N482 Final Exam HESIs

A client who is having a difficult labor is diagnosed with cephalopelvic disproportion. Which medical orders should the nurse question? a) Maintain NPO status b) Start peripheral IV of ¼ NS c) Record fetal heart tones every 15minutes d) Piggyback another 10-unit bag of oxytocin (Pitocin)

d) Piggyback another 10-unit bag of oxytocin (Pitocin)

On the third postpartum day after an unexpected cesarean birth, the nurse finds the mother crying. The client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" Which information would the nurse consider when responding? a. The client's feelings will pass after she has bonded with her infant. b. The client is probably suffering from postpartum depression and needs special care. c. A cesarean birth may be a traumatic experience, but most women know that it is a possible outcome d. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statements may reflect this.

d. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statements may reflect this.

A vaginal examination reveals that a client's cervix is 90% effaced and dilated 6 cm. The fetus's head is at station 0 and the fetus is in an ROA position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? a. early first stage of labor b. transition stage of labor c. beginning second stage of labor d. midway through first stage of labor

d. Midway through first stage of labor

After her baby's birth a client wishes to begin breast-feeding as soon as possible. How can the nurse best assist the client at this time? a. Giving the infant a bottle first to evaluate the sucking reflex b. Positioning the infant to grasp the nipple to express colostrum c. Leaving the infant and parents alone to promote attachment behaviors d. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

d. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

Which preexisting condition is an indication for a cesarean birth? a. gonorrhea b. chlamydia c. chronic hepatitis d. active genital herpes

d. active genital herpes

Which additional nursing care is needed for the postpartum client after a cesarean birth due to her postsurgical status? a. encouraging early ambulation b. assessing the fundus gently but firmly c. checking vital signs for evidence of shock d. administering the prescribed pain medications in scheduled intervals

d. administering the prescribed pain medications in scheduled intervals

Which answer would the nurse give to a client who asks what is the common cause of a spontaneous abortion? a. physical trauma b. unresolved stress c. congenital defects d. embryonic defects

d. embryonic defects

A client reports chills, severe abdominal pain, and increased vaginal discharge. Which infection would the nurse suspect? a. gonorrhea b. chlamydia c. trichomoniasis d. pelvic inflammatory disease

d. pelvic inflammatory disease

A registered nurse is teaching an adolescent female client with irregular menstruation about contraception. Which statements made by the client indicates the need for further education? Select all that apply. "The calendar method of oral contraception is best suitable for me." "The withdrawal method of contraception has high incidences of failure." "Condoms do not offer protection against sexually transmitted infections." "Oral contraceptive pills offer protection from sexually transmitted diseases." "Three-month injectable contraceptive medications may cause weight gain and decreased bone density.

"The calendar method of oral contraception is best suitable for me." "Condoms do not offer protection against sexually transmitted infections." "Oral contraceptive pills offer protection from sexually transmitted diseases."

An infant born in the 36th week of gestation weighs 4 lb 3 oz (2062 g) and has Apgar scores of 7 and 9. What nursing actions will be performed on the infant's admission to the nursery? (Select all that apply.) 1 Recording of vital signs 2 Administration of nasal cannula oxygen 3 Offering a bottle of dextrose in water 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable

1 Recording of vital signs 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. 1 The nurse keeps the newborn covered in warm blankets. 2 The nurse keeps the newborn under the radiant warmer. 3 The nurse places the newborn on the mother's abdomen. 4 The nurse measures the newborn's temperature regularly. 5 The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

1 The nurse keeps the newborn covered in warm blankets. 2 The nurse keeps the newborn under the radiant warmer. 3 The nurse places the newborn on the mother's abdomen.

A nurse is giving discharge instructions to a new mother. What is the most important instruction to help prevent postpartum infection? 1 "Don't take tub baths for at least 6 weeks." 2 "Eat a balanced diet and get plenty of rest." 3 "Douche with a dilute antiseptic solution twice a day and continue for a week." 4 "Tampons are better than sanitary napkins for inhibiting bacteria in the postpartum period."

2 "Eat a balanced diet and get plenty of rest."

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? Select all that apply .1. "Wash your hands before touching the newborn." 2. "Send the newborn to nursery to be monitored during the night." 3. "All client identification bands should remain in place until discharge." 4. "Do not let anyone remove the infant from your sight while you are in the hospital." 5. "Check the identification of staff, and if there is a question of validity, call the nursing station."

1. "Wash your hands before touching the newborn." 3. "All client identification bands should remain in place until discharge." 5. "Check the identification of staff, and if there is a question of validity, call the nursing station."

The nurse is caring for a client who is in the taking-in phase of the postpartum period. The area of health teaching that the client will be most responsive to is: 1. Perineal care 2. Infant feeding 3. Infant hygiene 4. Family planning

1. Perineal care

A woman who gave birth to a second child 3 weeks ago is depressed and having difficulty caring for her children. At the end of the day both of the children are dirty, wet, and crying. The woman tells her husband that she "just can't take this anymore." The husband calls the women's health clinic and asks what he should do. What is the best response by the nurse? 1. Telling him that his wife may be suffering from depression and needs emergency care 2. Telling him that fatigue is expected and that his wife needs to take rest periods during the day 3. Reassuring him that his wife is experiencing 4. Advising him to make an appointment for his wife to see her practitioner if the problem continues

1. Telling him that his wife may be suffering from depression and needs emergency care

Which information should the nurse include in the discharge teaching of a postpartum client? 1.The prenatal kegel tightening exercise should be continued 2. The episiotomy sutures will be removed at the first postpartum visit 3. She may not have a bowel movement for up to a week after birth 4. She should schedule a postpartum checkup as soon as her menses returns

1.The prenatal kegel tightening exercise should be continued

At 37 weeks' gestation a client's membranes spontaneously rupture but she does not have contractions. What action is most important in the nursing plan of care for this client? 1Assessing maternal temp 2Monitoring for signs of preeclampsia 3Monitoring for heavy vaginal bleeding 4Making preparations for fetal scalp pH sampling

1Assessing maternal temp

A client at 28 weeks' gestation has a sonogram. The results reveal a small-for-gestational age fetus and a low-lying placenta. For what complication should the nurse assess this client during the last trimester of pregnancy? 1 Preterm labor 2 Placenta previa 3 Premature separation of the placenta 4 Premature rupture of the membranes

2 Placenta previa

A client in her 36th week of gestation is admitted with vaginal bleeding, severe abdominal pain, a rigid fundus, and signs of impending shock. For which intervention would the nurse prepare? 1. A high-forceps birth 2. An immediate cesarean birth 3. Insertion of an internal fetal monitor 4. Administration of an oxytocin infusion

2. An immediate cesarean birth

Which response would the nurse provide to the client who is asking for guidance about sexual activity in pregnancy? 1 "You should discontinue intercourse after the second trimester." 2 "This information can be given only by your obstetrician or nurse-midwife." 3 "With an uncomplicated pregnancy, there are no limitations on sexual activity." 4 "Sexual activity should be avoided during the first and last 6 weeks of pregnancy."

3 "With an uncomplicated pregnancy, there are no limitations on sexual activity."

Which finding indicates that a newborn has vernix caseosa? 1 Brown hair on the skin 2 Rosy to yellowish skin 3 Cheese-like substance on the skin 4 Light-pink to reddish-brown skin

3 Cheese-like substance on the skin

A client admitted with preeclampsia is receiving magnesium sulfate. Which assessment finding indicates that a therapeutic level of the medication has been reached? 1Increased fetal activity 2Decreased urine output 3Deep tendon reflexes of +2 4Respiratory rate of 12 breaths/min

3Deep tendon reflexes of +2

Despite medication, a client's preterm labor continues, her cervix dilates, and birth appears inevitable. Which medication does the nurse anticipate will be prescribed to increase the chance of the newborn's survival? 1Carboprost tromethamine 2Misoprostol 3Nalbuphine HCl 4Betamethasone

4Betamethasone

A client expresses a desire to breast-feed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breast-feed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request? 1By telling the client that this is unnecessary because the infant is being fed by gavage 2By discouraging the client because of the time and effort it will take to pump her breasts 3By instructing the client that breast milk is inadequate because it does not contain the necessary nutrients 4By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion

4By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion

The nurse is caring for a preterm infant who is receiving oxygen therapy. What should the nurse do to prevent retinopathy of prematurity (ROP)? 1Cover the neonate's eyes with a shield 2Place the neonate in an elevated side-lying position 3Assess the neonate every hour with a pulse oximeter 4Support the neonate's oxygen saturation while providing minimal FiO2

4Support the neonate's oxygen saturation while providing minimal FiO2

Which action would the nurse take before birth when meconium staining is present? 1Monitoring the neonate's heart rate 3Assessing the neonate's respiratory effort 4Suctioning the neonate's mouth and nose 5Gathering equipment for neonatal resuscitation

5Gathering equipment for neonatal resuscitation

After a client gives birth, what physiologic occurrence indicates to the nurse that the placenta is beginning to separate from the uterus and is ready to be expelled? A sudden gush of blood

A sudden gush of blood

The nurse is assessing her assignment of four postpartum clients. Which conditions increase the risk for postpartum hemorrhage? Select all that apply. A. Twin birth B. Overdistended bladder C. Hypertonic uterine dystocia D. Retained placental fragments E. Mild gestational hypertension

A. Twin birth B. Overdistended bladder D. Retained placental fragments

Two days after being discharged a new mother calls the clinic stating that she is not sure that her baby is receiving enough breast milk. What information does the nurse need to determine whether the infant is being fed adequately? A. Voids four times before 2 pm B. Sleeps 3½ to 4 hours between feedings C. Has two or more bowel movements each day D. Nurses 5 minutes on the first breast and 10 on the other

A. Voids four times before 2 pm

Which intervention would the nurse anticipate when caring for a postpartum mother who is AB negative, had a negative Coombs test, and delivered a neonate whose blood group is B positive? a. Administering Rho(D) immune globulin IV to the mother within 1 week of delivery b. Administering Rho(D) immune globulin intramuscularly to the mother within 72 hours of delivery c. Administering Rho(D) immune globulin intramuscularly to the mother within 1 week of delivery d. Administering Rho(D) immune globulin IV to the mother within 72 hours of delivery

B. Administering Rho(D) immune globulin intramuscularly to the mother within 72 hours of delivery

Which physiological changes are expected during the first trimester of pregnancy? a. Fatigue b. Increased libido c. Morning sickness d. Breast enlargement e. Braxton hicks contractions

a. Fatigue c. Morning sickness d. Breast enlargement

A 25-year-old woman comes to the clinic complaining of increased vaginal discharge, milky gray in color with a "fishy" odor that both she and her husband have noticed. A wet smear is performed and the presence of "clue cells" confirmed. Which type of infection does the nurse suspect? Candidiasis Trichomoniasis Bacterial vaginosis Group B Streptococcus

Bacterial vaginosis

A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial reaction? A. obtaining the requested formula B. Administering the prescribed pain medication C. Assessing the client's breastfeeding technique D. Notifying the practicioner of the client's request to switch feeding methods

C. Assessing the client's breastfeeding technique

Based on the med chart, the nurse would need to inform the HCP regarding which client?

Client B

A client is admitted to the birthing suite with a blood pressure of 150/90 mm Hg, 3+ proteinuria, and edema of the hands and face. A diagnosis of severe preeclampsia is made. What other clinical findings support this diagnosis? Select all that apply. Headache Constipation Abdominal pain Vaginal bleeding Visual disturbances

Headache Abdominal pain Visual disturbances

A client with preeclampsia is admitted to the labor and birthing suite. Which signs or symptoms would the client display if she were developing hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome)? Select all that apply. Headache Constipation Right upper quadrant pain Vaginal bleeding Nausea and vomiting

Headache Right upper quadrant pain Nausea and vomiting

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time? Helping the client change her position Informing the client of the problem with the fetus Administering oxygen by mask. Readjusting placement of the fetal monitor on the client's abdomen

Helping the client change her position

The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information should the nurse give to this client? Insulin needs will increase during the second trimester. Insulin needs will decrease during the second trimester. Insulin needs will not change during the second trimester. Insulin will be switched to an oral antidiabetic medication during the second trimester.

Insulin needs will increase during the second trimester.

What does the nurse expect the size of a newborn to be if the mother had inadequately controlled type 1 diabetes during her pregnancy?Average for gestational age, term Small for gestational age, preterm Large for gestational age, postterm Large for gestational age, near term

Large for gestational age, near term

Which client is at increased risk for postpartum hemorrhage? One who breast-feeds in the birthing room One who receives a pudendal block for the birth One whose third stage lasts less than 10 minutes One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

One who gives birth to an infant weighing 9 lb 8 oz (4366 g)

A 28-year-old woman seeks advice about oral contraceptives from the nurse in her company health office. What should the nurse tell her if she is a smoker? Oral contraceptives can cause thrombophlebitis. Oral contraceptives can be used with other methods. Some oral contraceptives can be used without concern. Some oral contraceptives are safe while others are not safe

Oral contraceptives can cause thrombophlebitis.

Which foods would the nurse counsel the client at 14 week's gestation to avoid during pregnancy? Yogurt Oily fish Apricots Raw shellfish Herbal supplements Soft-scrambled eggs

Raw shellfish Herbal supplements Soft-scrambled eggs

A newborn is diagnosed as having neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? Administering an opioid antagonist Limiting fluid intake to inhibit vomiting Assessing for age-appropriate developmental level Reducing environmental stimuli to promote relaxation

Reducing environmental stimuli to promote relaxation

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately? Reposition the client from supine to left lateral Increase the IV flow rate from 125 to 150 mL/hr. Administer oxygen at a rate of 8-10 L/min by way of facemask. Assess the maternal blood pressure for a systolic BP of < 100.

Reposition the client from supine to left lateral

A female client reports a white, thick, odorless discharge from the vulva. Upon examination, the nurse finds that the vulva are swollen. What does the nurse suspect in the client? a. Candida infection b. bacterial vaginosis c. trichomonas d. chlamydia

a. Candida infection

A newborn is being treated with phototherapy for hyperbilirubinemia. What is the nurse's role when providing phototherapy? 1 Turning the infant every 2 hours 2 Measuring the bilirubin level every 2 hours 3 Maintaining the infant on daily 24-hour phototherapy 4 Applying a sterile gauze pad to the infant's umbilical stump

Turning the infant every 2 hours

The nurse is assessing a pregnant client at the end of her second trimester. Which clinical finding causes the nurse to suspect that the client has preeclampsia? Progressive weight gain Two urine samples showing proteinuria Dependent ankle edema during the late afternoon Blood pressure fluctuations on three successive measurements

Two urine samples showing proteinuria

A nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. What other parameter can the nurse use to estimate blood loss in a postpartum client? Odor of the lochia Color of the lochia Presence of small clots on the pad Weighing blood stained pads and items

Weighing blood stained pads and items

Which response would the nurse give to a client who asks what having a fetus in longitudinal lie means in relation to her labor and birth of the baby? a. "A vaginal birth is possible." b. "We're anticipating a cesarean delivery." c. "It has no relevance to the labor and birth." d. "Labor probably will be long, and you might have back pain."

a. "A vaginal birth is possible."

On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? a. Assess her breastfeeding techniques to identify possible causes. b. Provide a nipple shield to keep the infant's mouth off the nipples. c. Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. d. Explain that she should pump her breasts and give milk in a bottle until the soreness subsides.

a. Assess her breastfeeding techniques to identify possible causes.

While a client is being interviewed on her first prenatal visit she states that she has a 4 year old son who was born at 41 week's gestation and a 3 year old daughter who was born at 35 week's gestation. The client lost one pregnancy at 9 weeks and another at 18 weeks. using GTPAL system, how would you record this information a. G5 T1 P1 A2 L2 b. G4 T1 P1 A2 L2 c. G4 T2 P0 A0 L2 d. G5 T2 P1 A1 L2

a. G5 T1 P1 A2 L2

Which assessments and interventions are necessary once an epidural catheter has been inserted? SATA. a. Maintain IV fluid administration. b. Have oxygen available in case of hypotension. c. Check the bladder for distention every 2 hours. d. Position the client supine for ease of monitoring. e. Monitor fetal heart rate and labor progress per hospital protocol. f. Administer an oxytocin infusion to maintain the labor pattern.

a. Maintain IV fluid administration. b. Have oxygen available in case of hypotension. c. Check the bladder for distention every 2 hours. e. Monitor fetal heart rate and labor progress per hospital protocol.

Which information would the nurse include when teaching a client experiencing a postterm pregnancy? SATA. a. Monitor for signs of labor. b. Perform daily fetal movement counts. c. Go to the birthing facility soon after labor begins. d. Call the Primary HCP if the membranes rupture. e. Keep appointments for fetal assessment tests and cervical checks.

a. Monitor for signs of labor. b. Perform daily fetal movement counts. c. Go to the birthing facility soon after labor begins. d. Call the Primary HCP if the membranes rupture. e. Keep appointments for fetal assessment tests and cervical checks.

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next? a. Placing the newborn under a radiant warmer and attaching a skin probe b. checking the newborn for a wet diaper and then continuing skin to skin contact c. leaving the infant in skin to skin contact and rechecking the temp in 1 hr d. double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

a. Placing the newborn under a radiant warmer and attaching a skin probe

A woman arrives for an appointment at an obstetrics clinic. During the visit the nurse records the following information. Which finding indicates a need for future intervention? a. Rubella titer less than 1:8 (nonimmune) b. no fetal heartbeat heard with fetoscope c. hemoglobin 11 g/dL, hematocrit 31% d. Maternal blood type - A-negative, father O-negative

a. Rubella titer less than 1:8 (nonimmune)

Which are presumptive signs of pregnancy that the nurse would expect when assessing a client at 10 weeks gestation? a. amenorrhea b. breast changes c. urinary frequency d. abdominal enlargement e. positive urine pregnancy test

a. amenorrhea b. breast changes c. urinary frequency

Which assessment finding indicates that a client at 40 weeks gestation is experiencing true labor? a. cervical dilation b. membrane rupture c. decreased fetal heart rate d. intensification of contractions

a. cervical dilation

Which method is a barrier type of contraception? SATA. a. condom b. diaphragm c. lea's shield d. spermicidal foam e. coitus interruptus

a. condom b. diaphragm c. lea's shield

Which is the best time for the nurse to teach simple breathing and relaxation techniques to a client in labor that has not attended any childbirth classes? a. during the latent phase of the first stage of labor b. during the active phase of the first stage of labor c. during the active phase of the second stage of labor d. during the transition phase of the first stage of labor

a. during the latent phase of the first stage of labor

The charge nurse is delegating tasks for the nursing assistants regarding the postpartum care of a client. Which task is appropriate to be delegated to an unlicensed assistive personnel (UAP) to provide effective client care? Select all that apply. a. feeding the client b. providing basic hygiene c. teaching care of the infant d. encouraging breast-feeding e. administering IV fluids

a. feeding the client b. providing basic hygiene d. encouraging breast-feeding

A client in active labor is 100% effaced, dilated 3 cm, and at +1 station. Which stage of labor has this client reached? a. first b. latent c. second d. transitional

a. first

Which stage of syphilis is the client experiencing when there are not any clinical manifestations? a. latent b. tertiary c. primary d. secondary

a. latent

In which circumstance would newborn blood incompatibility be most likely to occur if the mother has blood type O and Rh factor positive? a. the newborn has type A or B blood b. The newborn is preterm c. The newborn has diabetes d. The newborn has blood type O and Rh factor positive

a. the newborn has type A or B blood

Which action would the nurse include in the plan of care for a client who is being treated for a sexually transmitted infection and reports fever and irregular bleeding? 1. use of analgesics 2. abdominal palpation 3. Complete blood count 4. culture of the cervical canal 5. administration of antibiotics as prescribed 6. teaching about negative effects of douching

all answers are correct

Which information regarding risks that may result from an untreated chlamydia infection would the nurse include when providing education for a female client? Select all that apply. One, some, or all responses may be correct. a. Sterility b. Ectopic pregnancy c. Blocked Fallopian tubes d. Pelvic inflammatory disease e. Increased likelihood of HIV infection

all answers are correct

After 8 postpartum hours the nurse determines that a client's fundus is 3 cm above the umbilicus and displaced to the right. Which statement is most significant in confirming the reason for the location of the uterus? a. "I've been so thirsty the past few hours." b. "I've been to the bathroom but I can't seem to urinate." c. "I've changed my pad since I got to my room." d. "I've had a lot of contractions, especially while I was nursing."

b. "I've been to the bathroom but I can't seem to urinate."

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. what is the primary reason for this instruction? a. The supine position can prolong the course of labor. b. Decreased placenta perfusion is seen in the supine position. c. This position can lead to transient episodes of HTN. d. Lying on the back interferes with free movement of the coccyx.

b. Decreased placenta perfusion is seen in the supine position.

Which medication is indicated for evacuation in case of a miscarriage? a. clomiphene b. Dinoprostone c. methylergonovine d. magnesium sulfate

b. Dinoprostone

A client presents to the clinic with complaints of nausea and amenorrhea and reports that she obtained a positive result on a home pregnancy test. Which component of the history is most indicative of pregnancy? a. Her menses is a week late b. Her urine immunoassay test is positive. c. She reports that she has urinary frequency d. She complains that she has nausea every morning.

b. Her urine immunoassay test is positive.

Which organism may be responsible for the condition of a client reporting painful urination, profuse purulent urethral discharge, and enlarged testicles who had a NAAT ordered by the PHCP? a. treponema pallidum b. Neisseria gonorrhea c. chlamydia trachomatis d. condylomata acuminata

b. Neisseria gonorrhea

Which changes would the nurse include in the childbirth class focusing on the maternal psychologic and physiologic alterations that occur near the end of pregnancy? a. Food cravings increase b. Nesting needs increase c. Dependency needs decrease d. Anxiety about childbirth increases e. Gastrointestinal motility decreases

b. Nesting needs increase d. Anxiety about childbirth increases e. Gastrointestinal motility decreases

A nurse is teaching a class of expectant parents about changes that are to be expected during pregnancy. What changes does the nurse explain result from the melanocyte-stimulating hormone? chloasma urinary frequency morning sickness cervical softening effacement linea nigra

chloasma linea nigra

Which finding(s) would the nurse identify as normal for a newborn? Select all that apply. One, some, or all responses may be correct a. The newborn has a flat abdomen. b. The newborn weighs 6 lbs (2700g) c. The newborn's hands and feet appear cyanosed. d. The newborn does not blink in the presence of light. e. The circumference of the head is 33 cm (13 inches).

b. The newborn weighs 6 lbs (2700g) c. The newborn's hands and feet appear cyanosed. e. The circumference of the head is 33 cm (13 inches).

The nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. Which is the physiological mechanism of this therapy? a. stimulates the liver to dispose of the bilirubin b. breaks down the bilirubin into a conjugated form c. facilitates the excretion of bilirubin by activating vitamin K d. dissolves the bilirubin, allowing it to be excreted by the skin

b. breaks down the bilirubin into a conjugated form

Which postpartum client would the nurse assess first? a. client who vaginally delivered a 7 lb baby 1 hour ago b. client who vaginally delivered a 9 lb baby 1 hour ago c. client who vaginally delivered a preterm baby 1 hour ago d. client who had a planned cesarean delivery of an 8 lb baby 2 hours ago

b. client who vaginally delivered a 9 lb baby 1 hour ago

Which intervention would the nurse suggest to ease back discomfort during labor? a. alternating lying on the back and side b. having support persons use back massage techniques c. using distraction techniques such as abdominal effleurage d. maintaining the knee-chest position before and after assessments of the fetal heart rate

b. having support persons use back massage techniques

Which would the nurse expect to find when assessing a client suspected of having abruptio placentae? a. bright-red vaginal bleeding and multiple clots b. uterine tenderness and increased fetal activity c. cessation of contractions and decreased uterine size d. concealed hemorrhage and fetal heart rate accelerations

b. uterine tenderness and increased fetal activity

During a routine second-trimester visit to the prenatal clinic a client expresses concern regarding gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response? a. "That's fine as long as you include a variety of foods daily." b. "It's a good idea for you to keep your weight down during your pregnancy." c. "If you add 340 calories a day to your regular diet, you won't become overweight." d. "Gain no more than 25 lb (11 kg) so that it'll be easier to lose the weight after the baby is born."

c. "If you add 340 calories a day to your regular diet, you won't become overweight."

During a childbirth class, several participants have questions about the elective induction of labor. One participant states that it is more convenient for a woman with a busy schedule. What evidenced-based information should the nurse provide to the participant? a. "Elective induction rates are dropping nationwide." b. "Elective induction is recommended if the client has a classic uterine incision." c. "There are risks and benefits to elective induction of labor to consider." d. "There is no evidence that elective induction makes any difference in the labor experience."

c. "There are risks and benefits to elective induction of labor to consider."

A nurse is caring for a postpartum client. Where does the nurse expect the fundus to be located if involution is progressing as expected 12 hours after birth? a. 2 cm below the umbilicus b. 3 cm above the umbilicus c. 1 cm above the umbilicus d. 3 cm below the umbilicus

c. 1 cm above the umbilicus

Which assessment finding would the nurse identify as significant in an infant of a diabetic mother who is LGA? a. temp < 98 b. HR 110 bpm c. BG < 40 d. increasing bilirubin during first 24 hours

c. BG < 40

Now, on admission to the newborn nursery, it is noted that the infant has signs of respiratory distress, and transient tachypnea of the newborn is suspected. The nurse reviews the mother's obstetric history and takes the neonate's vital signs. In light of this information and the nursery routine, what is the most appropriate intervention by the nurse for this newborn?. (Temp: 98, HR 144 Resp 78) a. Feed glucose water. b. Bathe with mild soap. c. Keep in overbed warmer. d. Take to mother's bedside for further bonding.

c. Keep in overbed warmer.

A client expresses a desire to postpone her first pregnancy for at least 5 years. She smokes 1.5 packs of cigarettes a day, has never been pregnant, and does not want to use a barrier method. Which method does the nurse anticipate the primary healthcare provider will recommend? a. a birth control patch b. a vaginal ring c. Medroxyprogesterone d. combined oral contraceptive pills

c. Medroxyprogesterone

The parents of a newborn who is undergoing phototherapy ask a nurse why their baby's eyes are covered with eye patches. What information should the nurse remember before responding? a. They keep the baby's eyes closed b. They reduce overstimulation from bright lights c. They prevent injury to the conjunctiva and retina d. They limit excessive rapid eye movements and anxiety.

c. They prevent injury to the conjunctiva and retina

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? a. Deltoid muscle b. Rectus femoris c. Vastus lateralis d. Gluteus maximus

c. Vastus lateralis

Which nursing action would the nurse perform to promote maternal-newborn bonding in the hospital? a. suggesting that the mother choose breast-feeding instead of formula-feeding b. advising the mother to call for the newborn to be taken to the nursery when she's tired c. encouraging the mother to perform simple aspects of her newborn's care d. observing the mother-infant interaction unobtrusively to evaluate the relationship

c. encouraging the mother to perform simple aspects of her newborn's care

A client comes to the emergency room reporting severe abdominal cramping and heavy bleeding at 10 weeks gestation. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experiencing? a. missed b. complete c. inevitable d. threatened

c. inevitable

What is the optimal method for the nurse to use for assessing a newborn's grasp reflex? a. stroking gently upward along the sole of the newborn's foot b. jarring the crib and watching the movement of the newborn's hands c. pressing the examiner's fingers against the palm of the newborn's hand d. holding the body upright and allowing the newborn's feet to touch a surface

c. pressing the examiner's fingers against the palm of the newborn's hand

Which intervention would the nurse implement to prevent infection of the newborn in a pregnant client with gonorrhea? a. oral antibiotics for newborn b. schedule a cesarean delivery c. silver nitrate ophthalmic ointment d. IV antibiotic before delivery

c. silver nitrate ophthalmic ointment