MN OB

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1 hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

"A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

A nurse is providing a dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

"I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia.

A nurse is teaching a client who is Rh negative about Rh0(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

"I will need this medication if I have an amniocentesis." Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?

"This medication stimulates fetal lung maturity." The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make?

"This procedure should have no effect on your sexual performance or adequacy." The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

"You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

"You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

"You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching?

"You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results.

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4hr. Which of the following statements should the nurse make?

"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?

1. Wipe the newborn's eyes from the inner canthus outward 2. Wash the newborn's neck by lifting the newborn's chin 3. Cleanse the skin around the newborn's umbilical cord stump 4. Wash the newborn's legs and feet 5. Clean the newborn's diaper area

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1g orally now." Available is 250 mg tablets. How many tablets should the nurse administer?

4 tablets

A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50mL

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?

A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply) A. Heart rate 154/min B. Axillary temperature 36° C (96.8° F) C. Respiratory rate 58/min D. Length 43 cm (16.9 in) E. Weight 2,600 g (5 lb 12 oz)

A, C, E A. Heart rate 154/min (The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake.) C. Respiratory rate 58/min (The expected reference range for a newborn's respiratory rate is from 30/min to 60/min.) E. Weight 2,600 g (5 lb 12 oz) (The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb).

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? A. "I can administer oxytocin 4 hours after the insertion of the medication." B. "You will need a full bladder prior to the insertion of the medication." C. "Remain in a side-lying position for 15 minutes after the medication is inserted." D. "An antacid will be given 20 minutes prior to the insertion o

A. "I can administer oxytocin 4 hours after the insertion of the medication." (The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.) The nurse should instruct the client to void prior to the administration of the medication. The nurse should instruct the client to remain in a side-lying position for 30 to 40 min after the insertion. The nurse should avoid administering aluminum hydroxide and magnesium-containing antacids with misoprostol.

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A. A client who is at 11 weeks of gestation and reports abdominal cramping B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

A. A client who is at 11 weeks of gestation and reports abdominal cramping (When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.) Tingling and numbness of the right hand is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. Therefore, there is another client that the provider should see first. Constipation is nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. Therefore, there is another client that the provider should see first. Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. Therefore, there is ano

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? A. Abruptio placenta B. Placenta previa C. Preeclampsia D. Maternal bradycardia

A. Abruptio placenta (Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.)

A nurse is caring for client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? A. BUN 25 mg/dL B. Serum creatinine 0.8 mg/dL C. Urine output of 280 mL within 8 hr D. Urine negative for ketones

A. BUN 25 mg/dL (The nurse should report an elevated BUN to the provider since it can indicate dehydration.) A serum creatinine level of 0.8 mg/dL is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. A urine output of 280 mL within 8 hr is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Urine testing positive for ketones is an indication of dehydration, which increases the risk of preterm labor. A negative test result is an expected finding. Therefore, the nurse does not need to report this finding to the provider.

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? A. Biophysical profile B. Amniocentesis C. Cordocentesis D. Kleihauer-Betke test

A. Biophysical profile (A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.) An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization.

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? A. Calcium gluconate B. Hydralazine C. Medroxyprogesterone acetate D. Methylergonovine

A. Calcium gluconate (The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote.) Hydralazine is an antihypertensive medication that can be administered to clients who have hypertension during pregnancy, rather than functioning as the antidote to magnesium toxicity. Medroxyprogesterone acetate is an injectable contraceptive hormone, rather than functioning as the antidote to magnesium toxicity. Methylergonovine is used to treat postpartum hemorrhage, rather than functioning as the antidote to magnesium toxicity.

A nurse is providing teaching about non-pharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? A. Cold cabbage leaves B. Purified lanolin cream C. A snug-fitting support bra D. Breast shells

A. Cold cabbage leaves (The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.) Purified lanolin cream is an over-the-counter product that is recommended for the treatment of sore nipples. A snug-fitting support bra is recommended to suppress lactation for a client who is not breastfeeding. The bra prevents strain on the breast muscles and places the breasts in proper alignment to decrease engorgement. Breast shells are recommended for clients who are postpartum and have sore nipples. They are used as a barrier to keep clothing away from the nipples and to allow air to circulate.

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? A. Depression B. Polyuria C. Hypotension D. Urticaria

A. Depression (The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.) Fluid retention can occur due to an excess of estrogen. Polyuria is not a common adverse effect of the medication. Hypertension, rather than hypotension, is a common adverse effect of combined oral contraceptives. Urticaria is not a common adverse effect of combined oral contraceptives.

A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? A. Hemoglobin 10 g/dL B. WBC count 10,000/mm3 C. Platelets 250,000/mm3 D. Fasting blood glucose 90 mg/dL

A. Hemoglobin 10 g/dL (A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia.) This finding is within the expected reference range of 5,000 to 15,000/mm3 and does not require reporting to the provider. This finding is within the expected reference range of 150,000 to 400,000/mm3 and does not require reporting to the provider. This finding is within the expected reference range of 60 to 105 mg/dL and does not require reporting to the provider.

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? A. Hypertension B. Hypothermia C. Constipation D. Muscle weakness

A. Hypertension (The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.)

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? A. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. B. Wrap the visible cord tightly with sterile, dry gauze. C. Apply oxygen to the client at 2 L/min via nasal cannula. D. Place the client in the lithotomy position and apply fundal pressure

A. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. (The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus.) The nurse should wrap the visible cord with a loose sterile towel saturated with warm 0.9% sodium chloride solution, rather than with sterile, dry gauze. The nurse should apply oxygen to the client at 8 to 10 L/min via nonbreather mask. The nurse should place the client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to relieve the compression of the umbilical cord.

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental aburption. Which of the following laboratory tests should the nurse expect the provider to prescribe? A. Kleihauer-Betke test B. Progesterone serum level C. Lecithin/sphingomyelin (L/S) ratio D. Maternal Alpha-fetoprotein (AFP)

A. Kleihauer-Betke test (The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative.) A progesterone serum level helps to determine if a client is pregnant and if the pregnancy is ectopic. Lecithin/sphingomyelin (L/S) ratio is done as a part of an amniocentesis to evaluate fetal lung maturity. Maternal Alpha-fetoprotein (AFP) is a laboratory test used to assess for neural tube defects or chromosome disorders.

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? A. Late decelerations B. Moderate variability of the FHR C. Cessation of uterine dilation D. Prolonged active phase of labor

A. Late decelerations (Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.) Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin. Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.

A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? A. Lays the newborn across her lap and gently sways B. Places the newborn in the crib in a prone position C. Offers the newborn a pacifier dipped in formula D. Prepares a bottle of formula mixed with rice cereal

A. Lays the newborn across her lap and gently sways (This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.) The parent should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome. Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn might become accustomed to it and refuse to take the pacifier in the future without added supplement. Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New ballard score. Which of the following findings should the nurse expect? A. Minimal arm recoil B. Popliteal angle of 90° C. Creases over the entire foot sole D. Raised areolas with 3 to 4 mm buds

A. Minimal arm recoil (The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.) A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks.

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? A. Protect the client's head and feet from cold air. B. Bathe the client within 12 hr following birth. C. Ambulate the client within 24 hr following birth. D. Offer the client a glass of cold milk with her first meal.

A. Protect the client's head and feet from cold air. (Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period.) Bathing the client within 12 hr following birth should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following birth. Ambulating the client within 24 hr following birth should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following birth. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Report of visual disturbances B. Report of tingling of the fingers C. Report of urinary frequency D. Report of leg cramps

A. Report of visual disturbances (Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed.) Tingling or numbness of the fingers is called brachial plexus traction syndrome resulting from drooping of shoulders during pregnancy. This is a common discomfort that occurs during the second trimester. Reports of urinary frequency is a common discomfort that occurs during the third trimester because of the reduction in bladder capacity due to the enlarged uterus. Leg cramps are a common discomfort that occurs during the third trimester because the nerves that supply lower extremities are compressed due to the enlarging uterus.

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? A. Reports increased urinary output B. Diaphoresis C. Reports blurred vision D. Shallow respirations

A. Reports increased urinary output (Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.) Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed, dry skin is a manifestation of hyperglycemia. Blurred or double vision is a finding of hypoglycemia. A report of dim vision is a manifestation of hyperglycemia. Shallow respirations are a finding of hypoglycemia. Rapid breathing is a manifestation of hyperglycemia.

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? A. Substernal retractions B. Acrocyanosis C. Overlapping suture lines D. Head circumference 33 cm (13 in)

A. Substernal retractions (The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention.) Acrocyanosis is an expected finding in the newborn for the first 24 hr following birth. Overlapping suture lines with molding are an expected variation for newborns who were delivered vaginally. A head circumference of 33 cm is within the expected reference range for a newborn following birth.

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? A. Verify that the parent's identification band matches the newborn's identification band. B. Scan the newborn's identification band to verify their identity. C. Check the newborn's security tag number to ensure it matches the newborn's medical record. D. Match the newborn's date and time of birth to the information in the parent's medical record.

A. Verify that the parent's identification band matches the newborn's identification band. (The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.)

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions?

Administer terbutaline The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth.

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression?

Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next?

Apply internal upward pressure to the presenting part using 2 gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

Assist the client to empty her bladder. The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? A. "I will not gain more than 15 to 20 pounds during my pregnancy." B. "I will likely need to use alternative positions for sexual intercourse." C. "I'm glad I had a breast reduction years ago, so they will not enlarge wit

B. "I will likely need to use alternative positions for sexual intercourse." (The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.) The recommended weight gain during pregnancy for a client who has a BMI within the expected reference range is 25 to 35 lb (11.3 to 15.9 kg). The recommended weight gain during pregnancy for a client who has a BMI above the expected reference range is 15 to 20 lb (6.8 to 9.1 kg). The mammary glands of the breasts grow during pregnancy, causing progressive enlargement during the second and third trimesters of pregnancy. A breast reduction will not prevent this from occurring. Stretch marks can occur as a response to pregnancy regardless of the client's complexion.

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestation should the nurse expect? (Select all that apply.) A. Yellow sclera B. Acrocyanosis C. Posterior fontanel larger than the anterior fontanel D. Positive Babinski reflex E. Two umbilical arteries visible

B. Acrocyanosis (Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet.) D. Positive Babinski reflex (Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age.) E. Two umbilical arteries visible (The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.)

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? A. Administer aspirin for pain. B. Maintain the client on bed rest. C. Massage the affected leg every 12 hr. D. Apply cold compresses to the affected calf.

B. Maintain the client on bed rest. (The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.) A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because it can lead to prolonged clotting times and increased risk of bleeding. The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. The nurse should apply warm compresses to the affected area to promote circulation and decrease edema.

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? A. Check the client's capillary refill. B. Massage the client's fundus. C. Insert an indwelling urinary catheter for the client. D. Prepare the client for a blood transfusion.

B. Massage the client's fundus. (Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss.) It is important for the nurse to monitor capillary refill to track baseline data for this client. Noninvasive assessments of cardiac output for clients who are experiencing postpartum hemorrhage include assessing: capillary refill; skin color, temperature, and turgor; level of consciousness; neck veins; and mucous membranes. However, another action is the nurse's priority. It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is urinary output of at least 30 ml/hr. However, another action is the nurse's priority. It is important for the nurse to

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? A. Determine progression of dilatation and effacement. B. Perform Leopold maneuvers. C. Complete a sterile speculum exam. D. Prepare a Nitrazine paper test.

B. Perform Leopold maneuvers. (The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.) The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.

A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Fundal height 34 cm B. Report of decreased fetal movement C. Report of occasional ankle swelling D. BP 110/80 mm Hg

B. Report of decreased fetal movement (The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress.) A client who is at 32 weeks of gestation should have a fundal height about the same as the number of weeks of gestation, plus or minus 2 cm. The nurse should identify that occasional ankle edema is a common discomfort associated with a client who is at 32 weeks of gestation. The nurse should identify that during pregnancy the client's blood pressure should remain the same or be slightly decreased. A blood pressure of 110/80 mm Hg is within the expected reference range of less than 120 mm Hg systolic and less than 80 mm Hg diastolic.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? A. Administer antiviral medication. B. Schedule an ultrasound examination. C. Administer Haemophilus influenzae type b vaccine. D. Schedule an indirect Coombs' test.

B. Schedule an ultrasound examination. (The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.) Currently, there are no antiviral medications available to treat fifth disease. The Haemophilus influenzae type b vaccine is given during infancy and childhood to protect against multiple infections caused by Haemophilus influenzae type b, not fifth disease. Currently, there are no vaccines to protect against fifth disease. An indirect Coombs' test determines whether the client has antibodies to the Rh antigen. The titer determines the prenatal client's sensitization and if there is Rh incompatibility.

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? A. To estimate the fetal weight B. To locate a pocket of fluid C. To determine multiparity D. To prescreen for fetal anomalies

B. To locate a pocket of fluid (An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.)

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? A. Lochia serosa vaginal drainage B. Vaginal pressure C. Intermittent vaginal pain D. Yellow exudate vaginal drainage

B. Vaginal pressure (The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.) A client who is 4 to 10 days postpartum will report lochia serosa. A client who has a vaginal hematoma will report persistent vaginal or rectal pain. A client who is 1 day postpartum and has a vaginal hematoma will report lochia rubra.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

Bilirubin 9 mg/dL A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

Blood glucose 30 mg/dL MY ANSWER Newborns less than 24 hr old should have a blood glucose of 40 to 60 mg/dL. Newborns who are greater than 24 hr old should have a blood glucose of 50 to 90 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider.

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? A. "Obtain an informed consent prior to obtaining the specimen." B. "Collect at least 1 milliliter of urine for the test." C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." D. "Premature newborns may have false negative tests due to immature development of liver

C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." (The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing.) The universal newborn screening is mandated by law for all newborns. Therefore, the nurse does not need to obtain informed consent prior to obtaining the specimen. The nurse should collect a capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test. Premature newborns have a delayed development of liver enzymes which can cause a false positive result.

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? A. "My sister will be able to carry my baby from the nursery to my room when she arrives." B. "The nurse will match my wrist band to my baby's crib card when they bring him to me." C. "The person who comes to take my baby's pictures will be wearing a photo identification badge." D. "My baby doesn't ne

C. "The person who comes to take my baby's pictures will be wearing a photo identification badge." (All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn.) A newborn should always be transported in a bassinet when outside the parent's room. The nurse will match the newborn's identification number with the parent's identification number when they bring the newborn to the parent's room. The newborn should wear the electronic security bracelet at all times. The bracelet is set to alarm if anyone removes the bracelet or if the newborn is brought near an exit door.

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instruction should the nurse include? A. "You can resume sexual activity in 1 week." B. "You won't need to do Kegel exercises since you had a cesarean." C. "You can still become pregnant if you are breastfeeding." D. "You are safe to start adding sit-ups to your exercise routine in 2 weeks."

C. "You can still become pregnant if you are breastfeeding." (The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.) The nurse should instruct the client that it is safe to resume sexual activity once all vaginal bleeding has stopped and the incision has healed, which can take 2 to 6 weeks. However, it is highly recommended that the client wait until after her 6-week follow-up with the provider because the incision and healing process should be assessed before sexual activity is resumed. The nurse should instruct the client to continue to perform Kegel exercises to maintain tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary continence in the future. The nurse should instruct the client to avoid abdominal exercises for 4 to 6 weeks following a cesarean birth. The nurse can instruct the

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? A. Decreased uterine contractions B. An increase in the client's hemoglobin levels C. A reduction in respiratory distress in the newborn D. Increased production of antibodies in the newborn

C. A reduction in respiratory distress in the newborn (Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.)

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? A. Monitor the FHR. B. Assess uterine activity. C. Administer oxygen via a nonrebreather mask. D. Start a bolus of IV fluids.

C. Administer oxygen via a nonrebreather mask. (When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus.) The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next. The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next.

A nurse in an antepartum clinic providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? __________________________________________ Exhibit 1 (Graphic Record) - Blood pressure 130/78 mm Hg - Respiratory rate 20/min - Heart rate 90/min Exhibit 2 (Diagnostic Results) - Hemoglobin 12 g/dL - Hematocrit 34% - 1-hr glucose tolerance test 120 mg/dL Exhibit 3 (Progress Notes) - Fund

C. Fundal height measurement (A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.) A glucose tolerance test result of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider. A hematocrit of 34% is within the expected reference range for this client. The level should be greater than 33%. This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation.

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a non-stress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? A. Give the client orange juice. B. Elevate the client's legs. C. Have the client change position. D. Establish IV access.

C. Have the client change position. (Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.) Giving the client orange juice is not an appropriate intervention for a variable deceleration in the FHR. Elevating the client's legs is an acceptable intervention for late decelerations associated with maternal hypotension. Establishing IV access is not indicated at this time.

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? A. Acrocyanosis B. Transient strabismus C. Jaundice D. Caput succedaneum

C. Jaundice (Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.) Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 24 to 48 hr after birth. Transient strabismus is a normal variation in the newborn's eyes that can persist until the third or fourth month of age. Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput.

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? A. Monitor the client's blood pressure every hour. B. Restrict the total hourly intake to 200 mL. C. Monitor the FHR continuously. D. Administer protamine sulfate for manifestations of toxicity.

C. Monitor the FHR continuously. (Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.) The nurse should monitor the client's vital signs, including blood pressure, every 15 to 30 min. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who have preeclampsia can have an alteration in kidney function, leading to increases in edema. The nurse should administer calcium gluconate if the client shows manifestations of magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes, respiratory depression, slurred speech, and cardiac arrest.

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? A. Fentanyl B. Butorphanol C. Naloxone D. Meperidine

C. Naloxone (Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client.) The nurse should administer fentanyl to the client for the relief of severe, recurrent, or persistent pain during labor. Fentanyl is most commonly administered via PCA pump or epidural, alone or with a local anesthetic agent. An adverse effect of this medication is respiratory depression. The nurse should administer butorphanol to the client for the relief of labor pain and severe postoperative pain after cesarean birth. An adverse effect of this medication is respiratory depression. The nurse should administer meperidine to the client for the relief of severe, persistent pain. An adverse effect of this medication is respiratory depression.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? A. Allow the sibling to hold the newborn during a bath. B. Make sure the sibling kisses the newborn each night. C. Obtain a gift from the newborn to present to the sibling. D. Switch the sibling's room with the nursery.

C. Obtain a gift from the newborn to present to the sibling. (Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family.) Allowing the sibling to hold the newborn during a bath is not an appropriate activity for a school-age child because of the safety risk. However, the parents could let the sibling assist with other things in regard to caring for the newborn. Forcing interactions between the sibling and the adoptive newborn can cause anger on the part of the sibling. It is more important to allow feelings to evolve naturally as the family unit bonds. Switching the sibling's room with the newborn's room might cause jealousy of the newborn or cause the sibling to feel that the newborn is taking their belongings.

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? A. Bruising over the buttocks B. Hard nodules on the roof of the mouth C. Petechiae over the head D. Bilateral periauricular papillomas

C. Petechiae over the head (Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.) A breech birth can cause bruising over the buttocks and swollen genitalia. Inclusion cysts, or whitish hard nodules on the gums or roof of the mouth, can be an expected finding. These are also called Epstein pearls. Bilateral periauricular papillomas are benign skin tags that can be an expected finding.

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? A. Excessive bleeding B. Oligohydramnios C. Premature rupture of membranes D. Proteinuria

C. Premature rupture of membranes (The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction.) A client who is pregnant and has gonorrhea is not at an increased risk for excessive bleeding. A client who is pregnant and has gonorrhea is not at an increased risk for oligohydramnios. Oligohydramnios is a decrease in amniotic fluid and is associated with congenital anomalies such as renal agenesis and intrauterine growth restriction. A client who is pregnant and has gonorrhea is not at an increased risk for proteinuria. Proteinuria is associated with preeclampsia.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? A. Feed the newborn 1 oz of water every 4 hr. B. Apply lotion to the newborn's skin three times per day. C. Remove all clothing from the newborn except the diaper. D. Discontinue therapy if the newborn develops a rash.

C. Remove all clothing from the newborn except the diaper. (The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.) The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin in the stool or provide nutritional value. The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment.

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? A. Client reports nausea B. Urinary output of 40 mL/hr C. Respiratory rate 10/min D. Client reports feeling flushed

C. Respiratory rate 10/min (The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.) Nausea is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. Oliguria is a manifestation of magnesium toxicity. The nurse should report a urinary output of less than 25 to 30 mL/hr to the provider. Flushing and feeling hot is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures.

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? A. Blood pressure 136/88 mm Hg B. Report of insomnia C. Weight gain of 2.2 kg (4.8 lb) D. Report of Braxton Hicks contractions

C. Weight gain of 2.2 kg (4.8 lb) (A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.) A blood pressure of 136/88 mm Hg is within the expected reference range for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. A regular occurrence of insomnia can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. Braxton Hicks contractions can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (SATA)

Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should increase my protein intake to 60 grams each day." B. "I should drink 2 liters of water each day." C. "I should increase my overall daily caloric intake by 300 calories." D. "I should take 600 micrograms of folic acid each day."

D. "I should take 600 micrograms of folic acid each day." (A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.) A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters. A client who is pregnant should consume 3 L of water each day. A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include? A. "The test should take 10 to 15 minutes to complete." B. "You will lay in a supine position throughout the test." C. "You should not eat or drink for 2 hours before the test." D. "You should press the handheld button when you feel your baby move."

D. "You should press the handheld button when you feel your baby move." (The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive.) The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins. The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's position with a slight lateral tilt to ensure optimal uterine perfusion. The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase her blood glucose level which will stimulate fetal movements.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A. A newborn who is 26 hr old and has erythema toxicum on his face B. A newborn who is 32 hr old and has not passed a meconium stool C. A newborn who is 12 hr old and has pink-tinged urine D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)

D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) (An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.) Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment. A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth. An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication o

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke," Which of the following intervention is the nurse's priority? A. Perform Nitrazine testing. B. Assess the fluid. C. Check cervical dilation. D. Begin FHR monitoring.

D. Begin FHR monitoring. (The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take.) The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. However, this is not the first action the nurse should take. The nurse should observe the characteristics of the fluid to document color, odor, and amount. However, this is not the first action the nurse should take. The nurse should check the client's cervical dilation to assess progress of labor. However, this is not the first action the nurse should take.

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? A. 2+ deep tendon reflexes B. Proteinuria of 200 mg in a 24-hr specimen C. Polyuria D. Blurred vision

D. Blurred vision (The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.) The nurse should identify that a client who has severe preeclampsia can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is indicative of an active or expected response. The nurse should identify that a client who has severe preeclampsia can have increased amount of urinary protein that is greater than 500 mg in a 24-hr specimen. The nurse should identify that a client who has severe preeclampsia can have decreased urine output or oliguria of 20 mL/hr or less than 400 to 500 mL in 24 hr. This is related to decreased perfusion of the kidneys and possible glomerular damage. The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to th

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? A. Deep tendon reflexes 4+ B. Fundal height 14 cm C. Urine protein 2+ D. FHR 152/min

D. FHR 152/min (The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.) Deep tendon reflexes (DTRs) are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia. From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm. The nurse should expect the urine protein for this client to be less than 1+. A urine protein concentration of 2+ is an indication of preeclampsia. Therefore, the nurse should investigate this finding further.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? A. Check the client's temperature. B. Observe for uterine contractions. C. Administer Rho(D) immune globulin. D. Monitor the FHR.

D. Monitor the FHR. (The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.) The nurse should check the client's temperature to monitor for infection following an amniocentesis. However, this is not the priority nursing intervention. The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis. However, this is not the priority nursing intervention. The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. However, this is not the priority nursing intervention.

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? A. Apply a cool pack for 10 min to the heel prior to the puncture. B. Request a prescription for IM analgesic. C. Use a manual lance blade to pierce the skin. D. Place the newborn skin to skin on the mother's chest.

D. Place the newborn skin to skin on the mother's chest. (Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.) A cool pack will constrict the blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a warm pack prior to the puncture. The pain experienced from a heel stick is too brief to warrant risking the adverse effects of parenteral analgesia. A spring-loaded, automatic puncture device is recommended to minimize pain by ensuring that the depth of the puncture is not too deep, avoiding injury to the newborn.

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? A. Singleton pregnancy B. BMI of 20 C. Maternal age 32 years D. Pregestational diabetes mellitus

D. Pregestational diabetes mellitus (Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.) Multifetal gestation, rather than a single fetus pregnancy, increases a client's risk for the development of preeclampsia. Having a BMI greater than 30 increases a client's risk for the development of preeclampsia. A maternal age of younger than 19 or older than 40 increases the client's risk for the development of preeclampsia.

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? A. Administer penicillin G 2.4 million units IM to the client. B. Instruct the client to schedule an annual pelvic examination. C. Tell the client she will start medication for HIV immediately after delivery. D. Report the client's condition to the local health department.

D. Report the client's condition to the local health department. (The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported.) The nurse should administer penicillin G 2.4 million units IM to a client who has syphilis. The nurse should instruct the client to schedule a pelvic examination every 6 months. The nurse should tell the client that treatment for HIV will be during the prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease the transmission of the virus to the newborn.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? A. Hypertonia B. Increased feeding C. Hyperthermia D. Respiratory distress

D. Respiratory distress (Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.) A newborn who has hypoglycemia can exhibit hypotonia. A newborn who has hypoglycemia can exhibit poor feeding behaviors. A newborn who has hypoglycemia can exhibit hypothermia.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count.

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statements as an indication of which of the following?

Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? SATA

Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

Have calcium gluconate readily available. The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?

Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.

A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider?

Hemoglobin 10 g/dL A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take?

Initiate continuous external fetal monitoring. The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?

Iron The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?

Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

Massage the client's fundus. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?

Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers?

Palpate with palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?

Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider?

Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

Staff members who take care of your baby will be wearing a photo identification badge. The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?

Stop suctioning when the newborn's cry sounds clear The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires interventions by the nurse?

Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta?

The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 t0 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Transition The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider?

Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?

You can share your room with your baby for the next few weeks The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.