Maternity (Antepartum, Intrapartum, Antepartum, Newborn)

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The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching?

"I need to apply heat packs to the hemorrhoids to help them shrink." Rationale:Hot packs will increase the blood flow to the area and worsen the discomfort from hemorrhoids. Remedies for the symptoms of hemorrhoids include ice packs, warm or cold sitz baths, gentle cleansing, and topical ointments and anesthetic agents. Kegel exercises help to strengthen the perineum.

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education?

"I need to apply my antiembolism stockings after breakfast."

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?

Ask the client about pain in the calf area.

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

Ask the client to urinate and empty the bladder.

The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?

"A fever on and off is expected and is nothing to worry about."

The parent of a preterm newborn is comparing the appearance of the preterm baby to the nearby full-term babies. The parent asks why the baby's skin appears so different. What is the best response for the nurse to provide?

"A preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat."

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. How would the nurse respond?

"A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen." Rationale:The nonstress test takes about 20 to 30 minutes. The test is termed nonstress because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions (medication is not given) to obtain the necessary data. The test is noninvasive (an informed consent is not required), and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen, where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement also is secured to the maternal abdomen. Fetal heart activity and movements are recorded.

The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement?

"An increase in pulse rate occurs." Rationale:Between 14 and 20 weeks' gestation, the maternal pulse rate increases slowly by 10 to 15 beats/minute, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy and returns to baseline in the second half of pregnancy.

A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information would the nurse provide to the client?

"An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." Rationale:A nonstress test is performed to assess fetal well-being. It is a noninvasive test, and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement is then secured to the maternal abdomen. Fetal heart activity and movements are recorded. The test is termed nonstress because it consists of monitoring only; the test does not include any invasive components. The fetus is not challenged or stressed by uterine contractions to obtain the necessary data. The nonstress test takes about 30 to 40 minutes.

The nurse is administering an intravenous analgesic to a laboring client. The client inquires as to why the nurse is waiting for a contraction to begin before infusing the medication into the intravenous line. Which is the nurse's most appropriate response?

"Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." Rationale:Intravenous medication would be administered slowly in small doses starting at the beginning of a contraction and carrying over for three to five contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. The statements in the remaining options are incorrect information about the medication effects.

The nurse is preparing to instruct a client on how to bathe a newborn. Which statement would the nurse include in the instruction?

"Begin with the eyes and face."

A pregnant client calls a clinic and tells the nurse about experiencing leg cramps that awaken the client at night. What would the nurse tell the client to provide relief from the leg cramps?

"Bend your foot toward your body while extending the knee when the cramps occur." Rationale:Leg cramps occur when the pregnant client stretches the leg and plantar flexes the foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Options 1, 3, and 4 are not measures that provide relief from leg cramps.

A pregnant client tests positive for the hepatitis B virus (HBV). The client asks the nurse if breast-feeding the baby can be done as planned after delivery. Which response by the nurse is most appropriate?

"Breast-feeding is allowed after the baby has been vaccinated with immune globulin." Rationale:Although HBV is transmitted in breast milk, after scheduled newborn vaccines and immune globulin have been administered to the newborn, the client may breast-feed without risk to the newborn. The remaining options are incorrect responses.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse would determine whether this method of family planning would be most appropriate?

"Do you plan to have any other children?" Rationale:Sterilization is a method of contraception for couples who have completed their families. It would be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure.

The nurse is assessing a client who is at 6 weeks' gestation. The client's prepregnancy body mass index (BMI) was 30.5 kg/m2. The nurse determines that the client has a need for further teaching if the client makes which statement?

"Due to my weight, it would be healthy for me and the baby if I maintained my current weight and did not gain weight." Rationale:Energy and nutrient needs vary for each pregnant individual. Weight gain recommendations depend on the client's prepregnancy body mass index (BMI). A BMI equal to or greater than 30 kg/m2 is considered obese. Options 1 and 2 indicate client understanding as it is unnecessary for the client to avoid all cravings and it is not recommended to engage in an extreme or restrictive diet during pregnancy in an attempt to lose weight. Option 3 indicates client understanding, as the recommended weight gain for the obese pregnant client is from 11 to 20 pounds (5 to 9.1 kilograms). Therefore, option 4 is the client statement that would require a need for further teaching from the nurse, as overweight and obese clients need to at least gain enough weight to equal the weight of the products of conception (fetus, placenta, and amniotic fluid). Therefore, option 4 is correct.

The nurse provides home care instructions to a pregnant client with a history of cardiac disease. Which statement made by the client indicates a need for further teaching?

"During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." Rationale:To avoid infections, visitors with active infections would not be allowed to visit the client; otherwise, restrictions are not required. Resting would be done while lying on the left side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased workload on the heart, and the client needs to be instructed to avoid stress.

A client who is at 8 weeks' gestation tells the nurse about experiencing severe, intermittent nausea that is worse in the morning. The nurse provides management strategies to the client for the nausea and includes which instruction?

"Eat dry crackers in bed before arising." Rationale:Nausea and vomiting in pregnancy, otherwise known as morning sickness, start between the first and second missed period and generally subside by the fourth missed period and can occur at any time of day. Strategies to mitigate or reduce the severity of symptoms include avoiding an empty or over-full stomach, resting until the feeling subsides, eating a dry carbohydrate in the morning before arising, avoiding trigger foods such as fried or spicy foods, and eating smaller, more frequent meals rather than larger, less frequent meals. Other options include using acupressure bands and ginger to alleviate nausea. Eliminate option 1 because nausea can be exacerbated by an empty stomach. Eliminate option 3 because spicy or fried foods can exacerbate nausea and vomiting. Next, eliminate option 4 because smaller, more frequent meals are preferable in the management of nausea and vomiting associated with pregnancy rather than larger, less frequent meals. Therefore, option 2 is correct as eating a dry carbohydrate before arising can be helpful in managing nausea and vomiting associated with pregnancy.

The nurse is providing instructions regarding the treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction?

"I need to apply heat packs to the hemorrhoids to help the hemorrhoids shrink." Rationale:Measures that provide relief from hemorrhoids include avoiding constipation and straining during bowel movements; applying ice packs to reduce the hemorrhoidal swelling; gently replacing the hemorrhoids into the rectum; using stool softeners, ointments, or sprays as prescribed; and assuming certain positions to relieve pressure on the hemorrhoids. Heat packs increase the blood flow to the area and worsen the discomfort from hemorrhoids.

The nurse is assessing a client who is at 30 weeks' gestation with a prepregnancy body mass index (BMI) of 32 kg/m2. Since the client's last appointment at 28 weeks' gestation, the client's weight has increased by 5 pounds (2.3 kilograms). Which instructions from the primary health care provider to the client would the nurse anticipate? Select all that apply.

"Engage in at least 30 minutes of physical activity every day Eat more nutrient-dense foods, and avoid foods with empty calories." Rationale:Energy and nutrient needs vary for each pregnant individual. Weight gain recommendations depend on the client's prepregnancy body mass index (BMI). This client's prepregnancy BMI is considered obese, and the recommended weekly weight gain for the obese pregnant client is 0.5 pounds (1.1 kilograms) per week. In the last 2 weeks, the client has gained 5 pounds, which is greater than the recommended weight gain rate of 0.5 pounds (1.1 kilograms) per week. Eliminate options 2, 4, and 5 because the client needs to implement lifestyle changes to ensure a healthy weight gain; furthermore, the physical activity recommendations presented in option 2 are inadequate as physical activity is recommended on most days of the week. Option 1 is correct because at least 20 to 30 minutes of physical activity on most days of the week is recommended for the pregnant client. Option 3 is correct because nonnutritious foods high in empty calories need to be avoided.

A client at 39 weeks of gestation calls the maternity unit, stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which is the best response made by the nurse?

"Fetal movements do not decrease as a person nears term; therefore, you need to be seen by your primary health care provider for further evaluation." Rationale:Fetal movements may decrease during fetal sleep cycles and while a person is taking depressant medication, drinking alcohol, or smoking cigarettes. A decrease in fetal movement over a period of one or more days or as the person approaches term is abnormal and requires further evaluation for fetal well-being. In most protocols for fetal movement, 10 movements in any designated amount of time (usually 2 or 3 hours) is the minimal number required to determine fetal health, so option 1 can be eliminated because it does not meet the minimal fetal movement requirement. Although fetal movement is a reassuring sign of fetal health, fetal movement that is perceived as being less than on the previous day could indicate a decrease in fetal oxygenation and a need for further evaluation; therefore, eliminate option 2. Option 3 can be eliminated because this recommendation would delay time that could be used to diagnose a possible at-risk fetus.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?

"Foods and fluids that will increase urine alkalinity need to be consumed."

"Foods and fluids that will increase urine alkalinity would be consumed."

A client infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the client indicates an understanding of the instructions? Select all that apply.

"I am going to need to bottle-feed my baby I need to wash my hands before and after bathroom use. I can transmit the infection to my baby when I breast/chest-feed. I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method?

"I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad."2"I would ask the client to keep a record and document every time the perineal pad is changed."3"I need to weigh the perineal pad before and after use and note the amount of time between each pad change."4"I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates an understanding of the instructions?

"I can use ice packs to assist in alleviating some of the discomfort."

The nurse is interviewing a 16-year-old client during the initial prenatal clinic visit. The client is beginning week 18 of their first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation?

"I don't like my face anymore. I always look as if I have been crying." Rationale:In the correct option, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension. Although the remaining options also deal with body image, and these comments would not be ignored, the need for follow-up is not urgent.

Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor?

"I feel like I need to push." Rationale:The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. At this time, the laboring client typically experiences the desire to push. Contractions becoming stronger are experienced throughout labor and do not indicate that the client has reached stage 2. Having several minutes to rest between contractions does not describe the end of transition. Leaking of amniotic fluid does not mean that the client is completely dilated.

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions?

"I need to avoid eating fatty foods and foods that produce gas." Rationale:Lying down is likely to lead to reflux of stomach contents, especially immediately after a meal. The client needs to be instructed to avoid spices, along with salt, because spices trigger heartburn. Salt produces edema. The client would be encouraged to eat between-meal snacks and would be instructed that to control heartburn, eating smaller, more frequent portions is preferred over eating three large meals. The client also needs to limit or avoid gas-producing and fatty foods.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I need to avoid exercise because of the negative effects on insulin production." Rationale:Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician.

The nurse has provided instructions about measures to clean the penis to the parent of a newborn who is not circumcised. Which statement, if made by the parent, indicates an understanding of how to clean the newborn's penis?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A prenatal client with a history of heart disease has been instructed on care at home. Which statement, if made by the client, indicates an understand of health needs?

"I need to avoid stressful situations." Rationale:Stress causes increased heart workload, and the client needs to be instructed to avoid stress. Too much weight gain can place further demands on the heart. Resting needs to be on the left side to promote blood return and avoid supine hypotension. To avoid infections, individuals with active infections would not be allowed to visit the client. Otherwise, restrictions are not required.

A pregnant client who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the client regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply.

"I need to breast/chest-feed, especially for the first 6 weeks postpartum." "My baby has no symptoms, so it is unlikely that my baby got the infection from me."

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of the infant. Which client statement indicates the need for further instruction?

"I need to chest-feed with my milk, especially for the first 6 weeks postpartum."

A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction?

"I need to do more exercises to strengthen my back muscles." Rationale:Some measures that will assist in relieving a backache include maintaining good posture and body mechanics, resting and avoiding fatigue, wearing flat-heeled shoes, and sleeping on a firm mattress. The back discomfort that occurs in a pregnant client is often caused by the exaggerated lumbar and cervicothoracic curves resulting from a change in the center of gravity because of the enlarged uterus. Performing more exercises to strengthen the back muscles could be harmful to a pregnant client.

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I need to drink adequate fluids and increase my intake of high-fiber foods." Rationale:Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver needs to be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium needs to be restricted as prescribed by the primary health care provider because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.

"I need to drink adequate fluids and increase my intake of high-fiber foods." Rationale:Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver needs to be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium needs to be restricted as prescribed by the primary health care provider, because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.

A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement?

"I need to drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses would be water." Rationale:The nurse would instruct the client to have an adequate fluid intake daily to assist in digestion and in the management of constipation. The pregnant client would consume at least 8 to 10 (8-oz) glasses of fluid each day, of which at least 6 glasses would be water. It is not necessary for the client to drink 12 glasses of fruit juices and milk every day. Because of their sodium content, diet soft drinks need to be consumed in moderation. Caffeinated beverages have a diuretic effect, which may be counterproductive to increasing fluid intake.

A prenatal clinic nurse is providing instructions to a group of pregnant clients regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction?

"I need to drink unpasteurized milk only." Rationale:All pregnant clients need to be advised to follow certain procedures to prevent the development of toxoplasmosis. All meats need to be cooked thoroughly. Pregnant clients need to avoid uncooked eggs and unpasteurized milk. All fruits and vegetables need to be washed before consumption. Contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sand boxes, or garden soil need to be avoided. Last, strict hand-washing technique needs to be done, and the pregnant client needs to avoid touching mucous membranes of the mouth or eyes while handling raw meat, thoroughly wash all kitchen surfaces that come in contact with uncooked meat, and wash the hands thoroughly after handling raw meat.

The nurse is providing instructions to a new parent regarding cord care for a newborn infant. Which statement, if made by the parent, indicates a need for further instructions?

"I need to fold the diaper above the cord to prevent infection."

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the client has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the client, indicates a need for further instruction?

"I need to isolate the infant for 48 hours after beginning the antibiotics."

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?

"I need to lie flat on my back to perform the procedure." Rationale:The client would sit or lie quietly on the side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place the hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. If the client feels fewer than 10 movements within a 2-hour period it could be because the baby is sleeping.

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?

"I need to lie flat on my back to perform the procedure." Rationale:The client would sit or lie quietly on the side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place the hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the primary health care provider (PHCP) if the client feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the PHCP. Note that if the client is obese, perception of fetal movements may be decreased and consequently the ability of the pregnant client to count them.

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching?

"I need to lie on my back to perform the procedure." Rationale:The client would lie on the side, not the back, when performing kick counts. Lying on the back increases the risk for vena cava syndrome. The client would use a timer or a clock and needs to record the number of movements felt during that time. The client is advised to count the fetal movements for 30 to 60 minutes 3 times a day. The client is instructed to place the hands on the largest part of the abdomen and concentrate on the fetal movements.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction?

"I need to stop breast/chest-feeding until this condition resolves."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding/chest-feeding the newborn. Which client statement would indicate a need for further instruction?

"I need to wash my nipples daily with soap and water."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast/chest feeding the newborn. Which client statement would indicate a need for further instruction?

"I need to wash my nipples daily with soap and water."

The nurse is providing postpartum instructions to a client who will be breast-feeding/chest-feeding the newborn. The nurse determines that the client has understood the instructions if the client makes which statements? Select all that apply.

"I need to wear a bra that provides support. Drinking alcohol can affect my milk supply. I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse is providing postpartum instructions to a client who will be breast/chest-feeding the newborn. The nurse determines that the client has understood the instructions if the client makes which statements? Select all that apply.

"I need to wear a bra that provides support. Drinking alcohol can affect my milk supply. I plan on having bottled water available in the refrigerator so that I can get additional fluids easily."

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instruction?

"I need to wear knee-high hose, but I would not leave them on longer than 8 hours." Rationale:Varicose veins often develop in the lower extremities during pregnancy. Any constrictive clothing, such as knee-high hose, impedes venous return from the lower legs and places the client at risk for developing varicosities. The client would be encouraged to wear support hose or panty hose. Flat nonslip shoes with proper support are important to assist in maintaining proper posture and balance and to minimize falls.

A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures?

"I need to wear underwear with a cotton panel liner." Rationale:Wearing items with a cotton panel liner allows for air movement in and around the genital area. Douching is to be avoided. Wearing tight clothing can irritate the genital area and does not allow for air circulation. Condoms need to be used to minimize the spread of genital tract infections.

The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, would alert the nurse to a potential psychosocial problem?

"I want to gain only 10 pounds because I want to have a small, petite baby." Rationale:Pregnant adolescents are at higher risk for complications. Peer pressure is an important influence on nutritional status. Adolescents often are concerned about their body image. If weight is a major focus for the adolescent, the adolescent is more likely to restrict calories to avoid weight gain. The correct option is the only one that suggests a possible psychosocial problem. The remaining options relate to physiological issues.

Which statement reflects a new birthing parent's understanding of the teaching about the prevention of newborn abduction?

"I will ask the nurse to attend to my infant if I am napping and my partner is not here."

Which statement reflects a new parent's understanding of the teaching about the prevention of newborn abduction?

"I will ask the nurse to attend to my infant if I am napping and my spouse is not here."

The nurse is discussing home care instructions with a client at 32 weeks' gestation diagnosed with vulvar varicose veins. Which statement made by the client indicates a need for further teaching?

"I will avoid lying on my left side in bed." Rationale:Vulvar varicosities more commonly occur during pregnancy due to increased blood flow and pressure on the perineum. Clinical manifestations include tortuous, dilated veins in the vulvar area that result in a feeling of pressure, pain, or fullness in the genitals that is exacerbated by standing or sitting for prolonged periods of time or sexual intercourse. Treatment of vulvar varicosities is supportive, as the varicosities usually resolve within a few weeks after delivery. The client would elevate the hips while lying down to improve venous return, and supportive compression underwear needs to be worn to improve circulation and reduce swelling. Lying on the left side is encouraged as this reduces pressure on the vena cava, thereby improving venous return to the heart. Heat and ice packs can be alternated on the affected area to aid with pain relief. It is possible for deep vein thrombosis to develop in a vulvar varicose vein; therefore, the client would contact the primary health care provider if there is increased swelling or pain in the affected area. Options 2, 3 and 4 are client statements that indicate adequate understanding of the nurse's instructions. Since the client needs to be encouraged to avoid lying on the right side (not the left side), which would reduce venous return to the heart, option 1 is the client statement that requires a need for further teaching.

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

The nurse is teaching a client in the first trimester measures to alleviate nausea and vomiting. Which statement by the client indicates that further teaching is required?

"I will eat dry crackers for breakfast after I get up." Rationale:Nausea and vomiting during the first trimester constitute a common complaint. Possible causes include the rise in the level of human chorionic gonadotropin and altered carbohydrate metabolism. Dry crackers need to be eaten before getting out of bed rather than after arising. The client needs to avoid fried foods and eat five or six small meals throughout the day rather than fewer larger meals. The nausea and vomiting would lessen throughout the day, but if they continue, the primary health care provider needs to be notified for further intervention.

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?

"I will eat fresh fruits and vegetables for snacks and for dessert each day." Rationale:Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums.

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutritional measures to minimize this problem?

"I will eat fresh fruits and vegetables for snacks and for dessert each day." Rationale:Fresh fruits and vegetables will provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums; cracked wheat bread may abrade the tender gums. Eating saltine crackers before arising helps to decrease nausea.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates an understanding of self-care for this diagnosis?

"I will report signs of infection immediately to my primary health care provider." Rationale:Signs of infection need to be reported immediately to the primary health care provider because of the risk of complications. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet that is balanced with all food groups. Exercise is safe for the client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is not necessary for the client to report to the laboratory daily for a blood test.

The nurse is providing home care instructions for a client at 30 weeks' gestation diagnosed with vulvar varicose veins. The nurse explains to the client that supportive treatment is used in the management of this condition. The nurse determines that the client understands the home care instructions if the client makes which statements? Select all that apply.

"I will elevate my hips with a pillow while lying in bed. Compression underwear needs to be worn to improve circulation. I can alternate between putting heat and ice packs on the affected areas." Rationale:Vulvar varicosities more commonly occur during pregnancy due to increased blood flow and pressure on the perineum. Clinical manifestations include tortuous, dilated veins in the vulvar area that result in a feeling of pressure, pain, or fullness in the genitals that is exacerbated by standing or sitting for prolonged periods of time or sexual intercourse. Treatment of vulvar varicosities is supportive, as the varicosities usually resolve within a few weeks after delivery. The client would elevate the hips while lying down to improve venous return, and supportive compression underwear needs to be worn to improve circulation and reduce swelling. Lying on the left side is encouraged as this reduces pressure on the vena cava, thereby improving venous return to the heart. Heat and ice packs can be alternated on the affected area to aid with pain relief. Acetaminophen may be taken for pain relief. Eliminate option 1 because ibuprofen is not recommended during pregnancy. Next, eliminate option 3 because lying on the right side would increase pressure on the vena cava, exacerbating venous stasis. Therefore, options 2, 4 and 5 are correct.

A client in the first trimester of pregnancy arrives at a health care clinic and reports has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?

"I will maintain strict bed rest throughout the remainder of the pregnancy." Rationale:Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client needs to watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider.

The nurse is providing instructions to a client who is at 25 weeks' gestation. The client is scheduled for the 1-hour oral glucose tolerance test (OGTT), and the nurse provides the client with instructions regarding preparation for the procedure and how the test is performed. The nurse determines that the client requires a need for further teaching if the client makes which statement?

"I will make sure dinner is my last meal and will fast the night prior to the test." Rationale:Screening for gestational diabetes mellitus is recommended for low-risk women between 24 and 28 weeks' gestation. The 1-hour oral glucose tolerance test (OGTT) involves orally administering a 50-gram glucose load followed by a plasma glucose level that is drawn 1 hour later. The 1-hour OGTT screening is considered positive if the glucose value is equal to or greater than 140 mg/dL (7.8 mmol/L). A positive 1-hour OGTT is followed up with a two-step 3-hour OGTT in which a fasting blood glucose level is drawn, followed by oral administration of a 100-gram glucose load. Blood glucose levels are then drawn 1, 2, and 3 hours later. Preparation differs for the 1-hour OGTT and the 3-hour OGTT. The 1-hour OGTT does not require fasting prior to the test, whereas the 3-hour OGTT requires fasting prior to the test as a fasting blood glucose level needs to be drawn prior to administering the oral glucose load. Therefore, option 1 is the client statement that requires a need for further teaching as the client does not need to fast prior to the 1-hour OGTT. Therefore, option 1 is correct.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

"I will need to increase my insulin dosage during the first 3 months of pregnancy." Rationale:Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about an understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

A client arrives at the health care clinic and tells the nurse that the last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that the client has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly?

"I will need to prepare myself and my family for the loss of this pregnancy." Rationale:The client is experiencing a spontaneous abortion (miscarriage), which cannot be prevented and will terminate the pregnancy. Bed rest will not reverse this process.

The nurse is assessing a client at 11 weeks' gestation during a routine prenatal appointment. The client has been experiencing nasal stuffiness and epistaxis once in the last week; the nurse reinforces instructions from the primary health care provider to help the client's symptoms. The nurse determines that the client has a need for further teaching if the client makes which statement?

"I will run a dehumidifier in the bedroom at night." Rationale:Increased estrogen levels during pregnancy result in hyperemia of the mucous membranes, which can cause nasal congestion or epistaxis. Preventive measures include moistening the air, which can be achieved by running a humidifier, and moistening nasal passages via adequate hydration and the topical application of moisturizing agents such as petroleum jelly or saline nasal spray or drops. Eliminate options 2, 3, and 4 because these are appropriate preventive measures for this client. Therefore, option 1 is the client statement that requires a need for further teaching from the nurse, as a humidifier, not a dehumidifier, should be used.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I would avoid exercise because of the negative effects on insulin production." Rationale:Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or PHCP's office. Signs of infection need to be reported to the PHCP.

The nurse is providing instructions to a client who is at 26 weeks' gestation and is scheduled for a 3-hour glucose tolerance test due to a positive 1-hour glucose tolerance test result. Which client statement would indicate to the nurse that there is a need for further teaching?

"I would follow a low-carbohydrate diet for at least 3 days prior to the test." Rationale:Screening for gestational diabetes mellitus is recommended for low-risk women between 24 and 28 weeks' gestation. The first screening test involves orally administering a 50-gram glucose load followed by a plasma glucose level that is drawn 1 hour later. The 1-hour oral glucose tolerance test (OGTT) screening is considered positive if the glucose value is equal to or greater than 140 mg/dL (7.8 mmol/L). A positive 1-hour OGTT is followed up with a two-step 3-hour OGTT in which a fasting blood glucose level is drawn, followed by oral administration of a 100-gram glucose load. Blood glucose levels are then drawn 1, 2, and 3 hours later. Preparation for the 3-hour OGTT differs when compared to the 1-hour OGTT. The client must be fasting prior to the 3-hour OGTT test and should avoid both caffeine and smoking prior to the test, as smoking and caffeine can raise blood glucose levels. The client should eat and exercise normally in the days leading up to the test. Eliminate options 1, 2, and 4 as these client statements are accurate and do not indicate a need for further teaching. Therefore, option 4 is the correct answer as a client would not change a usual diet in the days leading up to the test.

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction?

"If I develop a fever, chills, or body aches at any time after discharge, I need to stop breast/chest-feeding immediately."

The postpartum unit nurse has provided discharge instructions to a client planning to breast/chest-feed a normal, healthy infant. Which statement by the client indicates an understanding of the instructions?

"If I notice any pain, redness, or swelling in my breasts/chest, I need to contact the primary health care provider."

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions?

"Iron supplements may give me constipation." Rationale:Iron is needed both to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and the hematocrit level. This is a normal adaptation and is known as physiological anemia of pregnancy. Therefore, supplements are needed. Iron supplements usually cause constipation. One food source of protein is meats, and meats are an excellent source of iron. Iron is best absorbed if taken on an empty stomach.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

"It connects the umbilical vein to the inferior vena cava." Rationale:The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

The nursing instructor teaches a group of students about fetal circulation and then asks a student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

The nurse explains the purpose of effleurage to a client in early labor. Which statement would the nurse include in the explanation?

"It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." Rationale:Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus. Options 1, 2, and 4 are inaccurate descriptions of effleurage.

A nursing instructor asks a nursing student to describe the process of quickening. Which statements by the student indicate an understanding of this term? Select all that apply.

"It is the fetal movement that is felt by the pregnant client." Rationale:Quickening is fetal movement and is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements that gradually increase in intensity. A thinning of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant clients do not notice them until the third trimester. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, known as uterine souffle. This sound is caused by the blood circulation to the placenta and corresponds to the maternal pulse.

A nursing student is preparing to assist with the assessment of a pregnant client, gravida 2, para 1 (G2P1), at 18 weeks' gestation. The nursing instructor asks the student to describe expectations related to the process of quickening. Which statements, if made by the student, indicate an understanding of this process? Select all that apply.

"It is the fetal movement that is felt by the pregnant client." Rationale:Quickening is fetal movement and may occur as early as 16 weeks' gestation in the multigravida client. The primigravida client typically experiences quickening between weeks 18 and 20. The expectant parent first notices subtle fetal movements that gradually increase in intensity. Thinning of the lower uterine segment occurs at about the sixth week of pregnancy and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy, beginning as early as 16 weeks. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus, and this is known as uterine souffle. This sound is caused by the blood circulation to the placenta and corresponds to the maternal pulse. A multigravida experiences quickening sooner than the primigravida due to prior experience and more rapid physical changes.

The nurse is caring for a pregnant client who has herpes genitalis. The nurse provides instructions to the client about treatment modalities that may be necessary for this condition. Which statement made by the client indicates an understanding of these treatment measures?

"It may be necessary to have a cesarean section for delivery." Rationale:If a client has an active lesion, either recurrent or primary at the time of labor, delivery needs to be by cesarean section. Clients are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the client would continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated, and the genital area needs to be kept clean and dry to promote healing.

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

"It promotes the fertilized ovum's normal implantation in the top portion of the uterus." Rationale:The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.

The nurse is conducting a prenatal class on the reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

A new parent is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The client is complaining about symptoms of the flu and complains of fatigue and aching muscles. On further assessment, the nurse notes a localized area of redness on the left breast/chest, and the client is diagnosed with mastitis. The client asks the nurse about the condition. The nurse would make which response?

"Mastitis can occur at any time during breast/chest-feeding."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if the client makes which statement?

"My contractions will increase in duration and intensity." Rationale:True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if the client makes which statement?

"My contractions will last longer and be more intense." Rationale:True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the birthing parent asks the nurse why the infant needs the injection. What best response would the nurse provide?

"Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted?" What would be the nurse's response?

"Prolactin stimulates the secretion of milk, which is called lactogenesis." Rationale:Prolactin stimulates the secretion of milk, which is called lactogenesis. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. Testosterone is produced by the adrenal glands and induces the growth of pubic and axillary hair at puberty.

A COVID-19-positive birthing parent of a 2-day-old infant wishes to pump milk for the newborn, but is concerned about passing COVID-19 to the infant. The nurse provides teaching to the client and determines that there is a need for further teaching if the client makes which statement

"Sterilizing pumping equipment before use makes handwashing unnecessary."

The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client?

"The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis, owing to your results being elevated." Rationale:Recommendations for gestational diabetes mellitus (GDM) screening during pregnancy indicate that clients need to be screened using the 1-hour OGTT at 24 to 28 weeks' gestation. The OGTT is a screening tool, and when results are greater than 140 mg/dL (8 mmol/L), the recommendation is further assessment via the 3-hour OGTT. Although fetal macrosomia is associated with maternal glucose intolerance, this diagnosis cannot be made with a 1-hour OGTT, thus eliminating option 1. Option 2 indicates that the OGTT results are within normal limits; therefore this option can be eliminated because the client's 1-hour OGTT results exceed the normal level. Only when two or more of the four measured glucose levels are exceeded can a woman be diagnosed with GDM. This fact eliminates option 4.

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply.

"The client may complain of lack of sleep and fatigue. The client is self-focused and talks to others about labor."

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements would be included in the teaching plan? Select all that apply.

"The ductus arteriosus allows blood to bypass the fetal lungs. One vein carries oxygenated blood from the placenta to the fetus. Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." Rationale:The ductus arteriosus is a unique fetal circulation structure that allows blood to bypass the nonfunctioning fetal lungs. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heartbeat range is considered to be 110 to 160 beats per minute. Two arteries carry deoxygenated blood and waste products from the fetus, and one umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements would be included in the teaching plan? Select all that apply.

"The ductus arteriosus allows blood to bypass the fetal lungs. One vein carries oxygenated blood from the placenta to the fetus. Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." Rationale:The ductus arteriosus is a unique fetal circulation structure that allows the nonfunctioning lungs to receive only a minimal amount of oxygenated blood for tissue maintenance. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart rate range is considered to be 110 to 160 beats per minute. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.

A pregnant client who is anemic expresses concern about the infant's condition after delivery. Which nursing response would best support the client?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." Rationale:The effects of maternal iron-deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron even if a deficiency is present. Neonates of severely anemic pregnant clients have been reported to experience reduced red blood cell volume, hemoglobin level, and iron stores. Telling a client that there will not be any problems if the primary health care provider's advice is followed and advising the client not to worry because complications are rare provide false reassurance to the client. Telling the client that the baby will probably spend time in the neonatal intensive care unit will cause further concern. The correct option provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the client.

A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply.

"The exercises will help strengthen the pelvic floor in preparation for delivery. The exercises will help strengthen the muscles that support the bladder and urethra." Rationale:Kegel exercises will assist in strengthening the pelvic floor as well as the muscles that support the bladder and urethra. Pelvic tilt exercises will help to reduce backaches. Leg elevation will assist in preventing ankle edema. Instructing a client to drink 8 oz of fluids 6 times a day will help to prevent urinary tract infections.

The nurse is preparing to administer an injection of vitamin K to a newborn and provides the parent with information about the injection. Which information would the nurse provide?

"The injection is extremely important to prevent bleeding in your baby."

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?

"The iron is best absorbed if taken on an empty stomach." Rationale:Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake.

The nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn and discusses the prescription with the parent. Which statement, if made by the parent, demonstrates an understanding of why this medication is used?

"The medication will help protect my baby's eyes from certain infections transmitted during the labor and delivery process."

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement?

"The only medications I will take are my prenatal vitamins and stool softeners."

A primary health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy, and the client asks the nurse about the procedure. How would the nurse respond to the client?

"The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel." Rationale:Transvaginal ultrasonography allows clear visibility of the uterus, gestational sac, embryo, and deep pelvic structures, such as the ovaries and fallopian tubes. The client is placed in a lithotomy position and a transvaginal probe, encased in a disposable cover and coated with a gel that provides lubrication and promotes conductivity, is inserted into the vagina. The client may feel more comfortable if allowed to insert the probe. The procedure takes about 10 to 15 minutes. Options 2 and 4 identify components of abdominal ultrasound.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports noticing a thin, colorless vaginal drainage. The nurse would make which statement to the client?

"The vaginal discharge may be bothersome but is a normal occurrence." Rationale:Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but would not wear tampons because of the risk of infection. If the client uses panty liners, the client needs to change them frequently.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports noticing a thin, colorless vaginal drainage. The nurse would make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence." Rationale:Leukorrhea begins during the first trimester. Many clients notice a thin, colorless, or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but should not wear tampons because of the risk of infection. If the client uses panty liners, the client needs to change them frequently

A pregnant client seen in the prenatal clinic tells the nurse that the iron supplement started 1 week ago is causing nausea, constipation, and heartburn and that she would like to stop taking the medication. The nurse responds by making which statement to the client?

"These reactions are most prominent during initial therapy and lessen with continued use." Rationale:It is important that pregnant clients receive iron supplements because of the extra demands placed on maternal circulation by the fetus. Although the fetus does need iron, option 1 is not the best response, considering the other options presented. Option 2 is an inappropriate and incorrect response because the iron does not have to be discontinued. Seeing the primary health care provider immediately is unnecessary at this time.

The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the primary health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client?

"This is necessary to assist in identifying potential infections that may need to be treated." Rationale:The HIV-compromised client may be at high risk for superimposed infections during pregnancy. These include, for example, Candida infections, genital herpes, and anogenital condyloma. Early reporting of signs and symptoms may alert the members of the health care team that further assessment and testing are needed to diagnose and manage additional maternal and fetal physiological risks. All other options do represent possible outcomes of this nursing intervention, but they are not the priority of care when promoting maternal-fetal well-being.

A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements? Select all that apply.

"This test can be used as a screening for spina bifida." This test is a screening test, and I will need other testing if I have abnormal results. This test can indicate if I may be at an increased risk for having a child with Down's syndrome." Rationale:A triple screen test is a screening tool. Maternal blood is drawn and alpha-fetoprotein, human chorionic gonadotropin, and estriol values are assessed to determine whether the pregnant parent is at an increased risk for neural tube defects or chromosomal trisomies. Spina bifida and Down's syndrome are the two most common risks that fall into these categories, respectively. These results must be followed by additional diagnostic testing, as the triple screen is only a screening result. This test does not have any relationship to prematurity or sex determination of the fetus.

A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse would make which appropriate response?

"This test measures amniotic fluid volume and fetal activity." Rationale:The BPP assesses five parameters of fetal activity: fetal heart rate, fetal breathing movements, gross fetal movements, fetal tone, and amniotic fluid volume. In a BPP, each of the five parameters contributes 0 to 2 points, with a score of 8 considered normal and a score of 10 perfect. Results are available immediately. A BPP test deals with fetal, not maternal, well-being. Options 1 and 3 relate to maternal well-being. Amniotic fluid measurement is only one component of the BPP test.

The nurse in a maternity unit is providing emotional support to a client and significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

"What can I do for you?"

The nurse provides teaching on how to relieve discomfort to a client in the second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching?

"When I get home, I need to lie on the floor with my legs elevated on a couch and turn my hips and knees at right angles." Rationale:Lying on the floor with the legs elevated on a couch with the hips and knees at right angles will produce a posture of pelvic tilt while countering gravity, which is the force that leads to edema of the lower extremities. Lying on the left side with the feet dorsiflexed may help with the reduction of hemorrhoids. Remember that heat needs to be prescribed by a primary health care provider (PHCP).

The rubella vaccine has been prescribed for a postpartum client. Which statements would the postpartum nurse make when providing information about the vaccine to the client? Select all that apply.

"You need this vaccine because you are not immune to the rubella virus. You need to avoid becoming pregnant for 1 to 3 months after the administration of the vaccine."

The rubella vaccine has been prescribed for a postpartum client. Which statement would the postpartum nurse make when providing information about the vaccine to the client?

"You should not become pregnant for at least a month after administration of the vaccine."

A pregnant client in the second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the client?

"You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed." Rationale:Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks associated with birthing parent and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies. Rubella titer determination is a standard antenatal test for childbearing persons during their initial screening and entry into the health care delivery system. The correct option helps to clarify maternal concerns with accurate information based on the acquisition of rubella infection and potential fetal side effects.

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. Client's ChartHistory and PhysicalLaboratory and Diagnostic ResultsMedicationsGravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0Venereal Disease Research Laboratory (VDRL) nonreactivePrenatal vitaminsWeight 135 lb (61 kg)Rubella immunePositive Goodell and ChadwickRh positive, type O

"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." Rationale:Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the first trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard prenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information.

A pregnant client has a positive history of genital herpes but has not had lesions during this pregnancy. What would the nurse plan to tell the client?

"You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed." Rationale:With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures need to be obtained from potentially exposed newborn infants on the day of delivery.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care of the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response would the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response would the nurse make to the client?

"You will need to bottle-feed your newborn."

A client who has just been told about being pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the primary health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response?

"Your baby's heart right now has double heart chambers and has begun to beat, so we would be able to see it beat using an ultrasound machine." Rationale:By gestational week 5, double heart chambers are visible by ultrasound, and the heart begins to beat. The fetal heart is only two parallel tubes at week 3. At week 5, the heart can be visualized only by ultrasound. To be heard by Doppler, the gestation must be 9 to 12 weeks; to be heard by fetoscope, the gestation must be at least 20 weeks.

The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the parent asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response?

"Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time." Rationale:All pregnant parents need to be screened for prior rubella exposure during pregnancy. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to rubella. All children of pregnant parents would receive their immunizations according to schedule. In addition, no definitive evidence suggests that the rubella vaccine virus is transmitted from client to client.

The nurse would make which statement to a pregnant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth." Rationale:A gynecoid pelvis is a normal pelvis and is the most favorable for successful labor and birth. An android pelvis would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

The nurse would plan to make which statement to a pregnant client found to have a gynecoid pelvis?

The nurse is assessing a client who is at 18 weeks' gestation with a prepregnancy body mass index (BMI) of 31.2 kg/m2. The client asks the nurse how much weight should be gained each week. How would the nurse respond?

0.5 pounds (1.1 kilograms) per week Rationale:Energy and nutrient needs vary from each pregnant individual. Weight gain recommendations depend on the client's prepregnancy body mass index (BMI). A BMI equal to or greater than 30 kg/m2 is considered obese. The recommended weekly weight gain for the obese client is 0.5 pounds (1.1 kilograms) per week. Therefore, option 1 is correct.

The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse would perform which procedure to assess the brachioradialis reflex? Click on the image to indicate your answer.

1 Rationale:To assess the brachioradialis reflex, the client's thumb is held to suspend the forearm in relaxation. The nurse then strikes the forearm directly, about 2 to 3 cm above the radial styloid process. The normal response is flexion and supination of the forearm. Option 2 identifies the procedure for assessing the quadriceps reflex. Option 3 identifies the procedure for assessing the biceps reflex. Option 4 identifies the procedure for assessing the triceps reflex.

List in order of priority the actions the nurse would take when a client in labor is experiencing eclampsia?

1.Remain with the client. 6.Ensure that the client's airway is open, turn the client to the side, and provide 8 to 10 L/min of oxygen 2.Monitor fetal heart rate patterns. 3.Administer medications to control seizure. 5.Insert an oral airway after the seizure ends and suction the client's mouth. 4.Document the occurrence, client's response, and outcome. Rationale:If eclampsia occurs, the nurse remains with the client and calls for help. The nurse ensures an open airway. If the client is not on the side already, the nurse attempts to turn the client on the side. The side-lying position permits greater circulation through the placenta and may help to prevent aspiration. The nurse administers oxygen by face mask at 8 to 10 L/min to ensure adequate placental oxygenation. The nurse also notes the time the seizure began and the duration of the seizure and protects the client from injury during the event. The nurse monitors fetal heart rate patterns closely and administers medications as prescribed (magnesium sulfate may be prescribed). After the seizure has ended, the nurse inserts an oral airway to maintain airway patency and suctions the client's mouth as needed. If warranted, the nurse prepares for the delivery of the fetus after stabilization of the client. The nurse documents the occurrence, the client's response, and the outcome.

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse would document which Apgar score?

The nurse is caring for a client who just gave birth who tested positive for COVID-19 but is asymptomatic. The client has been following precautions while caring for the newborn, such as wearing a mask while within 6 feet of the newborn and keeping the newborn 6 feet away or more as much as possible. The client asks the nurse when these precautions can be stopped. What is the appropriate response?

10 days since the positive COVID-19 test

Which statement, if made by the parent of a 1-day-old newborn, indicates an understanding of gastrointestinal system functioning in the infant? Select all that apply.

10 to 20 mL is the stomach capacity of a 1-day-old newborn 90 to 150 mL is the stomach capacity of a 1-month-old infant

The nurse is assessing a client who is at 8 weeks' gestation with a prepregnancy body mass index (BMI) of 30.5 kg/m2. The client is concerned about healthy weight gain during the pregnancy and asks what is the recommended weight gain during the pregnancy. What is the appropriate nursing response?

11 to 20 pounds (5 to 9.1 kilograms) Rationale:Energy and nutrient needs vary for each pregnant individual. Weight gain recommendations depend on the client's prepregnancy body mass index (BMI). This client's prepregnancy BMI is considered obese, and the recommended total weight gain during the pregnancy for this client would be between 11 and 20 pounds (5 to 9.1 kilograms). Therefore, eliminate options 1, 3, and 4 because these are not the appropriate weight gain recommendations for this client. Furthermore, it is important for this client to understand it is not recommended to maintain current weight, as the client should at least gain enough weight to equal the weight of the products of conception (fetus, placenta, and amniotic fluid). Therefore, option 2 is correct.

The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Naegele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd).

1116 Rationale:Accurate use of Naegele's rule requires that the client have a regular 28-day menstrual cycle. To calculate the estimated date of delivery, the nurse would subtract 3 months from the first day of the LMP, then add 7 days, and add 1 year if appropriate. First day of LMP: February 9; subtract 3 months: November 9; add 7 days: November 16; and add 1 year as appropriate.

The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of the last menstrual period was, and the client reports February 14, 2024. Using Naegele's rule, the nurse determines that what is the estimated date of delivery? Fill in the blank. Record your answer using 6 digits (mmddyy).

112124 Rationale:Naegele's rule determines the estimated date of birth and works on the premise that the client has a 28-day menstrual cycle. To calculate the estimated date of delivery, subtract 3 months from the first day of the last menstrual period, add 7 days, and then add 1 year if needed. Therefore, start with the first day of the last menstrual period, February 14, 2024; subtract 3 months, November 14, 2023; add 7 days, November 21, 2023; and add 1 year, November 21, 2024.

The nurse is collecting data from a client during the first prenatal visit. The client is eager to know the sex of the fetus and asks the nurse when it will be known. The nurse plans to respond to the client, knowing that the sex of the fetus can be determined as early as which week?

12 Rationale:By the end of the twelfth week of gestation, the fetal sex can be determined by the appearance of the external genitalia on ultrasound; therefore, the other options are incorrect.

A client in the prenatal clinic asks the nurse about her delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2024, and ended the menses on March 14, 2024. Using Naegele's rule, the nurse would tell the client that the estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits (mmddyy).

121424 Rationale:Naegele's rule is a noninvasive method for estimating the date of birth and is based on the assumption that the menstrual cycle is 28 days. The rule states the following: Subtract 3 months from the first day of the last menstrual period, add 7 days, then adjust the year. March 7, 2024, minus 3 months is December 7, 2023. December 7, 2023, plus 7 days is December 14, 2023. Adding 1 year brings the date of delivery to December 14, 2024.

The nurse is educating a client at 27 weeks' gestation regarding blood glucose monitoring. The client was recently diagnosed with gestational diabetes mellitus. The nurse determines that the client understands the teaching if the client states that which reading is considered an ideal blood glucose level for 1 hour after a meal?

135 mg/dL (7.5 mmol/L) Rationale:Gestational diabetes mellitus occurs as a result of the pancreas being unable to produce sufficient insulin or because of the ineffective use of insulin as placental hormones, cortisol, and insulinase promote insulin resistance. The treatment aim of gestational diabetes mellitus involves strict blood glucose control. Recommended blood glucose levels are as follows: fasting blood glucose less than 95 mg/dL (5.3 mmol/L), 1-hour post-meal blood glucose less than 140 mg/dL (7.8 mmol/L), and 2-hour post-meal blood glucose less than 120 mg/dL (6.7 mmol/L). Options 2, 3 and 4 are higher than 140 mg/dL (7.8 mmol/L), which is considered the upper limit for the ideal 1-hour post-meal blood glucose level. Therefore, option 1 is correct.

A primigravida client asks the nurse in the clinic when fetal movement will be felt. The nurse responds by telling the client that fetal movements will be noted between which weeks of gestation?

18 and 20 Rationale:Quickening is fetal movement that is felt by the pregnant client. In the multiparous client, this may occur as early as the fourteenth to sixteenth weeks. However, the nulliparous (primigravida) client may not notice these sensations until the eighteenth week or later. Options 1, 2, and 3 are incorrect time frames because quickening does not occur this early during pregnancy in a primigravida client.

A nulliparous client asks the nurse when fetal movements will be felt. The nurse responds by telling the client that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

18 weeks Rationale:The first recognition of fetal movements, or feeling life, by the multiparous person may occur as early as 14 to 16 weeks' gestation. The nulliparous person may not notice these sensations until 18 weeks' gestation or later, as the person has no prior experience and the uterus has not been previously stretched during pregnancy adaptation. The first recognition of fetal movement is called quickening.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients would be assessed. How would the nurse plan assessments? Arrange the clients in the order that they would be assessed. All options must be used.

2,4,1,3

The nurse is providing dietary education to a client who is 16 weeks gestation. The client's body mass index (BMI) is 35 kg/m2. The client asks how many calories per day should be consumed. How would the nurse respond?

2200 calories per day Rationale:Energy and nutrient needs vary for each pregnant individual. Caloric recommendations also vary depending on pregnancy trimester. During the first trimester, the recommended daily caloric intake is 1800 calories per day. During the second trimester, the recommended daily caloric intake is 2200 calories per day. Lastly, during the third trimester the recommended daily caloric intake is 2400 calories per day. Therefore, since this client is in the second trimester of pregnancy, 2200 calories per day is recommended. Therefore, option 3 is correct.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame would the nurse relay to the client regarding the return of bowel function?

3 days postpartum

The postpartum nurse is providing instructions to a client after the birth of a healthy newborn. Which time frame would the nurse relay to the client regarding the return of bowel function?

3 days postpartum

The nurse is caring for a client in labor when a prolapsed umbilical cord is noted. In order of priority, which actions would the nurse take? All options must be used.

3.Elevate the fetal presenting part that is lying on the cord by applying gloved finger pressure. 5.Place the client in Trendelenburg or knee-chest position. 4.Administer oxygen 8 to 10 L/min via face mask. 2.Monitor fetal heart rate and tones. 1.Prepare for immediate birth. Rationale:If umbilical cord prolapse occurs, the cord is lying alongside or below the presenting part of the fetus and can be seen or felt in or protruding from the vagina. The nurse stays with the client and asks another nurse to call the primary health care provider immediately. The nurse must relieve cord pressure immediately so that the fetus receives adequate oxygenation. The nurse can relieve cord pressure by elevating the fetal presenting part that is lying on the cord; the nurse does this by quickly gloving the hand and inserting two fingers into the vagina to the cervix and exerting upward pressure on the presenting part. The nurse also relieves cord pressure by placing the client into an extreme Trendelenburg or modified left lateral position or a knee-chest position (a rolled towel is placed under the client's hip). The nurse administers oxygen, 8 to 10 L/min, by face mask to the client, monitors the fetal heart rate and fetal heart rate patterns, and assesses the fetus for hypoxia. The client is prepared for immediate birth (vaginal or cesarean). The nurse documents the event, actions taken, the client's response, and any additional pertinent information. The nurse never attempts to push the cord into the uterus. If the umbilical cord is protruding from the vagina, the cord is wrapped loosely in a sterile towel saturated with warm sterile normal saline.

The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)?

32 cm Rationale:From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect and the pregnancy is more advanced than previously thought. If the estimated date of delivery is correct, it may be possible that more than one fetus is present.

The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area? Click on the image to indicate your answer.

The nurse has determined that a postpartum client has uterine atony. The nurse would take actions in which priority order? Arrange the actions in the priority order that they would be done. All options must be used.

4,2,1, 3

A client who is a gravida 3, para 3 had a cesarean section 1 day ago and is being treated prophylactically for endometritis. The client is complaining of abdominal cramping at a pain level of 6 on a scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having a first bowel movement. These medications are prescribed and due to be administered now. Arrange the medications in the order that they would be administered. All options must be used.

4,3,2,1

The nurse is providing nutritional counseling to a parent who is breast/chest-feeding a newborn. The nurse would instruct the client that the client's calorie needs would increase by approximately how many calories a day?

500

The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/minute; the newborn has positive respiratory effort with a vigorous cry; muscle tone is active and well flexed; there is a strong gag reflex and cries with stimulus to the soles of the feet; body is pink, with cyanotic hands and feet. Which is the newborn's 1-minute Apgar score?

The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period?

A 26-year-old client with a family history of thrombophlebitis Rationale:Certain factors create a risk for the development of thrombophlebitis. These factors include smoking, varicose veins, obesity, a history of thrombophlebitis, those who are older than 35 years or have had more than three pregnancies, and those who have had a cesarean birth. The client described in the correct option is least likely to be at risk for the development of a thromboembolic disorder because this client has a family history rather than a personal history of thrombophlebitis.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at most risk for development of postpartum thromboembolic disorders?

A 39-year-old client who reports is a smoker

The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside?

A bottle of sterile normal saline

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction would the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present and active at the time of labor. Rationale:For clients with active lesions, either recurrent or primary at the time of labor, delivery would be by cesarean section to prevent the fetus from being in contact with the genital herpes. Clients would be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients need to continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. The safety of antiviral medications has not been established during pregnancy, and it would be used only when a life-threatening infection is present.

A postpartum care unit nurse is reviewing the records of five new clients admitted to the unit. The nurse determines that which client is most likely at risk for developing a puerperal infection? Select all that apply.

A client who had 10 vaginal exams during labor A client with a history of previous puerperal infections A client who experienced prolonged rupture of the membranes

The home care nurse is visiting a postnatal client 1 week after the client gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the client about the signs and symptoms of this disorder, the nurse instructs the client to monitor the infant for which findings? Select all that apply.

A copper-colored skin rash Mucopurulent nasal drainage (snuffles)

A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased?

A fetal heart rate of 180 beats/min

A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased?

A fetal heart rate of 180 beats/min Rationale:A normal fetal heart rate is 110 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin would be decreased in the presence of fetal tachycardia, which can occur from excessive uterine activity. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus would return to resting tone between contractions, and there would be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued?

A fetal heart rate of 90 beats/minute Rationale:A normal fetal heart rate is 110 to 160 beats/minute. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus would return to resting tone between contractions, and there would be no evidence of fetal distress.

The nurse in a maternity unit is reviewing the clients' records. Which clients would the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

A gravida II who has just been diagnosed with dead fetus syndrome A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia Rationale:In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

Which newborn is most at risk for a brachial plexus injury?

A large for gestational age infant with a history of shoulder dystocia at delivery

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How would the nurse document this finding?

A normal test result Rationale:Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider (PHCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the PHCP has documented the results as negative. How would the nurse interpret this finding?

A normal test result Rationale:Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds' duration in a 10-minute period. Repetitive late decelerations render the test results positive.

A primigravida with abruptio placentae A gravida 2 who has just been diagnosed with dead fetus syndrome A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension Rationale:In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

A private room two doors away from the nurses' station Rationale:A quiet room in which stimuli can be minimized is most important for the client with severe preeclampsia. A private room two doors away from the nurses' station is the best room assignment for this client. A private room across from the elevator or a semiprivate room across from the nurses' station may be noisy. A semiprivate room with a client who enjoys watching television would provide external stimuli, which must be kept minimal for the client with severe preeclampsia. The client with severe preeclampsia requires intense nursing observation and care.

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what would the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply.

A soft and flat anterior fontanel A triangular-shaped posterior fontanel

On delivery of a newborn, the nurse performs an initial assessment. When would the nurse determine the Apgar score?

At 1 minute after birth and 5 minutes after birth

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Based on the last normal menstrual period, they are 8 weeks' gestation. Appropriate physical assessments are completed. Which findings are anticipated to be present at this time? Select all that apply.

A softening of the cervix Bluish discoloration of the vaginal tissue The presence of human chorionic gonadotropin in the urine Rationale:At the beginning of the second month of gestation, the cervix becomes softer as a result of increased vascularity and hyperplasia, which cause Goodell's sign. Cervical softening is noted by the examiner during pelvic examination. Bluish discoloration of the vaginal tissue occurs due to hyperemia and is known as Chadwick's sign. Human chorionic gonadotropin is the basis for the positive pregnancy test and would be present in the urine. Eight weeks' gestation is too early for the presence of fetal movement. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulating through the placenta. This occurs later in the pregnancy.

The nurse is assessing a client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings would the nurse expect to note if abruptio placentae is present? Select all that apply.

Abdominal pain Firm uterus by palpation Rationale:Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis?

Abdominal tenderness and chills

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

Abnormal palmar creases

A pregnant client at 35 weeks' gestation is transferred to the maternity unit from the emergency department, after being treated for minor injuries sustained in a motor vehicle crash. The nurse's priority will be to assess for which complication?

Abruptio placentae Rationale:Trauma increases the incidence of miscarriage, preterm labor, abruptio placentae, and stillbirth. Careful evaluation of pregnant client and fetus after any incident of trauma is essential. Placenta previa indicates that a placenta is implanted in the lower uterine segment near or over the internal cervical os. Risk factors that may precipitate placenta previa are not related to a traumatic event. Polyhydramnios is a term for excessive amniotic fluid, which would develop over time and not be a result of trauma. Although a motor vehicle crash may increase a pregnant client's blood pressure, the client would not be a candidate for gestational hypertension only because of the traumatic event.

The nurse is teaching a new parent how to care for the newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and also notes that this is the client's first child. Which nursing actions are most appropriate in assisting the promotion of parent-infant interaction and bonding? Select all that apply.

Accepting the client's feelings Acknowledging the client's apprehension Assisting the client with giving the baths to allow the client to become more at ease

The nurse is providing education to a client with pregestational diabetes who is at 8 weeks' gestation and the client's partner. The nurse describes measures to take during a hypoglycemic episode. The client's partner asks the nurse how to respond if the client is hypoglycemic and becomes unconscious. The nurse would tell the client and partner that which is the most appropriate action?

Administer intramuscular glucagon. Rationale:Hypoglycemia is defined as a blood glucose level of less than 70 mg/dL (3.9 mmol/L). The signs and symptoms of hypoglycemia include irritability, nervousness, hunger, sweating, dizziness, headache, or blurred vision. If the client is unconscious, it is inappropriate to orally administer medications or food in an attempt to increase blood glucose as this places the client at risk for aspiration. Glucagon needs to be given intramuscularly to the hypoglycemic unconscious client. Therefore, option 1 is correct as options 2, 3, and 4 all involve giving the client food or medication by mouth.

Fetal distress is occurring with a client in labor. As the nurse prepares the client for a cesarean birth, what other intervention would the nurse implement?

Administer oxygen at 8 to 10 L/min via face mask. Rationale:Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The IV infusion would be increased, not decreased, so as to increase the maternal blood volume. The client's position needs to be lateral and with legs raised to increase maternal blood volume and improve the maternal vascular system.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask. Rationale:Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client needs to be turned onto the side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority?

Administer oxygen via resuscitation bag to the newborn infant.

The nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding, the nurse would prepare for which appropriate nursing action?

Administering oxygen via face mask Rationale:Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client needs to be turned on the side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise, the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Documenting and monitoring would delay necessary treatment.

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs would the nurse anticipate? Select all that apply.

Administration of subcutaneous heparin post-delivery as prescribed. An overbed lift may be necessary if the client requires a cesarean section. Thromboembolism stockings or sequential compression devices may be prescribed. Rationale:The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from an operating table to bed if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines which risk factors in the client's history places the client at risk for this complication? Select all that apply.

Age 45 years Body mass index of 28 Previous difficulty with fertility Rationale:Risk factors that increase a woman's risk for dystocia include the following: advanced age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 45 years is considered advanced age, and a body mass index of 28 is considered overweight. Previous difficulty with fertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal, and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed the client at risk for this complication? Select all that apply.

Age 54 Body mass index of 28 Previous difficulty with fertility Rationale:Risk factors that increase a client's risk for dysfunctional labor include the following: advanced age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 54 is considered advanced age, and a body mass index of 28 is considered overweight. Previous difficulty with infertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs.

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply.

Allows for fetal movement Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus Can be used to measure fetal kidney function Rationale:The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the birthing parent and the fetus.

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action would the nurse encourage the client to do to prevent thrombophlebitis?

Ambulate frequently.

The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?

An adolescent experiencing an emergency cesarean delivery for fetal distress

A contraction stress test is scheduled for a pregnant client who asks the nurse to describe the test. What would the nurse include in the teaching? Select all that apply.

An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation. Rationale:A contraction stress test assesses placental oxygenation and function, determines fetal ability to tolerate labor, determines fetal well-being, and is performed if the nonstress test is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the pregnant client, and a 20- to 30-minute baseline strip is recorded. The uterus is then stimulated to contract by the administration of a dilute dose of oxytocin or by having the pregnant client use nipple stimulation until three palpable contractions of 40 seconds or longer in a 10-minute period have occurred. Frequent maternal blood pressure readings are taken, and the client is monitored closely while increasing doses of oxytocin are given. Leopold's maneuvers help to determine fetal position and presentation. A treadmill is not used for a contraction stress test. Internal fetal monitoring is not possible until membranes have been ruptured.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats per minute

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats/minute

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock?

An increased pulse rate of 80 to 120 beats/min

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction would the nurse provide?

An informed consent needs to be signed before the procedure. Rationale:Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the primary health care provider's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction would the nurse provide?

An informed consent needs to be signed before the procedure. Rationale:Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the obstetrician's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.

The nurse is assisting the primary health care provider to perform Leopold's maneuvers on a pregnant client. Which action would the nurse perform before the procedure?

Ask the client to urinate. Rationale:An empty bladder contributes to a client's comfort during this examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonography (ultrasound). Often Leopold's maneuvers are performed to aid the examiner in locating the fetal heart tones.

The nurse is reviewing the medical record of a client scheduled for a weekly prenatal appointment. The nurse notes that the client has been diagnosed with mild preeclampsia. Which interventions would the nurse include in planning nursing care for this client? Select all that apply.

Assess blood pressure. Check the urine for protein. Assess deep tendon reflexes. Teach the importance of keeping track of a daily weight. Rationale:With mild cases of preeclampsia, the condition is monitored with self-care and bed rest at home. Before the need for hospitalization is discussed, the client would need to be assessed for progression of the disease process. The nurse must assess blood pressure, weight, and the presence of protein in the urine because an increase in these areas would indicate a worsening condition.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action would the nurse take?

Assess for hypovolemia and notify the primary health care provider (PHCP).

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client?

Assess for signs and symptoms of labor. Rationale:As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A nonstress test may be done, but not every 4 hours.

A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse about experiencing pain in the calf while walking. Which is the most appropriate nursing action?

Assess for signs of venous thrombosis. Rationale:If a client complains of calf pain during walking, it could be an indication of venous thrombosis of the lower extremities. The most appropriate nursing action is to check for the presence of additional signs of venous thrombosis. Ambulation is a necessary exercise, and the client needs to be encouraged to ambulate during pregnancy. Although it is important to elevate the legs during pregnancy, elevating the legs consistently is not the most appropriate nursing action. It is not appropriate to tell the client that this is normal during pregnancy.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate. Rationale:Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

Assess the baseline fetal heart rate. Rationale:Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

A type 1 diabetic birthing client delivered a 4400-gram newborn 3 hours ago. The client has already initiated breast/chest-feeding. What would the nurse plan to do to maintain euglycemia in this client?

Assess the blood glucose before administering any glucose-lowering medications.

The nurse assists the primary health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure?

Assess the fetal heart rate. Rationale:After amniotomy or rupture of the membranes in the birth setting, the nurse immediately assesses the fetal heart rate for at least 1 minute to detect changes associated with prolapse or compression of the umbilical cord. The quantity, color, and odor of the amniotic fluid also are noted. The client's temperature need to be assessed every 2 to 4 hours, and the nurse also would check the client's vital signs. The pads under the client need to be changed regularly to promote comfort and reduce the moist environment that favors bacterial growth, but this is not the priority.

After the spontaneous rupture of the membranes of a client in labor, the fetal heart rate drops to 85 beats/minute. Which would be the nurse's priority action?

Assess the vagina and cervix with a gloved hand. Rationale, Strategy, Tip Rationale:It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action would be to glove the examining hand and insert two fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the client to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression are the first interventions that need to be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, but not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL (238 mcmol/L). The nurse would plan to include which instruction in the teaching plan of care during the home visit to the parent of the newborn?

Assessing skin integrity and fluid status of the newborn

The postpartum unit nurse has provided information on performing a sitz bath to a postpartum client after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action?

Assist in healing and provide comfort.

The nurse is performing an assessment on a client who suspects being pregnant and is checking the client for probable signs of pregnancy. The nurse would assess for which probable signs of pregnancy? Select all that apply.

Ballottement Chadwick's sign Uterine enlargement Positive pregnancy test Rationale:The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response would the nurse make?

Between 16 and 20 weeks Rationale:Fetal movement, called quickening, is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements that gradually increase in intensity. Therefore, the remaining options are incorrect.

The nurse is caring for a client who is at 38 weeks' gestation with poorly controlled pregestational diabetes mellitus. The client is worried about birth complications and asks the nurse to explain macrosomia. How would the nurse define this condition?

Birth weight more than the 90th percentile Rationale:Pregestational diabetes mellitus increases the risk of various maternal and fetal complications, including macrosomia. Macrosomia is defined as either a birth weight of more than 4000 to 4500 grams or greater than the 90th percentile for birth weight. Eliminate options 1, 2, and 3 as these birth weight percentiles are not in the 90th percentile or greater. Therefore, option 4 is correct.

The nurse is caring for a postterm, small for gestational age (SGA) newborn infant immediately after admission to the nursery. What would the nurse monitor as the priority?

Blood glucose levels

Methylergonovine has been prescribed for a client who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside?

Blood pressure cuff

A client with chloasma is extremely stressed about the change in facial appearance. Which integumentary change observed by the nurse is consistent with this problem?

Blotchy brown macules across the cheeks and forehead Rationale:Chloasma is a condition caused by hormonal influences on melanin production and is characterized by blotchy brown macules across the cheeks and forehead. Options 1 and 2 refer to normal variations in skin color. Option 3 describes vitiligo.

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign?

Bluish discoloration of cervix and vagina Rationale:The cervix undergoes significant changes after conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Darkening of the areola occurs during pregnancy but is not related to Chadwick's sign. Softening of the uterine isthmus is known as Hegar's sign. The presence of the uterus (fundal height) just above the symphysis pubis dates the pregnancy to be about 13 weeks' gestation.

Which is considered a normal finding in a newborn less than 12 hours old?

Bluish discoloration of the hands and feet

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?

Breast/chest-feeding

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the primary health care provider to arrive. When the infant's head crowns, what instruction would the nurse give the client?

Breathe rapidly. Rationale:During a precipitous labor, when the infant's head crowns, the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the birthing parent and the fetus

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings would the nurse expect to note? Select all that apply.

Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age Rationale:Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings would the nurse expect to note? Select all that apply.

Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age Rationale:Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation, as the blood penetrates the myometrium and causes uterine irritability

The parent of a newborn calls the clinic and reports that when cleaning the umbilical cord, it was noted that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this parent?

Bring the infant to the clinic.

The parent of a newborn calls the clinic and reports that when cleaning the umbilical cord, the cord appeared moist and that discharge was present. What is the most appropriate nursing instruction for this parent?

Bring the infant to the clinic.

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food would the nurse instruct the client to eat to supplement the dietary source of calcium?

Broccoli Rationale:The best source of calcium is dairy products. Cheese is a dairy product but cannot be eaten when the client has lactose intolerance; therefore, women with lactose intolerance need other sources of calcium. Calcium is present in dark green leafy vegetables, broccoli, legumes, nuts, and dried fruits. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. In addition, creamed spinach may not be tolerated by a client with lactose intolerance. Orange juice does not contain significant amounts of calcium unless it has been fortified with calcium.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency?

Butorphanol tartrate Rationale:Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item would the nurse obtain?

Calcium gluconate injection Rationale:Toxic effects of magnesium sulfate may cause loss of deep tendon reflexes, heart block, respiratory paralysis, and cardiac arrest. The antidote for magnesium sulfate is calcium gluconate. An airway rather than a tongue blade is an appropriate item. A percussion hammer may be important to assess reflexes, but this item is not the highest priority. Potassium chloride is not related to the administration of magnesium sulfate.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention?

Complaints of severe abdominal pain Rationale:Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus indicates that the muscle is not contracting.

A pregnant gravida 1, para 0 client at 39 weeks' gestation arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that the client has had a positive group B streptococcus (GBS) laboratory report during the prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which would be the nurse's first action?

Call the primary health care provider (PHCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). Rationale:The client evidences progression toward delivery because the cervix is dilated 6 cm and the signs and symptoms of active labor are present. Because the client has had a positive GBS result during pregnancy, the neonate is at risk for becoming infected with GBS via vertical transmission during birth. GBS poses a significant risk for infant morbidity and mortality. To decrease this risk, it is recommended that IAP be administered during labor. Providing the client with instructions on pushing is not appropriate at a time when the client does not need to use this information; thus, this is not a priority. The client is not close to complete dilation; therefore, the PHCP is not required for delivery at this time.

A client calls the primary health care provider's office to schedule an appointment because the client has missed two menstrual cycles and has always been very regular. The client receives an appointment for the next day. The nurse would expect which findings to be present at this prenatal visit if the client is pregnant? Select all that apply.

Chadwick's sign Positive pregnancy test Rationale:Having missed two menstrual cycles with a normal history, the client is at approximately 8 weeks' gestation. Hormonal changes lead to vascular congestion in the cervix and vagina. The tissues have an appearance of looking "blue," and this change is identified by the term Chadwick's sign (hCG) is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for a positive pregnancy test. The pregnancy is not advanced enough to be able to determine a presentation. Fetal heart rate is not audible by fetoscope until approximately 20 weeks. the earliest a pregnant parent experiences fetal movement is approximately 14 weeks.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

The nurse is monitoring a postpartum client, who delivered 1 hour ago and received epidural anesthesia for delivery, for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

The nurse is providing education to a client with pregestational diabetes who is now at 14 weeks' gestation about measures to take during a hypoglycemic episode. The nurse would instruct the client to take which initial action?

Check the blood glucose level at the first sign of symptoms. Rationale:Hypoglycemia is defined as a blood glucose level of less than 70 mg/dL (3.9 mmol/L). If the client is experiencing signs and symptoms of hypoglycemia, such as irritability, nervousness, hunger, sweating, dizziness, headache, or blurred vision, the first action to take is to check the blood glucose level, which will guide subsequent action. If the blood glucose level is less than 70 mg/dL (3.9 mmol/L), the client would consume two to four glucose tablets or gel or a carbohydrate load of at least 8 to 16 grams immediately. Then, blood glucose needs to be rechecked 15 minutes later. If the blood glucose level is still less than 70 mg/dL (3.9 mmol/L), the same interventions need to be repeated by having the client consume an additional two to four glucose tablets or a carbohydrate load of at least 8 to 16 grams of carbohydrates. Blood glucose would then be rechecked again an additional 15 minutes later and if the blood glucose level is still below 70 mg/dL (3.9 mmol/L), the primary health care provider needs to be immediately contacted. While options 1, 2, and 4 may be appropriate interventions in managing a hypoglycemic episode, these are not the appropriate initial actions as the blood glucose level needs to first be measured. Therefore, option 3 is the correct answer.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse would take which first action?

Clear and maintain an open airway. Rationale:The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse would report which abnormal findings to the primary health care provider (PHCP)? Select all that apply.

Clear, dark amber amniotic fluid Light green amniotic fluid with no odor Thick white amniotic fluid with no odor Rationale:Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It would have a thin, watery consistency and may have a mild odor. The normal amount of amniotic fluid ranges from 500 to 1000 mL. Dark amber color, light green color, and thick white color are not descriptions of normal amniotic fluid and would be brought to the PHCP's attention.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron-deficiency anemia. The nurse would monitor the client to detect which manifestation indicating that this problem has not yet resolved?

Complaints of daily headaches and fatigue Rationale:Anemia is one of the most common problems in pregnancy, and iron-deficiency anemia and folic acid deficiency anemia are 2 of the most common types. It is estimated that between 20% and 60% of all pregnant clients are anemic at some point during pregnancy, with hemoglobin concentration lower than 10.0 to 11.0 g/dL (100 to 110 mmol/L). Complaints of daily headaches and fatigue are abnormal findings and may reflect complications caused by decreased oxygen supply to vital organs, thus supporting laboratory findings. The incorrect options are expected findings in the first trimester of pregnancy.

The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement, the client begins to feel light-headed. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the light-headedness?

Compression of the vena cava Rationale:Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the client turn onto the left side or elevating the left buttock during fundal height measurement will prevent or correct the problem. The remaining options are unrelated to this syndrome.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "Please, just let me die now!" Which client problem would be the priority for the client at this time?

Concern about the loss of the baby and personal health

The nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F (38.1° C) and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Contact the primary health care provider (PHCP).

The nurse suspects the presence of uterine atony and massages the uterus, but this action does not assist in controlling blood loss. Which is the next nursing action?

Contact the primary health care provider (PHCP).

The postpartum nurse is providing instructions to the parent of a newborn with hyperbilirubinemia who is being breast-fed. The nurse would provide which instruction to the parent?

Continue to breast-feed every 2 to 3 hours

The postpartum nurse is providing instructions to the parent of a newborn with hyperbilirubinemia who is being breast/chest-fed. The nurse would provide which instruction to the parent?

Continue to breast/chest-feed every 2 to 4 hours.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?

Continue to monitor the client. Rationale:The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.

The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?

Continue to monitor the client. Rationale:The data collected by the nurse are within normal limits and require no further action on the part of the nurse other than continued monitoring. The FHR is normally 110 to 160 beats/min. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. There are no data to indicate that delivery is imminent and no data to support contacting the anesthesiologist or PHCP.

The nurse is preparing to care for a client in labor. The primary health care provider (PHCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse would ensure that which is implemented before the beginning of the infusion?

Continuous electronic fetal monitoring Rationale:Continuous electronic fetal monitoring needs to be implemented during an IV infusion of oxytocin. There are no data in the question that indicate the need for antibiotics or complete bed rest. It is not necessary to place a code cart at the bedside of a client receiving an oxytocin infusion.

The nurse is preparing to care for a client in labor. The obstetrician has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion?

Continuous electronic fetal monitoring Rationale:Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring would be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.

A client arrives at the postpartum unit after delivery of an infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?

Cover the client with a warm blanket.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? Select all that apply.

Cyanosis Tachypnea Retractions Audible grunts

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention would the nurse prepare the client for?

Delivery of the fetus Rationale:The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Because delivery of the fetus is necessary, the remaining options are incorrect regarding management of the client with abruptio placentae.

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action?

Determine the fetal heart rate. Rationale:When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Taking the blood pressure and noting the characteristics of the amniotic fluid are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleaning, changing clothing, and providing peripads, but determining the fetal heart rate is the initial action.

During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement?

Diet and insulin needs change during pregnancy." Rationale:The diet for a pregnant client with diabetes mellitus is individualized to allow for increased fetal and metabolic requirements, with consideration of such factors as prepregnancy weight and dietary habits, overall health, ethnic background, lifestyle, stage of pregnancy, knowledge of nutrition, and insulin therapy. Dietary management during diabetic pregnancy must be based on blood, not urine, glucose changes. An increase of 600 calories a day is not required. Diet and insulin needs change during the pregnancy in direct correlation to hormonal changes and energy needs. In the second and third trimesters, insulin needs increase.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin. Rationale:The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse would reposition the laboring client. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin. Rationale:The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse would reposition the laboring client. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.

During a client's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What would be the nurse's next intervention?

Document findings in the electronic health record. Rationale:At 20 weeks' gestation, the fundus can be palpated at the umbilicus, the expected location. Because the assessment finding is normal, documentation of the finding would be the next step. Information will be shared with the PHCP, but since the finding is normal, there is no urgency to do this. A normal assessment finding does not need to be followed by an ultrasound or an extra prenatal visit.

The nurse determines the apical heart rate of a 2-day-old newborn to be 140 beats/minute. Which intervention is most appropriate related to this finding?

Document the finding in the electronic health record.

The nurse is caring for a term newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL (2 mmol/L). Based on this information, which nursing action would be implemented?

Document the finding in the electronic health record.

The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action would the nurse take?

Document the findings

The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action?

Document the findings and continue to monitor fetal patterns. Rationale:Early deceleration of the FHR refers to a gradual decrease in the heart rate followed by a return to baseline in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are unnecessary. Therefore, contacting the PHCP, changing the client's position, or administering oxygen is not necessary.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the client that the pattern on the monitor indicates fetal well-being. Rationale:Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.

The nurse checks the respirations of a newborn who was just delivered. The respiratory rate is 40 breaths/minute. Which intervention is most appropriate related to this finding?

Document the findings in the electronic health record.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate?

Document the findings.

The nurse is performing a physical assessment on a client during the first prenatal visit to the clinic. The nurse takes the client's temperature and notes that it is 37.3° C (99.2° F). Based on this finding, which nursing action is most appropriate?

Document the temperature. Rationale:The normal temperature during pregnancy is 36.6° C to 37.6° C (97.8° F to 99.6° F). A slight elevation may be noted because of the increased metabolic effect that occurs as a result of pregnancy. A temperature greater than normal may suggest an infection that could require medical management. The remaining options are unnecessary.

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that they frequently have leg cramps, primarily when reclining. The nurse would tell the client to implement which measure to alleviate the leg cramps?

Dorsiflex the feet until the spasms relax. Rationale:Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. For the pregnant client who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, heat on the affected area may be helpful if approved by the primary health care provider. The nurse would instruct the client to dorsiflex the feet until the spasm relaxes, or to stand and walk. The primary health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications.

A pregnant client calls the clinic and tells the nurse about experiencing leg cramps and is awakened by the cramps at night. Which activity would the nurse tell the client to perform when the cramps occur?

Dorsiflex the foot while extending the knee. Rationale:Leg cramps occur when the pregnant client stretches the leg and plantar flexes the foot. Dorsiflexing the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping. Therefore, the other activities are incorrect.

The nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food would the nurse encourage the client to consume because it is highest in folic acid?

Dried beans Rationale:Of the choices available, green leafy vegetables are highest in folic acid. Other sources of folic acid include whole grains, fruits, liver, dried peas, and dried beans. Chicken, rice, and cheese are not high in folic acid. Cheese is high in calcium, and rice and chicken are good sources of iron.

The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse would instruct the client to supplement the dietary source of calcium by eating which food?

Dried fruits Rationale:The best source of calcium is dairy products. Persons with lactose intolerance need other sources of calcium. Calcium is present in dark green leafy vegetables, broccoli, legumes, nuts, and dried fruits. Soft cheese is a dairy product and is not tolerated well by the client with lactose intolerance. Some hard cheeses are well aged and may be permissible on a lactose-free diet. Spinach contains calcium, but it also contains oxalates that decrease calcium availability. In addition, creamed spinach may not be tolerated by a client with lactose intolerance. Orange juice does not contain significant amounts of calcium unless fortified with calcium.

The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse would instruct the client to take which measure?

Drink 8 glasses of water per day. Rationale:The nurse would instruct the client to drink at least 8 to 10 (8-oz) glasses of fluid each day, of which 4 to 6 glasses are water, and to consume a diet that includes fiber to prevent constipation. The client would not use enemas or take stool softeners, laxatives, mineral oil, or other medications without first consulting with the primary health care provider or nurse-midwife.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that they are pregnant. Which statement, if made by the client, indicates a need for further instruction?

During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection." Rationale:To avoid infections, visitors with active infections would not be allowed to visit the client; otherwise, restrictions are not required. Resting needs to be done by lying on the side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased heart workload, and the client needs to be instructed to avoid stress.

A client who is 8 weeks' pregnant calls the prenatal clinic and tells nurse about experiencing nausea and vomiting every morning. The nurse would suggest which measure that will best promote relief of the signs and symptoms?

Eating dry crackers before arising Rationale:Some strategies for decreasing morning nausea are to keep crackers, Melba toast, or dry cereal at the bedside to eat before getting up in the morning; to eat smaller, more frequent meals; to decrease fat intake; and to consume adequate fluid between meals but not with meals. A high-carbohydrate diet could increase the episodes of nausea.

The nurse is reviewing the record of a newborn infant in the nursery and notes that the primary health care provider (PHCP) has documented the presence of a cephalohematoma. Based on this documentation, what would the nurse expect to note on assessment of the infant?

Edema resulting from bleeding below the periosteum of the cranium

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids, and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action?

Elevates the gastrostomy tube

The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed?

Elevation of the affected extremity

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations?

Encourage an upright or side-lying maternal position. Rationale:Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?

Encourage the client to take pain medication as prescribed.

The postpartum unit nurse is creating a plan of care for a first-time parent and identifies the need for measures that will promote parent-infant bonding. Which measure would the nurse include in the plan?

Encourage the parent to hold the infant when the infant cries.

The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action would the nurse plan to best facilitate bonding between the newborn and the parents?

Encourage the parents to touch their newborn.

A postpartum client is diagnosed with cystitis. The nurse would plan for which priority action in the care of the client?

Encouraging fluid intake

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action would the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections?

Establish a therapeutic relationship. Rationale:The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant client. It is planned, purposeful communication that focuses on specific content. The remaining options are incorrect and would not lend themselves to eliciting accurate information from the client.

A just-delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism?

Evaporation

A client in labor is dilated 10 cm. At this point in the labor process, at least how often would the nurse assess and document the fetal heart rate?

Every 15 minutes Rationale:The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often would the nurse plan to take the client's vital signs?

Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours

A postpartum unit nurse is caring for a stable client 12 hours after delivering a healthy newborn. At this time in the postpartum period, what is the recommended frequency for the nurse to assess the client's vital signs?

Every 4 hours

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura Rationale:Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and needs to be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which would be the nurse's initial action?

Explain to the client why a cesarean delivery is necessary. Rationale:Because neonatal infection of HSV is life-threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the client's perineum. An abdominal scrub will be necessary eventually for the cesarean delivery but would not be the nurse's initial action. Antiviral medications are used to control symptoms, not to eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV.

The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? Select all that apply.

Failure to thrive Coughing, wheezing, and short periods of apnea

The nurse is reviewing the home blood glucose log of a client at 30 weeks' gestation diagnosed with gestational diabetes mellitus. Which set of blood glucose values indicates that the client's gestational diabetes mellitus is controlled?

Fasting blood glucose 75 mg/dL (4.2 mmol/L), 1-hour post-meal blood glucose 130 mg/dL (7.2 mmol/L), 2-hour post-meal blood glucose 115 mg/dL (6.4 mmol/L) Rationale:Gestational diabetes mellitus occurs as a result of the pancreas being unable to produce sufficient insulin or because of an ineffective use of insulin as placental hormones, cortisol, and insulinase promote insulin resistance. The treatment aim of gestational diabetes mellitus involves strict blood glucose control. Recommended blood glucose levels are as follows: fasting blood glucose less than 95 mg/dL (5.3 mmol/L), 1-hour post-meal blood glucose less than 140 mg/dL (7.8 mmol/L), and 2-hour post-meal blood glucose less than 120 mg/dL (6.7 mmol/L). Eliminate option 2 as the 2-hour post-meal blood glucose level is greater than the recommended 120 mg/dL (6.7 mmol/L). Next, eliminate options 3 and 4 because both the fasting blood glucose and 2-hour post-meal glucose levels are elevated. Therefore, option 1 is correct.

The nurse is interpreting the 3-hour oral glucose tolerance test (OGTT) results of a client who is at 26 weeks' gestation. Which of the following plasma blood glucose levels indicate a diagnosis of gestational diabetes mellitus?

Fasting plasma glucose level 110 mg/dL (6.1 mmol/L), 1-hour plasma glucose level 200 mg/dL (11.1 mmol/L), 2-hour plasma glucose level 150 mg/dL (8.3 mmol/L), and 3-hour plasma glucose level 130 mg/dL (7.2 mmol/L) Rationale:Screening for gestational diabetes mellitus is recommended for low-risk women between 24 and 28 weeks' gestation. The 1-hour oral glucose tolerance test (OGTT) involves orally administering a 50-gram glucose load followed by a plasma glucose level that is drawn 1 hour later. The 1-hour OGTT screening is considered positive if the glucose value is equal to or greater than 140 mg/dL (7.8 mmol/L). A positive 1-hour OGTT is followed up with a two-step 3-hour OGTT in which a fasting blood glucose level is drawn, followed by oral administration of a 100-gram glucose load. Blood glucose levels are then drawn 1, 2, and 3 hours later. The 3-hour OGTT is considered positive if two or more of the plasma glucose levels are elevated. A positive fasting plasma glucose level is 105 mg/dL (5.8 mmol/L) or higher. A positive 1-hour plasma glucose level is 190 mg/dL (10.5 mmol/L) or higher. A positive 2-hour plasma glucose level is 165 mg/dL (9.2 mmol/L) or higher. A positive 3-hour plasma glucose level is 145 mg/dL (8.0 mmol/L) or higher. Options 2, 3, and 4 are negative three-hour OGTT results as these options do not have two or more elevated plasma glucose levels. Option 1 is considered a positive 3-hour OGTT as the fasting plasma glucose level is higher than 105 mg/dL (5.8 mmol/L) and the 1-hour plasma glucose level is higher than 190 mg/dL (10.5 mmol/L). Therefore, option 1 is correct.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes, and cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior?

Fear of losing control Rationale:Pain, helplessness, panic, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question.

A postpartum parent with mastitis in the right breast complains that the breast is too sore to feed. The nurse would tell the client to implement which measure?

Feed from the left breast and gently pump the right breast.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)?

Fetal heart rate of 180 beats per minute Rationale:A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000/mm3 (11 to 15 × 109/L) up to 18,000/mm3 (18 × 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000/mm3 (25 to 30 × 109/L) because of increased leukocytosis that occurs during delivery.

Fetal heart rate of 180 beats/minute Rationale:A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 mm3 (11 to 15 × 10 9/L), up to 18,000 mm3 (18 × 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 mm3 (25 to 30 × 109/L) because of increased leukocytosis that occurs during delivery.

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during the second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply.

Fetal heart rate of 180 beats/minute Elevated level of maternal serum alpha-fetoprotein (MSAFP) Rationale:The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160 to 170 beats/minute in the first trimester and slows with fetal growth. Near and at term, the fetal heart rate ranges from 110 to 160 beats/minute. An elevated MSAFP would be followed up with more specialized testing to determine whether a neural tube problem exists. The remaining options are normal expected findings.

Which assessment following an amniotomy would be conducted first?

Fetal heart rate pattern Rationale:Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy

Which assessment finding after an amniotomy needs to be conducted first?

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only two vessels. How would the nurse interpret this finding?

Finding two vessels may indicate an increased risk for other congenital anomalies.

The nurse working in a pediatric primary care clinic receives a call from a parent with a 10-day-old newborn who states that the COVID-19 test done 3 days ago is positive. The nurse determines that the parent is experiencing fever, fatigue, and shortness of breath. The nurse provides the parent with instructions on how to prevent infection transmission to the newborn and states that which criteria need to be met before transmission precautions can be safely discontinued? Select all that apply.

Five days have passed since symptom onset Fatigue and shortness of breath are improving No fever for at least 24 hours without taking fever-reducing medications

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which occurred?

Forceps delivery Rationale:Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.

The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How would the nurse interpret this finding?

Fundus is at the appropriate level.

Fundus is at the appropriate level. Rationale:At the previous routine visit at 20 weeks' gestation, the fundus was located at the umbilicus. For each subsequent week after 20 weeks, fundal height would increase by approximately 1 cm/week. At 24 weeks' gestation, the appropriate fundal height would be 24 cm plus or minus 2 cm. By 36 weeks' gestation, the fundus reaches its highest level at the xiphoid process.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse there is no history of any type of abortion or fetal demise. Using GTPAL, what would the nurse document in the client's chart?

G = 2, T = 1, P = 0, A = 0, L = 1 Rationale:Pregnancy outcomes can be described with the acronym GTPAL (included in gravida if before 20 weeks of gestation; included in parity if past 20 weeks of gestation); and L is the number of current living children. A person who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that there is no history of any type of abortion or fetal demise. Using GTPAL, what would the nurse document in the client's chart?

G = 2, T = 1, P = 0, A = 0, L = 1 Rationale:Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks of gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks of gestation; included in parity [number of births] if past 20 weeks of gestation); and L is the number of current living children. A person who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action?

Gently massage the uterine fundus.

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse would provide the client with which information?

Glucose crosses the placenta. Rationale:Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the pregnant client's demand for insulin and is referred to as the diabetogenic effect of pregnancy. Caloric requirements are not affected by diabetes.

A pregnant client seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information?

HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test. Rationale:Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the ELISA. HIV and herpes simplex virus are different types of infections. HIV infection occurs primarily through the exchange of body fluids, not via airborne disease. A neonate born to an HIV-positive pregnant parent is at risk for developing the virus, but it is not an absolute.

Which is considered a normal finding in a newborn less than 12 hours old?

Has not passed meconium yet

The nurse in the newborn nursery is obtaining admission vital signs for a newborn infant. The nurse documents that the vital signs are within normal range if which set of vital signs is noted on assessment?

Heart rate 130 beats/minute, respirations 46 breaths/minute

The nurse is reviewing the record of a client who has just been told that the pregnancy test is positive. The primary health care provider has documented the presence of first trimester pregnancy signs. Which signs would the nurse anticipate as being present during this time frame? Select all that apply.

Hegar's sign Goodell's sign Chadwick's sign Rationale:In the early weeks of pregnancy, the uterus and cervix undergo physical changes. The uterine isthmus softens (Hegar's sign); the cervix becomes softer as a result of pelvic vasoconstriction, causing Goodell's sign; and the cervix and vagina become vasocongested, which gives a blue appearance and is known as Chadwick's sign. Babinski's sign is related to neurological integrity. Ortolani's sign is related to the presence of hip dysplasia.

A pregnant client tells the nurse about craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from the backyard. Laboratory studies are performed, and the nurse determines that which finding indicates a physiological consequence of the client's practice?

Hemoglobin 9 g/dL (90 mmol/L) Rationale:Pica practices often lead to iron-deficiency anemia, resulting in a decreased hemoglobin level. The laboratory values in options 1, 2, and 4 are normal for the pregnant client.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse would prepare to monitor the client for which risk that is associated with placenta previa?

Hemorrhage

An infant is born to a postpartum client with hepatitis B. The nurse plans for which prophylactic measure for the infant?

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply.

History of Chlamydia Use of fertility medications Use of an intrauterine device History of pelvic inflammatory disease (PID) Rationale:An ectopic pregnancy is one that establishes itself somewhere other than inside the uterus. Multiple factors may predispose a woman to an ectopic pregnancy. Fertility medications, history of sexually transmitted infections, intrauterine devices, and PID have all been associated with ectopic pregnancy. There are no data to support any additional risk for ectopic pregnancy with the use of the diaphragm.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion?

History of syphilis Rationale:Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is no evidence that genital herpes is a causative agent in abortion, although the presence of active lesions at the time of birth presents concerns. Maternal age greater than 40 years and diabetes mellitus are considered high-risk factors in a pregnancy but are related to an increased risk of congenital malformations, not abortions.

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia?

Hypertension Rationale:A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions.

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4400 g. The nurse determines that this infant may be at risk for which complications? Select all that apply.

Hypoglycemia Fractured clavicle Congenital heart defect

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia would the nurse document that the client is experiencing?

Hypotonic Rationale:Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation.

A client in the first trimester of pregnancy arrives at a health care clinic and reports experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?

I will maintain strict bed rest throughout the remainder of the pregnancy. Rationale:Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client would watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the primary health care provider.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F (37.8° C). What is the priority nursing action?

Increase hydration by encouraging oral fluids.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply.

Increase in fundal height Hard, board-like abdomen Persistent abdominal pain Rationale:The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; a hard, board-like abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding.

The nurse is describing cardiovascular system changes that occur during pregnancy to a client. Which findings are normal for a client in the second trimester? Select all that apply.

Increase in pulse rate Increase in red blood cell production Rationale:Numerous cardiovascular adaptations occur during pregnancy. Between 14 and 20 weeks' gestation, the pulse rate increases about 10 to 15 beats/minute, which then persists to term. During pregnancy, there is an accelerated production of red blood cells. During the second trimester, systolic and diastolic pressures decrease by about 5 to 10 mm Hg until 24 to 32 weeks. The blood pressure by term usually is no higher than the prepregnancy level. Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus.

The nurse is providing instructions to the parent of a breast-fed/chest-fed newborn who has hyperbilirubinemia. Which instruction would the nurse provide to the parent?

Increase the frequency of the breast-feeding/chest-feeding.

A client arrives at a birthing center in active labor. Following examination, it is determined that the client membranes are still intact and the client is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

Increased efficiency of contractions The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord Rationale:Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

A client arrives at a birthing center in active labor. After examination, it is determined that the client's membranes are still intact and the client is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

Increased efficiency of contractions The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord Rationale:Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of blood pressure is unnecessary after this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment?

Increased insulin Rationale:Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy, can result in elevation of maternal blood glucose levels. This increases the pregnant parent's demand for insulin. This is referred to as the diabetogenic effect of pregnancy. Caloric intake and protein intake are not affected by diabetes.

A newborn infant of a postnatal client who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results?

Indicates the presence of infection in the birthing parent

A pregnant client is seen for a regular prenatal visit and tells the nurse about experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

Inform the client that these contractions are common and may occur throughout the pregnancy. Rationale:Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant individuals during pregnancy, there is no reason to notify the primary health care provider. This client is not in preterm labor; therefore, the client does not need to be placed on bed rest or be admitted to the hospital to be monitored.

The primary health care provider (PHCP) is assessing the client for the presence of ballottement. To make this determination, the PHCP would take which action?

Initiate a gentle upward tap on the cervix Rationale:Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger. Auscultating for fetal heart sounds and palpating the abdomen for fetal movement are a part of fetal assessment. Assessing the cervix for compressibility is determining the presence of Hegar's sign.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed.

The nurse reviews the plan of care for a client at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority?

Insufficient fluid volume Rationale:In a client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant client and for the fetus, such as an interruption of blood flow to the placenta. Although the remaining options may also be appropriate problems for the client with sickle cell anemia, they are not the priority.

The nurse is caring for a client with a history of diabetes mellitus who is in the first trimester of pregnancy. The client's current medication regimen includes insulin. Keeping in mind the effects of pregnancy on glucose regulation, the nurse would expect which adjustment to the client's medication regimen?

Insulin dosing may need to be reduced during the first trimester of pregnancy. Rationale:Pregnancy results in a diabetogenic state, requiring medication adjustments for clients with pregestational diabetes. During the first trimester, blood glucose levels are usually reduced, and those with well-controlled diabetes may require a reduction in their current insulin dosing. However, insulin resistance is more common beginning after the 14th week of gestation, and insulin requirements may be higher. Eliminate option 2 because insulin resistance peaks in the second and third trimesters and the insulin dose may need to be increased, not decreased. Eliminate option 3 because glucose levels in the first trimester are usually reduced and increasing the insulin dose would be unsafe for the client. Lastly, eliminate option 4 because pregnancy does have an effect on blood glucose levels. Therefore, since the client is in the first trimester of pregnancy in which blood glucose levels are normally reduced, option 1 is the correct answer; insulin dosing may need to be reduced to prevent hypoglycemia.

A pregnant client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions and provides the client with which information?

Irregular contractions are common and may occur throughout the pregnancy. Rationale:Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some pregnant clients during pregnancy, the other options are unnecessary and inaccurate.

The nurse is monitoring a newborn born to a client who abuses alcohol. Which finding would the nurse expect to note when assessing this newborn?

Irritability

The nurse is assessing a newborn who was born to a birthing parent who is addicted to drugs. Which findings would the nurse expect to note during the assessment of this newborn? Select all that apply.

Irritability Constant crying Difficult to comfort

The nurse is assessing a newborn who was born to a postpartum client who is addicted to drugs. Which findings would the nurse expect to note during the assessment of this newborn? Select all that apply.

Irritability Constant crying Difficult to comfort

A new parent reports that a sibling's child was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's parent asks the nurse if the newborn also has this diagnosis. Which findings would the nurse identify as potential indicators of GER? Select all that apply.

Irritability Failure to thrive Choking with feeding Spitting up and regurgitation

A pregnant client reports to a health care clinic, complaining of loss of appetite, cough, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction would the nurse include in the client's teaching plan?

Isoniazid plus rifampin will be required for 9 months. More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction would the nurse include in the client's teaching plan?

Isoniazid plus rifampin will be required for 9 months. Rationale:More than one medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses would the nurse give the client about the role of estrogen? Select all that apply.

It increases the blood flow to mucous membranes and causes them to swell and soften. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Rationale:Estrogen is a very important hormone of pregnancy. It is responsible for vasocongestion of the mucous membranes. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat; it is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

Which purposes of placental functioning would the nurse plan to include in a prenatal class? Select all that apply.

It is the way the baby gets food and oxygen. It provides an exchange of nutrients and waste products between the birthing parent and developing fetus. Rationale:The placenta provides an exchange of oxygen, nutrients, and waste products between the birthing parent and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

Which purposes of placental functioning would the nurse include in a prenatal class? Select all that apply.

It is the way the baby gets food and oxygen. It provides an exchange of nutrients and waste products between the parent and developing fetus. Rationale:The placenta provides an exchange of oxygen, nutrients, and waste products between the parent and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

A client arrives at the clinic for the first prenatal assessment. The client tells the nurse that the first day of the last normal menstrual period was October 19, 2023. Using Naegele's rule, which expected date of delivery would the nurse document in the client's chart?

July 26, 2024 Rationale:Accurate use of Naegele's rule requires that the client have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2023; subtract 3 months, July 19, 2023; add 7 days, July 26, 2023; add 1 year, July 26, 2024.

A client arrives at the clinic for the first prenatal assessment. The client tells the nurse that the first day of the last normal menstrual period was October 19, 2023. Using Näegele's rule, which expected date of delivery would the nurse plan to document in the client's chart?

July 26, 2024 Rationale:Accurate use of Näegele's rule requires that the pregnant individual have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date if necessary: first day of the last menstrual period, October 19, 2023; subtract 3 months, July 19, 2023; add 7 days, July 26, 2023; add 1 year, July 26, 2024.

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions would be included in the care plan for this client? Select all that apply.

Keep the room semi-dark. Initiate seizure precautions. Pad the side rails of the bed. Avoid environmental stimulation. Rationale:Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. In addition, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the client's central nervous system and causing a seizure.

The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid?

Kidney beans Rationale:Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, and beans such as kidney beans. Pork, cheese, and chicken are not high in folic acid. Pork is a good source of thiamine. Cheese is a dairy product and is high in calcium. Chicken is a good source of protein.

The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states will include which item in the daily diet?

Leafy green vegetables Rationale:Leafy green vegetables are rich in folate (folic acid). Milk and yogurt supply calcium; bananas provide potassium.

The nurse is performing an initial assessment on a newborn. On assessment, which finding could be indicative of a congenital defect?

Low-set ears

The nurse is planning care for a newborn of a client with diabetes mellitus. What is the priority nursing consideration for this newborn?

Maintaining safety because of low blood glucose levels

The nurse is planning care for the newborn of a birthing parent with diabetes mellitus. What is the priority nursing consideration for this newborn?

Maintaining safety because of low blood glucose levels

The nurse creates a plan of care for a birthing parent with human immunodeficiency virus (HIV) infection and the newborn. The nurse would include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

The nurse creates a plan of care for a client with human immunodeficiency virus (HIV) infection and the client's newborn. The nurse would include which intervention in the plan of care?

Maintaining standard precautions at all times while caring for the newborn

The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse would perform which action?

Make a loud, abrupt noise to startle the newborn.

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information would the nurse include in the teaching plan to prevent the development of mastitis?

Massage distended areas as the infant nurses.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse would take which initial action?

Massage the fundus

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse would take which initial action?

Massage the fundus until it is firm.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Massage the fundus until it is firm.

The nurse is conducting a prepared childbirth class and is instructing pregnant clients about the method of effleurage. The nurse instructs the clients to perform the procedure by doing which action?

Massaging the abdomen during contractions, using both hands in a circular motion Rationale:Effleurage is massage of the abdomen during contractions. Clients learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Touch relaxation helps the client to learn to loosen taut muscles when touched by the partner. Neuromuscular disassociation helps the client to relax the body even when one group of muscles is strongly contracted. In this procedure, the client contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body.

The nurse is assessing the fundus in a postpartum client and notes that the uterus is soft and spongy and not firmly contracted. The nurse would prepare to implement which interventions? Select all that apply.

Massaging the uterus Assisting the client to urinate Rechecking the uterus in 1 hour5Checking for a distended bladder

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia?

Maternal infection Rationale:The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to approximately 110 to 160 beats/minute near or at term. Near or at term, if the fetal heart rate is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. A fetal heart rate of 180 beats/minute indicates tachycardia and could indicate intrauterine infection and fetal distress. Gestational hypertension, gestational diabetes, and consuming a high-sugar diet may affect the fetal heart rate but are not the most likely causes.

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client?

Measure fundal height Rationale:Measuring fundal height is least appropriate because it would be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses need to be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the primary health care provider. A cesarean section may be necessary if a fetus is breech. The nurse would examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.

The goal for a client with partial premature separation of the placenta is: "The client will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved?

Moderate variability present Rationale:Reassuring signs in the fetal heart tracing include an FHR of 110 to 160 beats/minute, accelerations of the FHR, no variable decelerations, and the presence of moderate variability. The moderate variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations indicate cord compression.

The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents?

Monitor for appropriate weight gain patterns. Rationale:The nurse would teach the adolescents about appropriate weight patterns and how to monitor these patterns. The adolescent is more likely to follow suggestions and adhere to the appropriate dietary patterns if the nurse explains why the weight gain is important for the fetus and the pregnant parent. Advising an adolescent to eat only when hungry could lead to a deficit in nutrients. Telling an adolescent to avoid fast-food restaurants and eliminate snacks may cause the adolescent to rebel.

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit?

Monitor for fetal movement. Rationale:A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant parent also is asked to keep a record of fetal movements. A maternal blood glucose would not provide specific data related to preeclampsia. Bed rest with bathroom privileges is prescribed; complete bed rest is unnecessary. Urine would be checked for protein. Sodium restriction is unnecessary.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions would be included in the plan of care? Select all that apply.

Monitor skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with eye shields or patches.

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse would include which priority intervention in the plan of care?

Monitor the newborn's response to feedings and weight gain pattern.

The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

Monitoring fetal status Rationale:The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority?

Monitoring the apical pulse Rationale:Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Edema and weight gain are more of a concern for the client with preeclampsia or gestational hypertension, and an elevated temperature is an indicator of infection.

The labor room nurse assists with the administration of a lumbar epidural block. How would the nurse check for the major side effect associated with this type of regional anesthesia?

Monitoring the client's blood pressure Rationale:A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 5 minutes during the first 15 minutes and then at 30 minutes and 1 hour. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate Rationale:Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

Which is the priority nursing action for the client with an ectopic pregnancy?

Monitoring the pulse and blood pressure Rationale:Nursing care for a client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate and a drop in blood pressure are indicators of shock. Proteinuria may be associated with preeclampsia, and an elevation in temperature is an indicator of infection. Electrolyte values are unrelated to ectopic pregnancy.

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. The client's blood pressure during the past 3 weeks has been averaging 130/90 mm Hg and the client has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the client would alert the nurse to the worsening of gestational hypertension?

My vision for the past 2 days has been really fuzzy." Rationale:Visual disturbances such as blurred vision, double vision, or spots before the eyes indicate arterial spasms and edema in the retina and may be a warning sign of worsening gestational hypertension. Resolution of swelling is not an indicator of preeclampsia. Heartburn is a common discomfort of pregnancy, especially with intake of spicy foods. A continuous headache indicates poor cerebral perfusion; having just one headache that is relieved with medication is not an indicator of preeclampsia.

The nurse is providing education to a client who is pregnant and has gestational diabetes about the signs and symptoms of hyperglycemia. The nurse determines that the client understands the teaching if the client identifies which clinical manifestations as signs or symptoms of hyperglycemia?

Nausea Vomiting Abdominal pain Excessive thirst Fruity breath odor Rationale:Hyperglycemia is an elevated blood glucose level. Signs and symptoms include nausea and vomiting, excessive thirst and dry mouth, weakness, abdominal pain, and a fruity breath odor. Diarrhea is not a manifestation; constipation is more likely to occur

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the parent asks the nurse why the infant needs the injection. What best response would the nurse provide?

Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How would the nurse document this finding in the client's medical record? Refer to figure.

Normal Rationale:A reactive nonstress test is a normal result. To be considered reactive, the baseline fetal heart rate must be within normal range (120 to 160 beats/minute) with good long-term variability. In addition, two or more fetal heart rate accelerations of at least 15 beats/minute must occur, each with a duration of at least 15 seconds, in a 20-minute interval.

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the primary health care provider has documented the test results as reactive. How would the nurse interpret this result?

Normal findings Rationale:A reactive nonstress test is a normal result. To be considered reactive, the baseline must be within normal range (110 to 160 beats/minute with good variability), and there must be 2 or more fetal heart rate accelerations of at least 15 beats/minute, each with a duration of at least 15 seconds, in a 20-minute interval. Therefore, the other options are incorrect.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the obstetrician (OB).

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats per minute. On the basis of this finding, what is the priority nursing action?

Notify the obstetrician (OB). Rationale:The FHR depends on gestational age and ranges from 160 to 170 beats per minute in the first trimester but slows with fetal growth to 110 to 160 beats per minute. If the FHR is less than 110 beats per minute or more than 160 beats per minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse would notify the OB. Options 3 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the OB needs to be notified.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate?

Notify the pediatrician

The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be appropriate?

Notify the primary health care provider (PHCP).

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the primary health care provider (PHCP).

Notify the primary health care provider (PHCP). Rationale:A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

Notify the primary health care provider (PHCP). Rationale:A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate needs to be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 1, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 184 beats/minute. On the basis of this finding, what is the priority nursing action?

Notify the primary health care provider (PHCP). Rationale:The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse would notify the PHCP. Options 2 and 3 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the PHCP needs to be notified.

A client in the second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate?

Notify the primary health care provider (PHCP). Rationale:The fetal heart rate should be 110 to 160 beats/minute during pregnancy. A fetal heart rate of 90 beats/minute (bradycardia) requires that the PHCP be notified and the client be evaluated further. The other options are inappropriate and delay necessary intervention.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and would question which prescription?

Obtain equipment for a manual pelvic examination. Rationale:Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, which is at risk for severe hypoxia.

A client in active labor has requested a regional anesthetic. The client is currently 5 cm dilated. The primary health care provider has prescribed an epidural block. Which nursing intervention would be implemented after the epidural block has been placed?

Palpate the bladder at frequent intervals. Rationale:The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The client loses the sensation of the need to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Ambulation is not allowed because of the anesthesia. The client is encouraged to lie on the side to increase placental perfusion to the fetus. Hypotension, not hypertension, is a concern.

The nurse is providing instructions about taking iron supplements to a pregnant client. The nurse determines that the client understands the instructions if the client states that they will take the supplements with which drink?

Orange juice Rationale:Foods containing ascorbic acid will increase the absorption of iron. Calcium and phosphorus in milk and tannin in tea decrease iron absorption. Caffeine in coffee binds iron and prevents it from being fully absorbed. Orange juice is the only item that contains ascorbic acid and will increase the absorption of iron supplements.

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply.

Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high. The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy." Rationale:Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high, inhibiting the release of follicle-stimulating and luteinizing hormones, which are necessary for ovulation. All other options are incorrect.

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100 beats per minute, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. What would be the immediate nursing intervention for this newborn?

Oxygen supplementation and suctioning

The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the primary health care provider's prescriptions and would expect to note which prescribed treatment for this condition?

Oxytocin infusion Rationale:Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. The remaining options identify therapeutic measures for a client with hypertonic dysfunction.

A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding would the nurse expect to note when assessing this client?

Pain, itching, and vaginal discharge Rationale:Clinical manifestations of a vaginal Candida infection include pain; itching; and a thick, white vaginal discharge. Costovertebral angle pain, proteinuria, hematuria, edema, and hypertension are clinical manifestations that may be associated with a urinary tract infection.

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted?

Painless vaginal bleeding Rationale:The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Painful vaginal bleeding, abdominal pain, and back pain identify signs and symptoms of abruptio placentae.

The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data, knowing that which are characteristic of placenta previa? Select all that apply.

Painless, bright red vaginal bleeding Location in the lower uterine segment Rationale:Placenta previa is a condition in which the placenta is located in the lower uterine segment. It does not cause pain but does cause bright red vaginal bleeding. This occurs because the placenta is overriding the cervical os, and as the cervix dilates the placental vessels bleed. Abruptio placentae is painful and results in a rigid and tender uterus. Greenish discoloration of the amniotic fluid occurs as a result of meconium staining.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal?

Pale straw in color, with flecks of vernix Rationale:Amniotic fluid normally is pale straw in color and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid would not be thick and white; this could be an indication of infection.

An initial assessment of a large for gestational age (LGA) newborn infant is being done. Which physical assessment technique would the nurse assist in performing to assess for evidence of birth trauma?

Palpate the clavicles for a fracture.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action would the nurse take to determine fetal heart sounds accurately?

Palpating the maternal radial pulse while listening to the FHR Rationale:The nurse would simultaneously palpate the maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/minute or placing the diaphragm of the Doppler on the client's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuvers may help the examiner to locate the position of the fetus but will not ensure a distinction between the two heart rates.

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action?

Palpating the uterine fundus

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The nurse instructs the client to use the call button for assistance whenever the client needs to get out of bed or wishes to care for the infant. Which postpartum complication is the nurse most concerned about for this client?

Parental overexertion

The nurse is preparing to teach a new parent how to sponge bathe a 1-day-old newborn. Which actions would the nurse take? Select all that apply.

Pat the baby dry gently. Support the newborn's body during the bath. Make sure that the room is warm and free of drafts. Cleanse one body area at a time, keeping other body areas covered.

Which additional daily dietary intake will most closely match the number of additional calories needed by the breast/chest-feeding parent?

Peanut butter and jelly sandwich and glass of 2% milk

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription would the nurse question?

Perform a vaginal examination every shift Rationale:Vaginal examinations would not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

Perform a vaginal examination every shift. Rationale:Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor the client's vital signs, and administer an antibiotic.

The nurse is teaching the parent of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant?

Periodic well-baby examinations

On assessment of the fetal heart rate (FHR) of a laboring client, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations?

Periodic, early decelerations that indicate fetal head compression Rationale:An early deceleration is described as a visually apparent gradual decrease of the FHR with a gradual return to the FHR baseline. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described; therefore, eliminate option 3. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4.

The nurse in a birthing room is monitoring a client with dystocia for signs of clinical compromise. Which assessment finding would alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate Rationale:Signs of clinical compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Fatigue and infection can occur if the labor is prolonged but do not indicate clinical compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate Rationale:Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor.

The maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply.

Petechiae Hematuria Prolonged clotting times Oozing from injection sites Rationale:DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process. Coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. The presence of petechiae, hematuria, and oozing from injection sites are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

Which oral medication, if present in the client's history, indicates a need for teaching related to the client's potential risk for carrying a fetus with a congenital cleft lip or cleft palate?

Phenytoin Rationale:An antiseizure medication (specifically phenytoin) taken during pregnancy is a known risk factor in the development of cleft lip and cleft palate. Folic acid use is recommended during pregnancy to reduce the risk of cleft lip and palate. The use of an antidepressant (bupropion) has not been found to increase a client's risk of developing a fetus with cleft lip or palate. Although bupropion can be used for smoking cessation, and smoking can contribute to the development of cleft lip, taking bupropion does not increase a client's risk of having a fetus affected by cleft lip or palate. Methyldopa may be used during pregnancy for maintenance in those with chronic hypertension

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old newborn newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply.

Phototherapy lights Intravenous (IV) pump

Which medication would the nurse plan to administer to a newborn by the intramuscular (IM) route?

Phytonadione (vitamin K)

To prevent heat loss by conduction during physical examination of a newborn infant, which action would the nurse implement?

Place a warm blanket on the examining table before placing the newborn on the table.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

Place the client in Trendelenburg's position. Rationale:When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client would be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse would push the call light to summon help, and other staff members need to call the PHCP and notify the delivery room. If the cord is protruding from the vagina, no attempt would be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the client to increase fetal oxygenation.

The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse would take which action?

Place the fetal heart monitor on the client in order to do a nonstress test (NST). Rationale:The BPP includes five components, one of which is an NST. Each of these components allows the practitioners to assess whether the central nervous system is fully functional and whether the fetus is hypoxemic. Four components are included in the ultrasound portion of the profile in addition to an NST: fetal breathing movements, fetal movements, fetal tone, and amniotic fluid index. Each of the five components is given a score of either 2 or 0. Zero indicates an abnormal result, and a 2 indicates a normal result. After the ultrasound components, the client's BPP is 8 out of 8 possible points. This indicates fetal well-being, but there is a need to complete the BPP by obtaining an NST. Notifying the PHCP can be eliminated because the BPP result thus far is normal. Labor induction can be eliminated because the client's gestational age is not term and the BPP reveals no abnormalities or the need for induction. To complete a BPP, an NST must be done; therefore, it is inappropriate to send the client home at this point in care, so eliminate option 4.

The nurse in a newborn nursery is performing an assessment of an infant. What procedure would the nurse use to measure the infant's head circumference?

Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen. The nurse documents these observations as signs of which condition?

Placental separation Rationale:As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes a spurt of blood from the vagina. The nurse would document this observation as a sign of which condition?

The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the client has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes? Select all that apply.

Places the client at risk for dystocia Has an increased probability of cesarean section Has a flat shape that may impede fetal descent Rationale:A platypelloid pelvis has a flat shape that may impede fetal descent, making vaginal delivery more difficult. Because of the constricted shape of this pelvis, rapid delivery will not occur, and a cesarean section may be necessary. A gynecoid pelvis is roomy and ideal for vaginal birth. An anthropoid pelvis has an oval shape, and an android pelvis is heart shaped.

The nurse is counseling a pregnant client diagnosed with gestational diabetes at 29 weeks' gestation. Which information would the nurse discuss with the client? Select all that apply.

Plan for weekly nonstress tests at 32 weeks. Rationale:Gestational diabetes can result in delayed lung maturity and complications, and carrying the baby until full term is the goal. The nurse would discuss nonstress testing procedures, the plan for nutritional counseling, and the plan for delivery. Amniocentesis is not indicated at this time. Biophysical profile is done at 32 to 36 weeks' gestation.

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What would the nurse observe for following the client's labor?

Postpartum infection

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of a newborn. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation?

Pregnancy for 1 to 3 months after the vaccination

The clinic nurse is instructing a first-trimester pregnant client about nutrition. The nurse would determine that the client needs further teaching if the client believes that which is true about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the pregnant client. Rationale:Although pregnancy poses some nutritional risk for the pregnant client, the client is not at risk of becoming malnourished. Intake of dietary iron is usually insufficient for most pregnant clients, and iron supplements are routinely encouraged. Calcium is critical during the third trimester but must be increased from the onset of pregnancy. Good nutrition during pregnancy significantly and positively influences fetal growth and development.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.

Pregnancy needs to be avoided for 1 to 3 months. The vaccine is administered by the subcutaneous route. Exposure to immunosuppressed individuals needs to be avoided. A hypersensitivity reaction can occur if the client has an allergy to eggs.

The nurse is assessing a client who is 12 weeks pregnant when the client expresses worry about contracting COVID-19. The client asks the nurse about adverse outcomes related to COVID-19 during pregnancy. How would the nurse respond?

Pregnant people are more likely to become severely ill if infected with COVID-19. Rationale:COVID-19 infection during pregnancy is associated with several adverse outcomes. Pregnant people are more likely to develop severe illness from COVID-19 compared with nonpregnant people. Also, COVID-19 infection during pregnancy is associated with an increased risk of maternal and fetal adverse outcomes, such as preterm birth, gestational diabetes, preeclampsia, and low birth weight. Eliminate option 1 because pregnancy increases the risk of severe illness from COVID-19. Next, eliminate options 3 and 4 because COVID-19 is associated with an increased risk of adverse maternal and fetal outcomes. Therefore, option 2 is correct because COVID-19 infection during pregnancy is associated with an increased risk of severe illness.

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse would include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area.

The nurse in the labor room is performing an initial assessment on a newborn. The infant is exhibiting mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply.

Prepare for endotracheal tube (ET) placement. Notify the primary health care provider (PHCP). Insert an orogastric tube and connect it to low suction.

A pregnant client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum the client's systolic blood pressure has dropped 20 points, the diastolic blood pressure has dropped 10 points, and the client's pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the primary health care provider (PHCP), what is the nurse's next action?

Prepare the client for surgery.

The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant?

Presence of a cephalhematoma

The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor would the nurse ask the client about to determine this risk?

Presence of cats in the home Rationale:Toxoplasmosis is a systemic (and usually asymptomatic) illness caused by a protozoan parasite. Approximately one third of all women in the United States have positive antibody titers for toxoplasmosis, thus confirming prior exposure. Humans acquire the infection by consuming inadequately cooked meat, eggs, or milk; by ingesting or inhaling the oocyst stage excreted in feline feces or contaminated soil; or by receiving contaminated blood products. Other than transplacental infection, this disease is rarely transmitted from human to human. During pregnancy, the parasite may be transmitted across the placenta and cause severe infection in the developing embryo or fetus. The other options are questions unrelated to toxoplasmosis.

The clinic nurse is teaching a pregnant client about the warning signs in pregnancy. Which, if identified as a warning sign by the client, would indicate a need for further education?

Presence of irregular, painless contractions Rationale:Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout pregnancy. Rapid weight gain, visual disturbances, and generalized or facial edema are warning signs in pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection.

Which are considered normal findings in a newborn less than 12 hours old? Select all that apply.

Presence of vernix caseosa Anterior fontanel measuring 5 cm Bluish discoloration of hands and feet

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome?

Prevent dehydration and hypoxemia. Rationale:A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration.

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn, and the parent asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a parent with an untreated gonococcal infection

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn, and the birthing parent asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a parent with an untreated gonococcal infection.

The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider (PHCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care would include which nursing interventions? Select all that apply.

Protect defect from trauma. Maintain a thermoneutral environment. Assess for associated birth defects such as cleft palate.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.

Proteinuria Hypertension Rationale:The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.

A postpartum client is attempting to breast/chest-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action would the nurse take to assist the client in breast/chest-feeding the newborn infant?

Provide breasts/chest shells and assist the client with using a breasts/chest pump before each feeding to make the nipples easier for the newborn infant to grasp.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures. Rationale:Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention?

Provide pain relief measures. Rationale:Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes amniotomy and oxytocin augmentation to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

The nurse assists a pregnant client with cardiac disease to identify resources to help care for the client's 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources for which primary reason?

Reduce excessive maternal stress and fatigue Rationale:A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The use of resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. These resources are not intended to minimize the potential risk of maternal infection or to prepare the client and family for the subsequent labor, delivery, and hospitalization.

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse would include which nursing intervention in the plan?

Reduce external stimuli. Rationale:The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure need to be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the primary health care provider. Blood glucose is not monitored unless another condition necessitates it. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs.

The nurse is assessing a client who is at 28 weeks' gestation and is complaining of pelvic pain. The client is diagnosed with symphysis pubis dysfunction. The nurse explains that this condition occurs in response to hormones inducing joint instability and widening in the pelvis to accommodate childbirth. The nurse would explain to the client that which hormones increase joint laxity? Select all that apply.

Relaxin Progesterone Rationale:Symphysis pubis dysfunction is a painful condition that occurs due to separation of the symphysis pubis and instability of the sacroiliac joints. The hormones relaxin and progesterone cause loosening and separation of the symphysis pubis and sacroiliac joints to facilitate childbirth. Therefore, options 1 and 5 are correct. Options 2, 3, and 4 do not play a role in joint laxity in pregnancy.

Which instructions would the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply.

Report a foul-smelling discharge. Take a warm sitz bath Use warm water to rinse the perineum after elimination. Wipe the perineum from front to back after voiding and defecation.

The nurse is reviewing the laboratory results for a client with pre-eclampsia who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse would expect to note which in the client?

Respiratory depression Rationale:The normal magnesium level is 1.8-2.6 mEq/L (0.74-1.07 mmol/L). Neurological depression occurs in hypermagnesemia and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse?

Respiratory rate of 10 breaths/minute Rationale:Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the health care provider needs to be notified and continuation of the medication needs to be reassessed. A urinary output of 20 mL in a 30-minute period is adequate; less than 30 mL in 1 hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is within normal limits for a resting fetus.

The nurse has been working with a laboring client and notes that the client has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions Rationale:The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions Rationale:The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips would be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction?

Restrict visitors who may have an active infection. Rationale:The client needs to avoid exposure to infection and not allow persons with active infections to visit. Too much weight gain causes an increase in body requirements and increases stress on the heart. The client needs to rest on the left side to promote blood return. Stress causes increased heart workload, with the potential for adverse consequences.

The postpartum nurse is caring for a client who just delivered a healthy newborn. The nurse would be most concerned about the presence of subinvolution if which occurs?

Retained placental fragments from delivery

A rubella titer is performed on a client who has just been told they are pregnant. The results of the titer indicate that the client is not immune to rubella. Which would the nurse anticipate to be prescribed for this client?

Retesting rubella titer during pregnancy Rationale:A rubella titer is performed to determine immunity to rubella. If the client's titer is less than 1:8, the pregnant client is not immune. A retest during pregnancy is prescribed, and the client is immunized postpartum if they are not immune. Antibiotics are not prescribed. Counseling the client regarding therapeutic abortion is an inaccurate option.

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. Which exercise would the nurse instruct the client to engage in?

Swimming Rationale:Non-weight-bearing exercises are preferable to weight-bearing exercises. Non-weight-bearing exercise, such as swimming, is allowed during pregnancy. Competitive or high-risk sports, such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, aerobic exercise, and gymnastics, need to be avoided. Other exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position needs to be avoided.

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs would the nurse anticipate? Select all that apply.

Routine administration of subcutaneous heparin may be prescribed. An overbed lift may be necessary if the client requires a cesarean section. Thromboembolism stockings or sequential compression devices may be prescribed. Rationale:The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, will likely be prescribed due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.

The nurse is preparing a pregnant client for a transvaginal ultrasound examination. The nurse would tell the client that which will occur?

Some pressure may be felt when the vaginal probe is moved. Rationale:Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most clients because it alleviates the need for a full bladder to perform the test. The client is placed in a lithotomy position or with the pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the client may feel pressure as the probe is moved.

The nurse provides dietary instructions to a pregnant client regarding food items that contain folic acid. Which food item would the nurse recommend as a good source of folic acid?

Spinach Rationale:Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant person needs to have at least four servings of folic acid-rich foods per day. Food items high in folic acid include glandular meats, yeast, legumes, whole grains, and dark green leafy vegetables. Milk products and cheese supply calcium, potatoes provide vitamin B6, and bananas provide potassium.

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply

Station Dilation Effacement Rationale:The vaginal examination for a client in labor specifically determines effacement 0% to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.

The nurse is checking the reflexes of a newborn. Which action would the nurse perform in eliciting the rooting reflex?

Stimulate the perioral cavity with a finger.

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis?

Stimulating for reflex responses in the extremities

The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse would take which action first?

Stop the oxytocin infusion. Rationale:Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The primary health care provider is notified. The nurse would monitor the client's blood pressure and intake and output; however, the nurse would first stop the infusion.

A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and would tell the client that which change may persist after giving birth?

Striae gravidarum Rationale:Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. After birth they usually fade, although they never disappear completely. Options 1, 2, and 3 are incorrect. An epulis is a red raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, browning hyperpigmentation of the skin over the cheeks, nose, and forehead and is especially noticed in dark-complexioned pregnant individuals. Chloasma usually fades after the birth. Telangiectasias, or vascular "spiders," are tiny star-shaped or branch-shaped, slightly raised, and pulsating end arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. The spiders usually disappear after delivery.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse would place the client in which position?

Supine position with a wedge under the right hip Rationale:Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is impractical for this type of abdominal surgery.

Supine position with a wedge under the right hip Rationale:Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is not practical for this type of abdominal surgery.

After a precipitous delivery, the nurse notes that the new parent is passive and touches the newborn infant only briefly with their fingertips. What would the nurse do to help the client process the delivery?

Support the parent's reaction to the newborn infant.

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what would the nurse determine?

The newborn requires some resuscitative interventions.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply.

Tachycardia Fetal hypoxia Metabolic acidemia Congenital anomalies Rationale:The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into four different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than six beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn would alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

The nurse is performing an assessment on a newborn and is preparing to measure the head circumference of the newborn. Which item is essential to perform this assessment?

Tape measure

The charge nurse on a labor and delivery unit has numerous admissions and must transfer one of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client is the most appropriate one to transfer?

The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding Rationale:The fetus of the client at 10 weeks' gestation is in a previability stage, whereas those of the other clients are at a stage of viability. There is limited monitoring that can be done with a 10-week fetus; Doppler monitoring is not feasible during the first trimester. Bed rest and continued monitoring are most likely the primary treatments for this client at this point in the pregnancy. Bed rest could be maintained, and bleeding could be monitored by a postpartum nurse. The clients with preterm and postterm gestations (24 and 42 weeks, respectively) are those most at risk, so these clients require more fetal monitoring. The client who is at 38 weeks' gestation is also in need of fetal monitoring because of a possibility of decreased fetal movement. Until the fetal well-being can be confirmed with fetal monitoring, this client would remain on the labor and delivery unit to be continuously monitored. In addition, the two older clients (36 and 40 years) are considered to be of advanced maternal age, indicating a need for closer monitoring.

A client in week 35 of the pregnancy is placed on the fetal heart monitor for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes which conclusion regarding the NST? Refer to figure.

The FHR is reactive, with a baseline of 130 beats/minute, moderate variability, and no decelerations. Rationale:The monitor strip clearly reveals that the FHR evidences at least two accelerations at 15 beats/minute above baseline and lasting for 15 seconds or more within a 20-minute period or less. These accelerations also are associated with fetal movements that are evidenced by the green blocks on the lower portion of the strip. This interpretation meets the criteria for a reactive NST. Terms used to assess or describe an NST are reactive or nonreactive (110 to 160 beats/minute); and variability amplitude of 10 or more beats/minute. No decelerations are noted on the fetal monitor strip. The fetal monitor strip identifies these criteria; therefore, option 2 is correct

A pregnant client tells the clinic nurse that they want to know the sex of the baby as soon as it can be determined. The nurse plans to inform the client that they will be able to find out the sex at 16 weeks' gestation because of which factor?

The appearance of the fetal external genitalia Rationale:Between weeks 16 and 20, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes begin to descend into the scrotal sac at the end of the 38th week. Internal differences in the genders occur at the end of the seventh week.

A pregnant client tells the clinic nurse about wanting to know the sex of the baby as soon as it can be determined. The nurse informs the client that the sex of the baby could be determined at 12 weeks' gestation because of which factor?

The appearance of the fetal external genitalia Rationale:Sex differentiation begins in the embryo during the seventh week. External genitalia are indistinguishable until after the ninth week. Distinguishing characteristics of external genitalia appear around the ninth week and are fully differentiated by the twelfth week. By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Testes descend into the scrotal sac at the end of the thirty-eighth week.

The nurse evaluates the ability of a hepatitis B-positive birthing parent to provide safe bottle-feeding to the newborn during postpartum hospitalization. Which action best exemplifies the birthing parent's knowledge of potential disease transmission to the newborn?

The birthing parent washes and dries the hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply

The breast changes occur because of the secretion of estrogen and progesterone. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida. Rationale:During pregnancy, the breasts change in size and appearance. The increase in size occurs because of the effects of estrogen and progesterone. Estrogen stimulates the growth of mammary ductal tissue, and progesterone promotes the growth of lobes, lobules, and alveoli. A delicate network of veins is often visible just beneath the surface of the skin. The remaining options are unrelated to breast changes during pregnancy.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

The cervix is dilated completely The Ferguson reflex is initiated from perineal pressure. Rationale:The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The client has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply

The cervix is dilated completely. The spontaneous urge to push is initiated from perineal pressure. Rationale:The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

The nurse has provided instructions to a client on how to bathe the newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly?

The client begins to wash the newborn by starting with the eyes and face.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?

The client complains of a headache and blurred vision. Rationale:If the client complains of a headache and blurred vision, the PHCP needs to be notified because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.

The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?

The nurse is monitoring the client for signs of postpartum depression. Which behavior indicates the need for further assessment related to this form of depression?

The client constantly complains of tiredness and fatigue.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease. Rationale:Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetrical problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease. Rationale:Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetrical problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.

Which data places the client at risk for developing gestational diabetes during pregnancy?

The client has a history of gestational diabetes with a previous pregnancy. Rationale:Known risk factors that increase the risk of developing gestational diabetes include obesity (more than 198 lb), chronic hypertension, family history of type 2 diabetes, previous birth of a large infant (more than 4000 g), and gestational diabetes in a previous pregnancy. The other options are not risk factors associated with the development of gestational diabetes.

The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection, which site would the nurse select?

The lateral aspect of the middle third of the vastus lateralis muscle

The nurse is performing a prenatal assessment on a pregnant client. The nurse would plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment?

The client has a history of hypertension. Rationale:Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. Abruptio placentae is associated with conditions characterized by poor uteroplacental circulation, such as hypertension, smoking, and alcohol or cocaine abuse. The condition also is associated with physical and mechanical factors, such as overdistention of the uterus, which occurs with multiple gestation or polyhydramnios. In addition, a short umbilical cord, physical trauma, and increased maternal age and parity are risk factors.

The clinic nurse is performing a psychosocial assessment of a client who is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply.

The client has a history of intravenous drug use. The client has a history of sexually transmitted infections. Rationale:HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected birthing parent to the fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.

The clinic nurse is performing a psychosocial assessment of a client who has been told that they are pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply.

The client has a history of intravenous drug use. The client has a history of sexually transmitted infections. Rationale:HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected pregnant person to the fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.

The nurse is checking lochia discharge in a client in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse would make which interpretation?

The client is experiencing normal lochia discharge.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How would the nurse interpret this finding?

The client is measuring normal for gestational age. Rationale:During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

The client is measuring normal for gestational age. Rationale:During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks' gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

On March 10, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of the last menstrual period (LMP) was July 7 the previous year. The nurse plans care based on which interpretation?

The client is possibly in preterm labor Rationale:According to Naegele's rule, by subtracting 3 months and adding 7 days and 1 year to this client's LMP the nurse can determine that the estimated date of delivery (EDD) is April 14. This client is in the labor and delivery unit to be evaluated for the presence of labor more than 1 month before the EDD; therefore, the client is possibly in preterm labor. Viability is said to occur between the 22nd and 25th weeks of gestation. This fetus is approximately 4 weeks before term. If this client truly is in labor, the primary health care provider's plan would be to try to stop the labor in order to prevent delivery at this early stage in the pregnancy. This would eliminate option 3, labor augmentation. Because of the typical 36-week gestational size of a fetus, 2200 to 2900 g, there would be no risk for a difficult shoulder delivery.

A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on the client. Which observations made by the nurse during the assessment indicate a need for further teaching? Select all that apply.

The client is wearing knee-high nylon stockings. The client is wearing sweatpants with snug elastic ankle bands. Rationale:Varicose veins often develop in the lower extremities during pregnancy. Any constricting clothing such as knee-high stockings or snug elastic ankle bands impedes venous return from the lower legs and thus places the client at higher risk for developing varicosities. Clients need to be encouraged to wear pantyhose or support hose. Flat nonslip shoes with proper support are important to assist the pregnant client to maintain proper posture and balance and to minimize the risk for falls. Pants with an elastic waistband are comfortable and are not constricting.

A 25-year-old client arrives on the maternity unit on February 2. The client states that the estimated date of delivery (EDD) is March 22. The client is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 37.2° C (99° F). The nurse plans care based on which interpretation?

The client requires further evaluation for preterm labor. Rationale:Classic signs and symptoms of preterm labor include lower abdominal cramping, possibly accompanied by diarrhea; dull and intermittent low back pain; painful menstrual-like cramps; suprapubic pain or pressure; pelvic pressure or heaviness; urinary frequency; change in character and amount of vaginal discharge; and rupture of amniotic membranes. Early recognition of preterm labor is essential so that interventions such as tocolytic therapy and administration of antenatal glucocorticoids can be initiated; therefore, further evaluation of the cervix, membrane status, uterine activity, and fetal heart rate is necessary to determine whether the client is in preterm labor (the correct option). The client's temperature is only slightly elevated, and the diarrhea presents in addition to the signs and symptoms of preterm labor, so option 2 can be eliminated. The client is not exhibiting signs of gestational hypertension, so therefore eliminate option 3. Because the client has additional complaints that may possibly relate to preterm labor, instruction on pelvic tilts to decrease back pain is irrelevant at this time, so therefore eliminate option 4.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

The client with lochia that is red and has a foul-smelling odor

The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The client becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time?

The client's fear Rationale:The client is anxious and frightened, and the most appropriate problem to address for the client at this time is fear. There are no data in the question to support a client problem with fatigue, inability to control the situation, or inability to cope with the situation. These problems may be considered for this client at some point during the hospitalization experience.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?

The client's last baby weighed 10 pounds at birth. Rationale:Known risk factors that increase the risk of developing gestational diabetes include obesity (more than approximately 198 pounds, depending on height), chronic hypertension, family history of diabetes mellitus, previous birth of a large infant (greater than 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors associated with the development of gestational diabetes.

The nurse is preparing to provide instructions to a new parent regarding cord care for a newborn infant. Which instructions would the nurse provide? Select all that apply.

The cord needs to be kept clean and dry." You need to do cord care until the cord dries up and falls off."

The nurse is teaching a postpartum client about breast-feeding/chest-feeding. Which instruction would the nurse plan to include in the teaching session?

The diet needs to include additional fluids.

The nurse is teaching a postpartum client about breast/chest feeding. Which instruction would the nurse include?

The diet needs to include additional fluids.

The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time? Select all that apply.

The fetus is approximately 42 to 48 cm long. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1. Rationale:At gestational week 36, the fetus weighs 2200 to 2900 g and is approximately 42 to 48 cm long. The fetal skin is transparent at week 16, but at 36 weeks the skin is pink and the body is rounded. Lanugo is disappearing, and the L/S ratio is greater than 2:1. At gestational week 8, the eyelids begin to fuse. The fetal heart begins to beat at week 5. At 28 weeks' gestation, the fetus weighs approximately 1200 g.

A pregnant client is diagnosed with tuberculosis. Which instruction would the nurse provide to the client regarding therapeutic management of tuberculosis?

The newborn will be tested at birth and may be started on preventive therapy. Rationale:More than one medication may be used to prevent the growth of resistant organisms in the pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for a total of 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing on the infant would be repeated at 3 months, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid would be given. Therefore, options 1, 2, and 3 are incorrect.

The postpartum nurse teaches a parent how to give a bath to the newborn infant and observes the parent performing the procedure. Which observation indicates a lack of understanding of the instructions?

The parent bathes the newborn infant after a feeding.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new birthing parent, indicates a need for follow-up or further assessment related to this form of depression?

The parent constantly complains of tiredness and fatigue.

The home care nurse's assignment is to visit a postpartum client at home 24 to 48 hours after discharge. What would the nurse expect to note in a healthy client who is breast/chest-feeding the newborn infant?

The parent is breast/chest-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

The nurse in the postpartum unit is observing the parent-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction?

The parent requests that the nurse feed the newborn because of feeling fatigued.

The nurse evaluates the ability of a hepatitis B-positive parent to provide safe bottle-feeding to the newborn during postpartum hospitalization. Which action best exemplifies the parent's knowledge of potential disease transmission to the newborn?

The parent washes and dries their hands before and after self-care of their perineum and asks for a pair of gloves before feeding.

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding would alert the nurse to a compromise?

The passage of meconium.. Rationale:Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate; fetal acidosis; and the passage of meconium. Maternal fatigue can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

A client is diagnosed with placenta previa. The nurse plans care with the understanding that which is associated with placenta previa?

The placenta is implanted in the lower uterine segment.

A postpartum client develops a urinary tract infection. The nurse instructs the client on measures to take for treatment of the infection. Which statements, if made by the client, would indicate a need for further instruction? Select all that apply.

The prescribed medication needs to be taken until I feel better I need to try to hold my urine as long as I can and urinate 3 to 4 times a day."

A couple is seen in the fertility clinic. After several tests it has been determined that the spouse is not sterile and that the other spouse has nonpatent fallopian tubes. The nurse is preparing the couple for an in vitro fertilization. Which statement by the couple indicates a need for further information about the procedure?

The procedure is performed using artificial insemination of sperm instilled through the vagina." Rationale:In vitro fertilization is a method of medically assisted reproduction for clients with nonpatent, diseased, or missing fallopian tubes or with infertility of unknown cause. Ova and sperm are obtained from the potential parent or donor, placed in a nutrient medium, and allowed to incubate; then the fertilized ovum is transferred into the client's uterus. The client houses the pregnancy throughout gestation and gives birth. Option 4 describes the procedure for artificial insemination. Options 1, 2, and 3 are correct statements regarding in vitro fertilization.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal?

The saturation of more than 1 peripad per hour

A pregnant client reports noticing a thin, colorless vaginal drainage. Which information would the nurse provide to the client?

This is a normal occurrence. Rationale:Many pregnant clients notice an increased thin, colorless, or yellow vaginal discharge throughout pregnancy. The increase in the amount of discharge may be bothersome, but it is usually a normal occurrence. This occurrence is not an emergency and does not require immediate obstetrician notification. If vaginal discharge is profuse, peripads can be worn, but the amount of drainage does not need to be measured. If peripads are used, they need to be changed frequently.

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority at this time is to perform which action?

Thoroughly dry the newborn.

The nursery room nurse is assessing a newborn infant who was born to a postpartum client who abuses alcohol. Which assessment finding would the nurse expect to note? Select all that apply.

Tremors Irritability Poor feeding

The nurse in the newborn nursery is assessing a neonate who was born of a person addicted to cocaine. Which assessment findings would the nurse expect to note in the neonate? Select all that apply.

Tremors Tachycardia Exaggerated startle reflex

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a loss of variability. What is the initial nursing action?

Turn the client on the side and administer oxygen by face mask at 8 to 10 L/min. Rationale:If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To facilitate oxygen to the parent and the fetus, the client is turned to the client's side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the client by face mask.

Shortly after receiving epidural anesthesia, a laboring client's blood pressure drops to 95/43 mm Hg. Which immediate actions would the nurse take? Select all that apply.

Turn the client to a lateral position. Increase the rate of the intravenous infusion. Administer oxygen by face mask at 10 L/minute. Rationale:Hypotension results in decreased placental perfusion, so the focus of nursing care would be to initiate interventions that increase oxygen perfusion to the fetus. Turning the client to left lateral position assists in deflecting the uterus off the vena cava, thus improving circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the circulation and increase oxygen delivery to the fetus. The client is not revealing any signs or symptoms of imminent delivery, as the client just received an epidural which is typically administered at 6 cm or earlier dilation, so option 1 can be eliminated. Administering a tocolytic can be eliminated because the decrease in placental perfusion is the result of hypotension, not uterine hyperstimulation. Administering an opioid antagonist can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.

A postpartum client is diagnosed with a urinary tract infection. Which measures would the nurse instruct the client to take regarding treatment and the prevention of a future infection?

Urinate frequently throughout the day.

At 10 days postpartum, a breast/chest-feeding parent develops mastitis in the right breast. The nurse instructs the client on which interventions? Select all that apply.

Using ice packs Using analgesics Wearing proper breast/chest support Completing the full course of prescribed antibiotics

The nurse is caring for a client with a diagnosis of subinvolution. The nurse would recognize which conditions as causes of this diagnosis? Select all that apply.

Uterine infection Retained placental fragments from delivery

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding would the nurse expect to note if this condition is present?

Uterine tenderness Rationale:Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.

Uterine tenderness Rationale:Abruptio placentae, or placental abruption, is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness is present, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa.

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply.

Uterine tenderness Acute abdominal pain A hard, "board-like" abdomen Increased uterine resting tone on fetal monitoring Rationale:In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply.

Vaginal bleeding Excessive nausea and vomiting Larger-than-normal uterus for gestational age Elevated levels of human chorionic gonadotropin (hCG) Rationale:The most common findings of gestational trophoblastic disease (hydatidiform mole) include vaginal bleeding, excessive nausea and vomiting, larger-than-normal uterus for gestational age, elevated levels of hCG, failure to detect fetal heart activity even with sensitive instruments, and early development of gestational hypertension. Fetal activity would not be noted.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations Rationale:Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.

The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply.

Viruses Bacteria Nutrients Antibodies Medications Rationale:Bacterial or viral infection of the pregnant parent during the course of pregnancy can cross the placenta and actively infect the fetus. However, especially for bacteria, it is more common for pregnant clients to experience an infection that can be treated without overt fetal infection. Additionally, nutrients, medications, antibodies, and recreational drugs can pass through the placenta and potentially affect the fetus. Metabolic waste products of the fetus cross the placental membrane from the fetal blood into the maternal blood. The maternal kidneys then excrete them.

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. The nurse would tell the client that which exercise is safest?

Walking Rationale:Non-weight-bearing exercises are preferable to weight-bearing exercises during pregnancy. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the knee-chest position would be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics would be avoided. Non-weight-bearing exercises such as walking or swimming are allowed.

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast/chest tenderness. Which instruction would the nurse provide?

Wash the breasts/chest with warm water and keep them dry. Rationale:The pregnant client needs to be instructed to wash the breasts/chest with warm water and keep the skin dry. The client needs to be instructed to avoid using soap on the nipples and areolar area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease tenderness. Tight-fitting shirts or dresses cause discomfort. The client is instructed to wear soft-textured clothing to decrease nipple tenderness and to use breast/chest pads inside the bra to prevent leakage through the clothing if colostrum is a problem.

The nurse working in a pediatric primary care provider office receives a call from a parent who has tested positive for COVID-19. The parent states there is a 10-day-old newborn at home and asks the nurse how to prevent the spread of the infection to the newborn. Which of the following are appropriate measures the nurse would tell the parent to take? Select all that apply.

Wear a mask while within 6 feet of the newborn Wash hands for at least 20 seconds before caring for the newborn When not directly caring for the newborn, keep the newborn at least 6 feet away as much as possible

The nurse visits at home a client who delivered a healthy newborn 2 days ago. The client is complaining of breast/chest discomfort. The nurse notes that the client is experiencing engorgement. Which instructions would the nurse provide to the client regarding relief of the engorgement? Select all that apply.

Wear a supportive bra between feedings. Apply moist heat to both breasts/chest area for about 20 minutes before a feeding. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. Massage the breasts/chest area gently during a feeding, from the outer areas to the nipples.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions would be included on the list? Select all that apply.

Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed/chest-feed if the breasts are not too sore.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions would be included on the list? Select all that apply.

Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed/chest-feed if the breasts/chest are not too sore.

The nurse is assigned to care for a client who has chosen to formula-feed the infant. The nurse would plan to provide which instruction to the client?

Wear a supportive brassiere continuously for 72 hours.

A client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the client about the signs that need to be reported to the primary health care provider (PHCP). The nurse would tell the client to call the PHCP if which occurs?

Weight increases by more than 1 pound in a week. Rationale:The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and would be reported.

The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse would tell the client to consume which food that contains the highest source of dietary iron?

Whole-grain cereal Rationale:Dietary sources of iron include lean meats; liver; shellfish; dark green, leafy vegetables; legumes; whole grains and enriched grains; cereals; and molasses. Milk is high in calcium and also contains phosphorus. Potatoes and cantaloupe are high in vitamin C.

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that that "my water broke" before coming to the hospital. What is the appropriate nursing action?

Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline. Rationale:When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help accomplish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified left lateral recumbent position. The primary health care provider is also notified immediately. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.

Maternity (Antepartum, Intrapartum, Antepartum, Newborn)

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