maternity

The nurse is caring for a client in labor whose fetus is in the breech presentation. Which would be an expected finding for this client?

Meconium in the amniotic fluid

A client who is at 38 weeks' gestation is admitted to the birthing unit because her membranes ruptured 24 hours ago and contractions have started. The fetus is in a breech presentation. The nurse observes that the amniotic fluid is green. What does the nurse conclude from these findings?

Meconium is being expelled with contractions

During the initial assessment of a dark-skinned neonate the nurse observes several dark round areas on a newborn's buttocks. How should this observation be documented?

Mongolian spots

What is the priority nursing care immediately after an amniocentesis?

Monitoring for signs of uterine contractions

A nurse in the birthing suite has just admitted four clients. Which client should the nurse anticipate may require a cesarean birth?

Multipara with a shoulder presentation

A client who is pregnant for the first time attends the prenatal clinic. She tells the nurse, "I'm worried about gaining too much weight, because I've heard that it's unhealthy." How should the nurse respond?

"A 25-lb (11.3-kg) weight gain is recommended; however, the pattern of weight gain is more important than the total amount."

A client attending the prenatal clinic for a follow-up appointment has been diagnosed with mild preeclampsia. How should the nurse instruct the client regarding her fluid and nutritional intake?

"Continue the pregnancy diet."

Which statement helps the nurse determine that a woman with genital herpes (HSV-2) understands her self-care in regards to this infection?

"I must be careful when I have sex because herpes is a lifelong problem.

A couple at the prenatal clinic for a first visit tells the nurse that their 2-year-old child has just been found to have cystic fibrosis. They state there is no family history of this disorder. They ask the nurse about the chances of their having another child with cystic fibrosis. Knowing that this disorder has an autosomal-recessive mode of inheritance, how should the nurse respond?

"There is a 25% chance the baby will be affected and a 50% chance that the baby will be a carrier."

When does a nurse caring for a client with eclampsia determine that the risk for another seizure has decreased?

48 hours postpartum

A newborn's total body response to noise or movement is often distressing to the parents. How would the nurse best explain this response to the parents?

A reflex that is expected in the healthy newborn

A client who has had a lumpectomy of the breast is about to undergo radiation therapy. What should the nurse's initial action be when the client visits the surgeon's office for the first postoperative appointment?

Assess the extent of wound healing.

The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds?

Back of the thigh

After the client gives birth, her vital signs are temperature 99.3° F (37.4° C); pulse 80 beats/min, regular and strong; respirations 16/min, slow and even; and blood pressure 148/92 mm Hg. Which vital sign should the nurse check more frequently?

Blood pressure

A client in the prenatal clinic is diagnosed with preeclampsia. Which clinical findings support this diagnosis?

Blood pressure higher than 140 mm Hg systolic accompanied by proteinuria rationale: A blood pressure higher than 140 mm Hg systolic and 90 mm Hg diastolic along with proteinuria is diagnostic of preeclampsia; assessments should be performed twice, 4 to 6 hours apart.

A client with a suspected placenta previa is to have a repeat sonogram at 16 weeks' gestation. Which nursing intervention is necessary to prepare for this procedure?

Ensuring that the client drinks two 8-oz (237 mL) glasses of water rationale: A full bladder helps stabilize the uterus during sonography, allowing better visualization of the fetus. Two full glasses of water, ingested 1 hour before the test, will fill the bladder. Emptying the bladder is inadvisable, because a full bladder supports the uterus and improves visualization.

An infant is born precipitously in the emergency department. What should the nurse's initial action be?

Establish an airway for the newborn

The nurse is reviewing the obstetric history of a client who has had an abruptio placentae. Which prenatal condition does the nurse expect to find in this client's history?

Gestational hypertension

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)?

Gravida I who has had an intrauterine fetal death

A 15-year-old client tells a school nurse, "I have this awful pain during my periods—it never stops." What should the nurse encourage her to do?

Have a gynecologic examination

The cervix of a client in labor is dilated to 8 cm. She tells the nurse that she has a desire to push and is becoming increasingly uncomfortable. The client requests pain medication. How should the nurse respond at this time?

Help her to take panting breaths.

After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that both she and her partner are visibly upset. The partner has tears in his eyes, and the client is sobbing quietly with her face turned to the wall. At this time, what is the nurse's most therapeutic statement?

I'll be here if you want to talk."

Three days after birth, a breast-feeding newborn becomes jaundiced. The parents bring the infant to the clinic, and blood is drawn for an indirect serum bilirubin determination, which reveals a concentration of 12 mg/dL (100 mcmol/L). The nurse explains that the infant has physiologic jaundice. What is the cause of this benign condition?

Immature liver function

A nurse is interviewing a female client with a tentative diagnosis of cystitis pending laboratory results. The nurse anticipates that the causative agent of the cystitis is Escherichia coli. Why does the nurse anticipate this microorganism?

It inhabits the intestinal tract

A client is visiting the prenatal clinic for the first time. While giving the nursing history the client states that her last menstrual period started on June 10. What is her expected date of birth (EDB), according to Nägele's rule?

March 17 rationale: subtract 3 months from the first day of the last menstrual period and add 7 days.

An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most often when the fetus is in what position?

Occiput posterior

A 37-year-old client with endometriosis visits the women's health clinic because she has dysmenorrhea and dyspareunia. Which statement is the most accurate description of dysmenorrhea?

Pain with menses

A client arrives at the hospital in the second stage of labor. The head of the fetus is crowning, the client is bearing down, and birth appears imminent. What instruction should the nurse provide to the client in this situation?

Pant while resisting the urge to bear down

Which clinical finding is most important for the nurse to assess if a client has had a precipitous birth?

Profuse bleeding

A multipara whose membranes have ruptured is admitted in early labor. Assessment reveals a breech presentation, cervical dilation of 3 cm, and fetal station at -2. For what complication should the nurse assess when caring for this client?

Prolapse of the umbilical cord

A client who is in preterm labor at 34 weeks' gestation is receiving intravenous tocolytic therapy. The frequency of her contractions increases to every 10 minutes, and her cervix dilates to 4 cm. The infusion is discontinued. Toward what outcome should the priority nursing care be directed at this time?

Promotion of maternal and fetal well-being during labor

A client is admitted with a diagnosis of preeclampsia. Which significant clinical finding does the nurse expect when reviewing the client's history?

Proteinuria

Which action involving client needs may a nurse delegate to an unlicensed health care worker?

Providing ice chips to a primigravida in early labor per the primary healthcare provider's prescription

At a routine monthly visit, while assessing a client who is in her 26th week of gestation, the nurse identifies the presence of striae gravidarum. The nurse describes this condition to the client as what?

Reddish streaks on the abdomen and breasts

The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement?

Referring the client to a psychiatric healthcare provider as prescribed

During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action should the nurse take?

Rewarm gradually

A nurse explains to a nursing class that the efficiency of the basal body temperature method of contraception depends on fluctuation of the basal body temperature. Which factor can alter the effectiveness of this method?

Stress

A nurse who is assessing a full-term newborn elicits the Moro reflex. Which method would the nurse utilize to best elicit this reflex?

Striking the surface of the infant's crib suddenly

A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. What does the nurse conclude?

The fetus may be compromised in utero rationale: Greenish-brown amniotic fluid is a sign of meconium in utero, which may indicate that the fetus is compromised.

A client visiting the prenatal clinic for the first time asks the nurse about the probability of having twins because her husband is one of a pair of fraternal twins. What is the appropriate response by the nurse?

There's no greater probability of you having twins than in the general population."

A client is admitted to the labor and delivery unit for labor augmentation with oxytocin. She is postterm at 40 weeks, 3 days, and has gestational diabetes. The cervix is dilated to 2 cm and 90% effaced. The primary healthcare provider performed an amniotomy to permit internal electronic fetal monitoring. The amniotic fluid is pale yellow and moderate in amount. Immediately after the amniotomy the nurse will assess the fetal heart rate for at least 1 full minute for signs of what?

Uterine cord prolapse

The nurse is caring for a woman who just had a positive contraction stress test (CST). Which complication of pregnancy is of most concern when there is a positive CST?

Uteroplacental insufficiency rationale: A positive CST indicates a compromised fetus during contractions, which is associated with uteroplacental insufficiency.

The nurse is caring for a client during the early postpartum period. The client alerts the nurse that she is experiencing severe pain. The nurse interviews the client, obtains her vital signs, and performs a physical assessment. What does this assessment most likely reveal?

Vaginal hematoma

Which nursing intervention holds the highest priority for a client with class I heart disease during the postpartum period?

Watching for signs of cardiac decompensation

While performing a newborn assessment after a vaginal birth, a student nurse observes a swelling on one side of the top of the head that does not cross the suture line. The student nurse has identified what clinical manifestation?

cephalhematoma

Which position should the nurse instruct a client to avoid when the client is experiencing severe back pain during labor?

supine rationale: Low back pain is aggravated when the mother is in the supine position because of increased pressure from the fetus. The Sims, sitting, and side-lying positions will all help relieve back pain.

While being admitted for a lumpectomy the client begins to cry and says, "I found the lump a few months ago, but I didn't go to the doctor because of what it could be." How should the nurse reply?

"This has been frightening for you."

A pregnant client who has type 2 diabetes and a history of three spontaneous abortions is scheduled for a contraction stress test. Before the test she begins to cry while answering the nurse's questions regarding her previous pregnancies. She states, "I know it's my diabetes. This baby will never live. It's all my fault." What is the best response by the nurse?

"This must be very stressful for you."

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

"Yes, you're risking kidney damage."

A 49-year-old client is admitted with a diagnosis of cervical cancer. As the nurse is obtaining her health history, she says, "I haven't had a Pap smear for more than 5 years. I probably wouldn't be in the hospital today if I'd had those tests more often." What is the nurse's most appropriate response?

"You feel as though you've neglected your health."

A 23-year-old woman comes to the clinic for a Pap smear. After the examination, the client confides that her mother died of endometrial cancer 1 year ago and says that she is afraid that she will die of the same cancer. Which risk factor stated by the client after an education session on risk factors indicates that further teaching is needed?

Late-onset menarche rationale: Early-onset, not late-onset, menarche is a risk factor for endometrial cancer. A high-fat diet, hypertension, and obesity are all risk factors for endometrial cancer.

While assessing a client during the fourth stage of labor a nurse notes that the perineal pad is soaked end to end with approximately 75 mL of lochia rubra. What is the priority nursing action?

Massage the uterine fundus.

A pregnant client with a history of heart disease asks how she can relieve her occasional heartburn. The nurse teaches her self-care measures. What statement indicates to the nurse that the client understands the teaching?

"I won't take antacids that contain sodium."

A nurse teaches the warning signs that should be reported throughout pregnancy. Which statement by the client indicates an understanding of the prenatal instructions?

"I'll call the clinic if I have abdominal pain."

After an uneventful 8-hour labor a client gives birth. Once the airway has been ensured and the neonate has been dried and wrapped in a blanket, the nurse places the newborn in the mother's arms. The mother asks, "Is my baby normal?" What is the best response by the nurse?

"Let's unwrap your baby so you can see for yourself."

A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. The priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential?

Fundal height rationale: It is vital that a baseline measurement be obtained, because increasing fundal height may be a sign of concealed hemorrhage.

A 47-year-old client comes to the clinic for a Papanicolaou (Pap) smear. She tells the nurse that she has been experiencing hot flashes and that her periods have been occurring at longer, less regular intervals, with a scanty flow. What does the nurse conclude is the most likely cause of these changes?

Expected menopausal changes

A 28-year-old woman who has phenylketonuria (PKU) visits the fertility clinic for genetic counseling. After deciding that she wants to become pregnant, she tells the nurse that she ate a low-phenylalanine diet until she was 18 years old. What is the nurse's best response?

"Return to the low-phenylalanine diet before becoming pregnant."

A client has just given birth to an infant with Down syndrome. The mother is crying and asks the nurse what she is supposed to do now. What is the nurse's best response?

"Tell me what you know about Down syndrome."

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

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

Two hours after a client gives birth, her physical assessment findings include a blood pressure of 86/40 mm Hg; temperature of 98 °F (36.7 °C); pulse rate of 100 beats/min; respirations of 22 breaths/min; a firm fundus, four fingerbreadths above the umbilicus; small spots of lochia rubra on the perineal pad; and a distended bladder. After a urinary catheterization the client's fundus remains firm and four fingerbreadths above the umbilicus. What should the nurse do next?

-Notify the client's primary healthcare provider immediately rationale: The primary healthcare provider should be notified, because the increased height of the uterus may be the result of accumulation of blood in the uterus caused by internal hemorrhaging. Also, the blood pressure is low and the pulse is rapid, possibly indicating impending shock.

A pregnant woman who is in the third trimester arrives in the emergency department with vaginal bleeding. She states that she snorted cocaine approximately 2 hours ago. Which complication does the nurse suspect as the cause of the bleeding?

Abruptio placentae

On a return visit to the fertility clinic a couple requests fertility drugs because, despite having a 28-day menstrual cycle and temperature readings that demonstrate an ovulatory pattern, the woman has been unable to conceive. Which guidance should the nurse provide to this couple?

An examination of semen will be needed.

What is the optimal method for the nurse to use to assess blood loss in a client with placenta previa?

Count or weigh perineal pads

During her sixth month of pregnancy, a woman visits the prenatal clinic for the first time. As part of the initial assessment a complete blood count and urinalysis are performed. Which laboratory finding should alert the nurse to the need for further assessment?

Hemoglobin of 10 g/dL (100 mmol/L

A 16-year-old client has a steady boyfriend with whom she is having sexual relations. She asks the nurse how she can protect herself from contracting human immunodeficiency virus (HIV). Which guidance is most appropriate for the nurse to provide?

Insist that her partner use a condom when having sex.

The nurse is performing the nursery intake assessment of a 1-hour-old newborn. The assessment reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when the infant cries or feeds. What action should the nurse perform based on these findings?

Notify the practitioner, because circumoral pallor may indicate cardiac problems

Before discharge, what suggestion should the nurse give to a nonnursing mother to help limit breast engorgement?

Place raw cabbage leaves over the breast rationale: Fresh, raw cabbage leaves placed over the breasts between feedings can help relieve engorgement. It is thought that the effect of the cabbage leaves is related to the coolness of the leaves and the presence of phytoestrogens.

A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex elicited?

Stroking the outer sole of the foot from the heel to the little toe

At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. What is the nurse's initial action?

Suctioning the mouth