Newborn and OB

a breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8 F, chills, and malaise. which condition would the nurse suspect? 1. mastitis 2. engorgement 3. blocked milk duct 4. inadequate milk production

1

a newborn has an APGAR score of 3 at 1 minute after birth. which is the immediate nursing action in response to this APGAR score? 1. start resuscitation 2. administer oxygen 3. place in a heated crib 4. stimulate by tapping the toes

1

a primigravida, unsure of the date of their last menstrual period, is told by the nurse that they appear to be at 22 weeks gestation. which data supports the nurse's conclusion? 1. fundus just above the umbilicus 2. fundus just above the symphysis 3. fundal height of 13 inches 4. fundal height of 14 inches

1

while a client is being interviewed on her first prenatal visit she states that she has a 4 yo son who was born at 41 weeks' gestation and a 3 yo daughter who was born at 35 weeks' gestation. the client lost one pregnancy at 9 weeks and another at 18 weeks. using the GTPAL system, how would you record this information? 1. G5 T1 P1 A2 L2 2. G4 T1 P1 A2 L2 3. G4 T2 P0 A0 L2 4. G5 T2 P1 A1 L2

1

while caring for a client during labor, which would the nurse remember about the second stage of labor? 1. it ends at the time of birth 2. it ends as the placenta is expelled 3. it begins with the transition phase of labor 4. it begins with the onset of strong contractions

1

which characteristics are scored on a biophysical profile? select all that apply 1. fetal tone 2 fetal position 3. fetal movement 4. amniotic fluid index 5. fetal breathing movements 6. contraction stress test results

1, 3, 4, 5

at 42 weeks' gestation a client gives brith to a newborn weighing 8 lb 5 oz. on examining the infant, which would there nurse expect to observe? select all that apply 1. long nails 2. wrinkled skin 3. edematous skin 4. abundant body hair 5. obvious blood vessels in the skin

1, 2

which are presumptive signs of pregnancy that the nurse would expect when assessing a client at 10 weeks' gestation? select all that apply 1. amenorrhea 2. breast changes 3. urinary frequency 4. abdominal enlargement 5. positive urine pregnancy test

1, 2, 3

a 42 yo client at 39 weeks' gestation has a reactive non stress test (NST). which interpretation pertains to this result? 1. immediate birth is indicated 2. this is the desired response at this stage of gestation 3. further testing is unnecessary with this desired outcome 4. the result is inconclusive, indicating the need for further evaluation

2

a client who is having her labor induced with oxytocin has internal fetal monitoring in place. her contractions are occurring every 2 minutes, are lasting 70 seconds, and are reaching 65 mm Hg on an intrauterine pressure catheter. the baseline fetal heart rate is 130 to 140 beats/min with variability of about 15 beats/min. the nurse notices that with the past two contractions the featl heart rate began to drop during the peak of the contraction to 110 beats/min, where it remained for about 40 seconds before returning to baseline. which type of pattern is this? 1. bradycardia 2. late decelerations 3. early decelerations 4. variable decelerations

2

the nurse in the postpartum unit is teaching self-care to a group of new mothers. which color would the nurse teach them that the lochial discharge will be on the fourth postpartum day? 1. dark red 2. deep brown 3. pinkish brown 4. yellowish white

3

a client who is pregnant with twins is scheduled for a cesarean birth. which information would the nurse give the client? 1. "we'll give you an enema before the surgery" 2. "we'll be encouraging you to ambulate early after surgery" 3. "you'll be discharged from the hospital in a week" 4. "you should take sponge baths until the incision is healed"

2

a pregnant client asks how smoking will affect her baby. which information about cigarette smoking will influence the nurse's response? 1. it relives maternal tension, and the fetus responds accordingly to the reduction in stress 2. the resulting vasoconstriction affects both fetal and maternal blood vessels 3. substances contained in smoke permeate through the placenta and compromise the fetus's well-being 4. effects are limited because fetal circulation and maternal circulation are separated by the placental barrier

2

which is a risk factor for postpartum hemorrhage? 1. primiparity 2. multiple gestation pregnancy 3. hyperemesis gravidarum 4. family history of postpartum hemorrhage

2

which finding(s) would the nurse identify as normal for a newborn? select all that apply 1. the newborn has a flat abdomen 2. the newborn weighs 6 pounds (2700 g) 3. the newborns hands and feet appear cyanosed 4. the newborn does not blink in the presence of light 5. the circumference of the head is 33 cm (13 inches)

2, 3, 5

which characteristic would the nurse expect infants with failure to thrive to exhibit? select all that apply 1. hyperactivity 2. language deficit 3. being overweight 4. tendency to illness 5. responsiveness to stimuli

2, 4

assessment of a primipara who has had a vaginal birth 2 hours earlier reveals a moderate to large amount of lochia rub, a firm fungus that is at the umbilicus and deviated to the right, and pain that she rates as a 3 on a scale of 1 to 10. which is an immediate goal of nursing care for this client? 1. relieve pain 2. prevent hypotension 3. facilitate client voiding 4. decrease the amount of lochia

3

five minutes after birth, a newborn is given an APGAR score of 8. twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. which would the nurse suspect is the cause of these clinical findings? 1. cerebral palsy 2. neonatal syphilis 3. opioid drug withdrawal 4. fetal alcohol syndrome

3

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? select all that apply 1. food cravings increase 2. nesting needs increase 3. dependency needs decrease 4. anxiety about childbirth increases 5. gastrointestinal motility decreases

2, 4, 5

the nurse is assessing a newborn for signs of hyperbilirubinemia (pathologic jaundice). which finding confirms this complication? 1. muscle irritability within 1 hour of birth 2. neurologic signs during the first 24 hours 3. jaundice that develops in the first 12 to 24 hours 4. audience that develops between 48 and 72 hours after birth

3

the nurse notes that a healthy newborn is lying in the supine position with the head turned to the side with the legs and arms extended on the same side and flexed on the opposite side. which reflex would the nurse document? 1. moro 2. babinski 3. tonic neck 4. palmar grasp

3

which assessment findings correlate with a diagnosis of unruptured tubal pregnancy? select all that apply 1. rigid abdomen 2. referred shoulder pain 3. unilateral abdominal pain 4. history of untreated chlamydia 5. ecchymotic blueness around the umbilicus

3, 4

a newborn is admitted to the nursery with a spiral scalp electrode from an internal monitor in place. how would the nurse remove the electrode? 1. giving the electrode a quick jerk 2. turning the electrode clockwise until it is free 3. untwisting the wires before pulling the electrode out 4. twisting the electrodes counterclockwise until it is free

4

a vaginal examination reveals that a client's cervix is 90% effaced and dilated to 6 cm. the fetus's head is at station 0, and the fetus is in a right occiput anterior position. the contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. which description is appropriate to use when reporting on the client's condition? 1. early first stage of labor 2. transition stage of labor 3. beginning second stage of labor 4. midway through first stage of labor

4

the nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. which other parameter can the nurse use to estimate blood loss in a postpartum client? 1. odor of the lochia 2. color of the lochia 3. presence of small clots on the pad 4. weighing blood stained pads and items

4

which intervention would the nurse perform as soon as a newborn is delivered? 1. removing nasopharyngeal secretions 2. covering the newborn in a warm blanket 3. determining the newborn's APGAR score 4. placing the newborn directly on the mother's abdomen

1

which is the optimal nursing intervention to minimize perineal edema after an episiotomy? 1. applying ice packs 2. offering warm sitz bath 3. administering aspirin as needed 4. elevating the hips on a pillow

1

which direction would be given to a client with a fourth-degree perineal laceration to protect the area from additional trauma? 1. "take sits baths at least 3 times each day" 2. "apply a remoistened anesthetic pad to the area" 3. "avoid straining at stool by use of an enema" 4. "eat a high-fiber diet with increased fluid intake"

4

how would the nurse explain physiological anemia to a pregnant client? 1. erythropoiesis decreases 2. plasma volume increases 3. utilization of iron decreases 4. detoxification by the liver increases

2

for which condition are pregnant women at a five to sixfold increased risk? 1. bradycardia 2. hypetension 3. thromboembolic disease 4. decreased cardiac output

3

the parents of a newborn who is undergoing phototherapy ask the nurse why their baby's eyes are covered with eye patches. how would the nurse respond? 1. "they keep the baby's eyes closed" 2. "they reduce overstimulation from bright lights" 3. "they prevent injury to the conjunctiva and retina" 4. "they limit excessive rapid eye movements and anxiety"

3

a client in labor is having an indwelling urinary catheter inserted. which action by the nurse would help prevent late decelerations of the fetal heart rate during this procedure? 1. position both the client's legs in stirrups simultaneously 2. urge the client to take deep breaths frequently 3. place a rolled towel under the client's right hip 4. loosen the transducer belts around the client's abdomen

3

which assessment findings in a 1-hour -old newborn are characteristic of a preterm gestational age? 1. skin: thin, veins visible; flat areolae, no buds; plantar creases: absent; lanugo: abundant 2. skin: parchment/wrinkled; breasts: flat areolar, no buds; plantar creases: covering the entire sole; lanugo: abundant 3. skin: thin, veins visible; breasts: raised areolar, no buds; plantar creasesL covering the entire sole; lanugoL abundant 4. skin: cracking/few veins; breasts: raised areolae (3 to 4 mm buds); plantar creases: covering the anterior two-thirds of the sole; lanugo: thinning

1

which finding would the nurse report to the health care provider after assessing a 12 hour old newborn? 1. jaundice 2. cephalhematoma 3. erythema toxicum 4. edematous genitalia

1

which impending problem would the nurse suspect when caring for a client with bloody urine in the indwelling catheter collection bag, after an emergency cesarean birth? 1. surgical trauma to the bladder 2. urinary infection from the catheter 3. uterine relaxation with increased lochia 4. disseminated intravascular coagulopathy

1

which information would the nurse include in the discharge teaching of a postpartum client? 1. the prenatal Kegel tightening exercises should be continued 2. a bowel movement may not occur for up to a week after the birth 3. the episiotomy sutures will be removed at the first postpartum visit 4. a postpartum checkup should be scheduled as soon as menses returns

1

which is the priority nursing action when a client at 40 weeks' gestation has an amniotomy performed to facilitate labor? 1. assessing the fetal heart rat e 2. obtaining the maternal vital signs 3. documenting the time of the procedure 4. monitoring the frequency of contractions

1

which laboratory finding of a pregnant client would alert the nurse to the need for further assessment? 1. hemoglobin of 10 2. urine specific gravity of 1.020 3. glucose level of 1+ in the urine 4. white blood cell count of 9000

1

which parent education would the nurse provide about the preferred carrying position for an infant with cerebral palsy prone to scissoring of the legs? 1. astride one of her hips 2. strapped in an infant seat 3. wrapped tightly in a blanket 4. under the arm in a football hold

1

which nursing care interventions are most appropriate if an adolescent client has a positive pregnancy test? select all that apply 1. providing emotional support 2. discussing prenatal notification 3. discussing the client's options for the pregnancy 4. informing the parent before the adolescent 5. asking who else is aware that the client may be pregnant

1, 2, 3

which nursing interventions help prevent heat loss in 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 the maintain the fluid balance

1, 2, 3

how would the nurse explain the cause of caput succedaneum in a newborn to the new mother? 1. overlap of fetal bones as they pass through the maternal birth canal 2. swelling of the soft tissue of the scalp as a result of pressure during labor 3. hemorrhage of ruptured blood vessels that does not cross the suture lines 4. accumulation of fluid resulting from partial blockage of cerebrospinal fluid drainage

2

the nurse is assessing a new mother at a healthcare facility. which symptom would the nurse identify as a symptom of postpartum blues? 1. frantic energy 2. mild irritability 3. hallucinations 4. unwillingness to sleep

2

twelve hours after a spontaneous birth a client's temperature is 100.4 F. which condition would the nurse suspect as the cause of this increase in temperature? 1. mastitis 2. dehydration 3. puerperal infection 4. urinary tract infection

2

which fetal heart pattern indicates cord compression? 1. smooth, flat baseline tracings of 135 beats/min 2. abrupt decreases in fetal heart rate that are unrelated to the contractions 3. accelerations in the fetal heart rate of 10 beats/min above baseline 4. decelerations when a contraction begins that return to baseline when the contraction ends

2

when assessing a client who gave birth 1 day ago, the nurse finds the fungus is firm at 1 finger breadth below the umbilicus and the perineal pad is saturated with lochia rub. which is the nurse's next action? 1. recording these expected findings 2. obtaining a prescription for an oxytocin medication 3. asking the client when she last changed the perineal pad 4. notifying the primary health care provider of excessive bleeding

3

when the fetal monitor is applied to a client's abdomen, it records late decelerations. which action would the nurse take? 1. notify the health care provider 2. elevate the head of the bed 3. reposition the client on her left side 4. administer oxygen by way of facemask

3

which is an appropriate response to a 24 yo client with type 1 diabetes who asks how her pregnancy will affect her Diest and insulin needs? 1. "insulin needs will decrease; the excess glucose will be used for fetal growth" 2. "diet and insulin needs won't change, and maternal and fetal needs will be met" 3. "protein needs will increase, and adjustments to insulin dosage will be necessary" 4. "insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring"

4

which is the priority nursing intervention immediately following amniocentesis? 1. providing perineal care 2. encouraging lots of fluids every hour 3. changing the abdominal dressing 4. monitoring for uterine contractions

4

which is the purpose of a vitamin K injection in a newborn? 1. it promotes conjugation of bilirubin 2. it promotes formation of red blood cells 3. it prevents destruction of red blood cells 4. it provides protection form hemorrhage

4

which education would the nurse provide the parent of an infant with cerebral palsy to support setting care goals? 1. cognitive impairments require special education 2. progressive deterioration requires future institutionalizaiton 3. unknown extent of the disability requires continual adjustments 4. diminished immune responses require protection from infection

3

which finding would prompt the nurse to further assess an infant with Down syndrome? 1. flat occiput 2. small. low-set ears 3. circumoral cyanosis 4. protruding furrowed tongue

3

which is the appropriate nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station? 1. document the fetal heart rate every 5 minutes 2. call the anesthesia department to alert the staff there of an imminent birth 3. assist the client's coach in helping her with the use of breathing techniques 4. suggest that the client accept the as-needed (PRN) medication for pain that has been prescribed

3

which is the optimal method for the nurse to use for assessing a newborn's grasp reflex? 1. stroking gently upward along the sole of the newborn's foot 2. jarring the crib and watching the movement of the newborn's hands 3. pressing the examiner's fingers against the palms of the newborn's hands 4. holding the body upright and allowing the newborn's feet to touch a surface

3

which is the priority nursing action for a client in the second stage of labor? 1. check the fetus's position 2. administer medication for pain 3. promote effective pushing by the client 4. explain that breast-feeding can start right after birth

3

which nursing action would the nurse perform to promote maternal-newborn bonding in the hospital? 1. suggesting that the mother chose breast-feeding instead of formula-feeding 2. advising the mother to call for the newborn to be taken to the nursery when she's tired 3. encouraging the mother to perform simple aspects of her newborn's care 4. observing the mother-infant interaction unobtrusively to evaluate the relationship

3

which nursing intervention would be needed before a client undergoes amniocentesis at 16 weeks' gestation? 1. starting an intravenous infusion of normal saline 2. perfomring a vaginal and rectal examination 3. ensuring that informed consent has been obtained from the client 4. informing the client that she will need bed rest after amniocentesis

3

which sign along with abdominal pain indicates a possible ruptured ectopic pregnancy? 1. bradycardia 2. bleeding 3. hypotension 4. hypertension

3

a newborn who has remained in the hospital because the mother had a cesarean birth is to be tested for phenylketonuria (PKU) on the morning of discharge. how would the nurse explain the purpose of PKU testing to this mother? 1. it detects thyroid deficiency 2. it reveals possible brain damage 3. it identifies chromosomal damage 4. it is used to measure protein metabolism

4

a nurse in the pediatric clinic would be most observant for signs of cerebral palsy in a 6 month old infant in which instance? 1. has a 40 yo mother 2. exhibiting the moro reflex 3. delivered by an elective cesarean birth 4. born at 32 weeks' gestation

4

ten minutes after administering nalbuphine to a woman in active labor, the nurse notes a fetal heart rate of 132 with minimal variability. contractions continue every 2 to 3 minutes, are 60 seconds in duration, and the client reports pain is more tolerable. which action would the nurse take next? 1. reposition the client on the left side to increase placental perfusion 2. administer oxygen via mask to minimize apparent fetal compromise 3. have an opioid antagonist available to be administered to the infant at the time of birth 4. document the findings, including the stable fetal heart rate variability after administration

4

the nurse notes that a child is exhibiting signs of cerebral palsy. at which age are these signs usually first noticeable? 1. 2 years 2. 3 years 3. 3 months 4. 12 months

4

the nurse prepares to administer vitamin K to a newborn. which rationale explains why newborns are deficient in this vitamin? 1. alterations in blood coagulation interfere with vitamin K production 2. a newborn's liver does not produce it immediately after birth 3. increased bilirubin levels interfere with vitamin K synthesis during the neonatal period 4. a newborn's intestinal tract does not synthesize it for several days after birth

4

where would the nurse expect the funds to be located on the second postpartum day? 1. at the level of the umbilicus 2. 1 finger breadth above the umbilicus 3. above and to the right of the umbilicus 4. 1 or 2 finger breadths below the umbilicus

4

which action would the nurse take when a laboratory report indicates that. a postpartum client being prepared fro discharge has a white blood cell (WBC) count of 16,000? 1. check with the nurse manager to see whether the client may go home 2. reassess the client for signs of infection by taking her vital signs 3. delay the client's discharge until the health care provider has conducted a complete examination 4. place the report in the client's record because this is an expected postpartum finding

4

which finding would the nurse be most concerned about hone reviewing the chart of a client scheduled for an amniocentesis? 1. hepatitis B 2. prior uterine surgery 3. active genital herpes 4. B negative blood type

4

according to Naegele rule, which is the expected date of delivery (EDD) of a client whose last menstrual period began on April 15? 1. January 8 2. January 22 3. February 8 4. February 22

2

after the vaginal birth of an infant weighing 8 lb, 13 oz an ice pack is applied to a client's perineum to ease the swelling and pain. subsequently the client complains, "my vagina feels so full and heavy and the pain in it and in my rectum is excruciating." which problem would then nurse suspect is the cause of the pain? 1. full bladder 2. vaginal hematoma 3. infected episiotomy 4. enlarged hemorrhoids

2

which instruction would the nurse give to the pregnant client with anemia? 1. take an iron and calcium supplement together daily 2. drink organ juice with an iron supplement 3. include fresh fruit at every meal 4. include 4 servings of calcium-rich foods daily

2

which intervention would the nurse plan for the breast-feeding client with a diagnosis of mastitis? 1. help hew wean the infant gradually 2. teach her to empty her breasts frequently 3. review nutritional benefits of breast-feeding 4. send a sample of her milk to the laboratory for testing

2

which postpartum client would the nurse assess first? 1. client who vaginally delivered a 7 lb baby 1 hour ago 2. client who vaginally delivered a 9 lb baby 1 hour ago 3. client who vaginally delivered a preterm baby 4 hours ago 4. client who had a planned cesarean delivery of an 8 lb baby 2 hours ago

2

which would the nurse ask the postpartum client to do before assessing her uterine fundus? 1. drink fluids 2. empty her bladder 3. perform the valsalva maneuver 4. assume the semi-fowler position

2

a non stress test (NST) is scheduled for a client with mild preeclampsia. during an NST, the client asks what it means when the fetal heart rate goes up every time the fetus moves. which is an appropriate response? 1. "these accelerations are a sign of fetal well-being" 2. "theses accelerations indicate fetal head compression" 3. "umbilical cord compression is causing these accelerations" 4. "uteroplacental insufficiency is causing these accelerations"

1

a woman who gave birth to a second child 3 weeks ago is depressed, crying, and having extreme difficulty caring for her children. which approach would the nurse take when the husband calls the women's health clinic and asks what he should do? 1. tellings him that his wife may be suffering from depression and needs emergency care 2. letting him know that fatigue is expected and that his wife needs to take rest periods during the day 3. reassuring him that his wife is experiencing postpartum blues that will lessen in several days 4. advising him to make an appointment for his wife to see her primary health care provider if the problem continues

1

an infant has been admitted with failure to thrive. the nurse knows that more education is needed when one of the parents makes which statement? 1. "I can double the amount of water in the formula to save money" 2. "I need to hold her head up a little higher than her stomach when I feed her" 3. "I need to burp the baby when the feeding is done to get rid of swallowed air" 4. "I need to make sure that the formula is in the nipple so she doesn't swallow so much air"

1

an infant has received 3 days of enteral feedings for failure to thrive; all feedings have been retained, but the skin and mucous membranes are dry, and the infant has lost weight. which action would the nurse take next? 1. notify the practitioner 2. document the assessment findings 3. increase the fluid component in the feeding 4. increase the calorie component of the feeding

1

at 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes cyanotic. which is the nurse's initial action? 1. suctioning the mouth 2. administering oxygen 3. notifying the practitioner 4. inserting an endotracheal tube

1

between contractions that are 2 to 3 minutes apart and last about 45 seconds the internal fetal monitor shows a fetal heart rate (FHR) of 100 beats/min. which is the priority nursing action? 1. notify the health care provider 2. resume continuous fetal heart monitoring 3. continue to monitor the maternal vital signs 4. document the fetal heart rate as an expected response to contractions

1

which area of health teaching would the client be most responsive to during the taking-in phase of the postpartum period? 1. perineal care 2. infant feeding 3. infant hygiene 4. family planning

1

which phrase would the nurse use to document a fetal heart rate (FHR) increase of 15 beat over the baseline rate of 135 beats per minute that lasts 15 seconds? 1. an acceleration 2. an early increase 3. a sonographic motion 4. a tachycardia heart rate

1

which rationale would the nurse provide to the client for the instruction to drink water and not void before a scheduled sonogram and amniocentesis at 16 weeks' gestation? 1. to improve visualization of the fetus 2. to hydrate the mother and increase circulation 3. to hydrate the fetus and decrease fetal movement 4. to replace fluid lost during the procedure

1

which test would be used to determine fetal lung maturity in a client in preterm labor? 1. amniocentesis 2. ultrasonography 3. measurement of human gonadotropin hormone 4. chorionic villus sampling

1

which would be included in a plan of care to limit the development of hyperbilirubinemia in the breast-fed neonate? 1. encouraging mire frequent breast-feeding during the first 2 days 2. instituting phototherapy for 30 minutes every 6 hours for 3 days 3. substituting formula feeding for breast-feeding on the second day 4. supplementing breast-feeding with glucose water during the first day

1

which iron-rich foods would the nurse encourage the client with mild anemia in early pregnancy to eat? select all that apply 1. dark leafy green vegetables 2. legumes 3. dried fruits 4. yogurt 5. ground beef patty

1, 2, 3, 5

which consideration would be included in caring for an infant who is failing to thrive (FTT)? select all that apply 1. dietary history 2. signs of malnutrition 3. familial stress factors 4. 75th percentile for weight 5. parent and infant interaction 6. sustained growth under 5th percentile

1, 2, 3, 5, 6

a client who has just begun breast-feeding reports that her nipples feel very sore. which instructions would the nurse provide to this new mother? select all that apply 1. deeply latch the infant to the breast with each feeding 2. take the analgesic medication prescribed to limit the discomfort 3. remove the infant from the breast for a few days to rest the nipples 4. never expose the nipples to air; wear only a tight-fitting brassiere 5. assume a different position when breast-feeding to adjust the infant's sucking

1, 2, 5

which interventions are included in the immediate care plan of a postpartum client with a fourth-degree laceration? select all that apply 1. pain management with oral analgesics 2. continuous application of a warm pack 3. assessment of the site every 15 minutes 4. gentle cleansing with antibacterial cleanser 5. application of an ice pack for 20 minute intervals 6. instructing the client in how to promote normal bowel function

1, 3, 5

the nurse assessing a newborn suspects Down syndrome. which characteristic supports this conclusion? 1. hypotonia 2. high-pitched cry 3. rocker-bottom feet 4. epicentral eye folds

1, 4

which medications would the nurse identify as being used to induce labor in pregnant clients? select all that apply 1. oxytocin 2. ergonovine 3. carboprost 4. misoprostol 5. dinoprostone

1, 4, 5

a client with hyperemesis gravid arum is receiving rehydration infusion therapy at home. which is the priority nursing activity for the home health nurse? 1. determining fetal well-being 2. monitoring for signs of infection 3. monitoring the client for signs of electrolyte imbalance 4. teaching about changes in nutritional needs during pregnancy

3

when the nurse is performing a newborn assessment, which finding indicates the need for follow-up care? 1. presence of the Babinski reflex 2. a head circumference of 33 cm 3. 30 degree abduction of the infant's hips 4. an umbilical cord containing three vessels

3

which behavior indicates a client has entered the second stage of labor? 1. restless, thrashing about 2. complaint of sudden, intense back pain 3. report of feeling pressure on the rectum 4. request for medication to live pain from the strong contractions

3

which clinical finding supports the nurse withholding methylergonovine maleate from a postpartum client? 1. urine output of 50 mL/h 2. third-degree perineal laceration 3. blood pressure of 160/90 mm Hg 4. respiratory rate of 12 breaths/min

3

which condition is most commonly associated with late decorations of the fetal heart rate? 1. head compression 2. maternal hypothyroidism 3. uteroplacental insufficiency 4. umbilical cord compression

3

which ling-term effect is associated with untreated congenital hypothyroidism? 1. myxedema 2. thyrotoxicosis 3. spastic paralysis 4. cognitive impairment

4

which nursing action is most accurate when assessing the chest circumference of a newborn? 1. measuring during expiration only 2. taking 3 measurements and recording the average 3. measuring during inspiration and plotting this data on the growth chart 4. placing the measuring tape around the rib cage at the nipple line

4

which nursing action is most appropriate for a pregnant client at 23 weeks' gestation with pica? 1. offering referral to a mental health care provider 2. explaining the potential danger of pica to the fetus 3. obtaining a prescription for an iron supplement 4. determine whether the diet is safe and nutritionally adequate

4