flexed arms and legs to reduce self-stimulating behaviors. - B: Naloxone should never be administered to a newborn who is experiencing manifestations of opiate withdrawal. The medication can cause an immediate withdrawal and severe symptoms and seizures in infants. - D: The mother should bond with the infant and gain confidence in her ability to provide care. Additionally, the mother needs to learn and understand the behaviors of an infant with NAS.

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

C. Prolapsed umbilical cord The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately. - A: Signs of uterine rupture include constant abdominal pain, loss of fetal station, abnormal fetal heart rate tracing, and cessation of contractions. It is not related to rupture of membranes. - B: Manifestations of placenta abruption include abdominal pain, vaginal bleeding, uterine tenderness and contractions. Rupture of membranes is not a contributing factor. - D: Signs of amniotic fluid embolus include maternal respiratory distress, and hemodynamic instability. Spontaneous rupture of membranes is not a contributing factor.

A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention? A. A newborn who has acrocyanosis B. A newborn who has a macular, papular, vesicular rash on the torso C. A newborn who has a blood glucose level of 54 mg/dL D. A newborn whose axillary temperature is 36.1c (96.9f)

D. A newborn whose axillary temperature is 36.1c (96.9f) This temperature places the newborn at risk for cold stress, which can diminish pulmonary perfusion. - The nurse should place the newborn under a radiant heat warmer, monitor the temperature of the newborn, and continue to assess the newborn's respiratory and cardiovascular status. - A: Acrocyanosis, which is a bluish discoloration of the hands and feet, is a common finding during the first 24 to 48 hours after birth and does not require intervention. - B: This finding described erythema toxicum, a common, transient rash that appears on the skin of many newborns during the first 24 to 72 hours after birth and does not require intervention. - C: The nurse should continue to check this newborn's blood glucose levels in case they decrease to a level that would put the newborn at risk for a neurological injury. However, no intervention is necessary until the newborn's blood glucose drops below 40 mg/dL.