OB ATI practice
A nurse is caring for a client who is at 16 weeks gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? - 20-gauge needle and administer the medication using the Z-track method - 25-gauge needle and administer into the deltoid - 22-gauge needle and administer into the thigh - 18-gauge needle and administer into the rectus femoris muscle
20-gauge needle and administer using the Z-track method - correct size, Z-track prevents staining of tissue - iron is thick and only given in the very large ventrogluteal muscle
A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? - increased platelet count - fetal distress - decreased urinary output - dark red vaginal bleeding
dark red vaginal bleeding - clients w a MILD abruption will have platelets, FHR, and urinary output within expected ranges
A nurse is caring for a client who is at 39 weeks gestation and in active labor. Which of the following actions should the nurse include in the plan of care? - keep all 4 side rails up while the client is in bed - monitor the FHR every hour - insert an indwelling urinary catheter - check the cervix prior to analgesic administration
check the cervix prior to analgesic administration - if given too close to delivery, analgesic could cause resp depression in the newborn - raising side rails not usually required unless clients have been medicated - FHR should be monitored every 15-30 in the first stage of labor and 5-15 minutes in the second stage (high risk patients = more frequently) - not necessary under normal circumstances. assess bladder fullness, especially w epidural anesthesia, straight cath for patients who can't void
A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. The nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? - check the newborn's heart rate - place a pressure dressing on the cord stump - administer vitamin K - check the integrity of the cord clamp
check the cord clamp - if it's loosened or opened, immediately apply a new clamp - pressure dressing will not stop bleeding from a vessel, but is used to stop bleeding from a laceration or incision (circumcision) - vitamin K is given immediately after delivery for clotting
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? - prepare to initiate a warm water sitz bath for the client's perineum - encourage the client to sit on a soft pillow - apply cold ice packs to the client's perineum - admin an acetaminophen suppository rectally
apply cold ice packs to the client's perineum - 3rd degree extends from perineum to external rectal sphincter causing severe discomfort, ice packs for the first 24 to decrease edema, pain, discomfort - warm sitz baths are appropriate AFTER the first 24, cool sitz baths are recommended for the first 24 - sit on firm surfaces instead; soft pillows can separate the buttocks and decrease venous flow causing more pain - suppositories and enemas are contraindicated in clients who have 3rd degree lacerations
A nurse is assisting with FH monitoring during labor for a client who is at 40 weeks gestation. The nurse should identify that which of the following findings on the fetal monitoring tracing requires intervention? - FHR of 180/min for 15 minutes - a decel that returns to baseline at the end of a contraction - an acceleration of 20/min for 18 sec during a contraction - an occasional variable decel in the FHR
FHR of 180/min for 15 minutes - fetal tachycardia = 160/min for 10 minutes or longer; can signify fetal hypoxemia - early decels are harmless - 15/min at 15 seconds indicates fetal well being - occasional variable decels do not require intervention, persistent variable decels require action
A nurse is assessing a 12-hour-old newborn and notes resp. rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? - perform chest percussion - place the newborn in a prone position - continue routine monitoring - request a prescription for supplemental oxyen
continue routine monitoring - short periods of apnea are expected, indicating adaptation to extrauterine life - signs of need to supp. O2: tachypnea, nasal retractions, stridor, gasping
A nurse is caring for a client who is 24 years old and 13 weeks gestation. The client's history shows a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4167.38 g. (9 lb. 3 oz.). Which of the following lab values should the nurse expect to collect? - maternal serum alpha-fetoprotein - pregnancy associated plasma protein A - chorionic cillus sampling - HbA1c
HbA1c - considering hx, patient is at risk for impaired glucose metabolism and needs to be screened at the end of the 1st trimester - serum alpha-fetoprotein is for open neural tube defects at 16-18 weeks, not related to obesity or macrosomia - plasma protein A is for potential birth defects at 16-18 weeks - chorionic villus sampling is for women over 35, those with hx of spont. abortion, pregnancies w chromosomal defects, abnormal US findings
A nurse is reviewing the lab findings of a 24-hour old newborn. Which of these should be reported to the provider? - Hgb 12 g/dL - platelet count 200,000 - total bilirubin 4 mg/dL - glucose 50 mg/dL
Hgb 12 g/dL - expected range 14-24 /dL - platelet count range 150k-300k -bilirubin 2-6 mg/dL - serum glucose 40-60 mg/dL
A nurse is prepping to administer naloxone to a newborn. Which of the following conditions can require administration of the medication? - IV narcotics administered to the mother during birth - maternal drug use - hyaline membrane disease - meconium aspiration
IV narcotics administered to the mother during labor - reverse resp depression d/t acute narcotic toxicity - using naloxone in a newborn with narcotics exposure can result in immediate withdrawal symptoms - no effect on hyaline membrane disease - no effect on meconium aspiration
A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? - place the client's hand in warm water - administer an analgesic to the client - pour water from a squeeze bottle over the client's perineum - assist the client to the bathroom
assist the client to the bathroom - encourage spontaneous voiding before other methods - yes, or a warm shower/sitz bath, but not first - can facilitate voiding, helpful with pain, but not first - can stimulate voiding, not first
A nurse in a postpartum unit is caring for a client who plans to breastfeed her newborn exclusively. She has a presciption for depot medroxyprogesterone acetate (DMPA). At which of the following time should she receive the firsts dose? - after 3 months postpartum - at six weeks postpartum - within the first five days postpartum - during the first week of the first postpartum menstrual cycle
at 6 weeks postpartum - after ensuring they're not pregnant - it's depo provera - the second dose is given 3 months after the first - if the mom isn't breastfeeding, the first dose is given within the first 5 PP days - in a not pregnant patient, the first dose should be given during the first 5 days of a normal menstrual period...after ensuring they're not pregnant
The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns for PKU? - X-linked recessive - X-linked dominant - autosomal recessive - autosomal dominant
autosomal recessive - like cystic fibrosis and sickle cell
A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer? - betamethasone - misprostol - methylergonovine - poractant alfa
betamethasone - IM, glucocorticoid, stimulates fetal lung maturity - misoprostol to stimulate UCs for labor induction - methylergonovine to stimulate UCs for PP hemorrhage - poractant alfa, synthetic surfactant, to preterm newborns experiencing resp distress
A nurse administers betamethasone to a client who is 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? - hyperthermia - decreased blood glucose - rapid pulse rate - irritability
decreased blood glucose - beta causes hyperglycemia (corticosteroid) and predisposes baby to hypoglycemia in the first hours after delivery - does not affect temp, not an adverse effect of beta - does not affect baby's vitals, if the baby has a rapid apical pulse it's related to another cause (prematurity, resp distress) - irritability is not an adverse effect
A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take? - prepare for emergency cesarean delivery - discontinue oxytocin infusion - position the parent to facilitate the McRoberts maneuver - gather equipment for neonatal resuscitation
gather equipment for neonatal resuscitation - meconium aspiration syndrome - indications for c-section: abnormal FHR, malpresentation, maternal HIV, active herpes lesions, congenital abnormalities - does not require oxytocin to stop. oxytocin should be discontinued w late or variable decels - the McRoberts maneuver is done w shoulder dystocia
A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? - admin magnesium sulfate 4 g IV bolus - insert an indwelling urinary catheter - give O2 10 L/min via facemask - keep the environment quiet and the lights dimmed
give O2 at 10 L/min via face mask - ABCs - magnesium sulfate is appropriate, not first - yes, to monitor output. fluids should be restricted for a client who has eclampsia, but output should be at least 25 mL/hr. not the priority here - yes, but not the priority
A nurse is reviewing the lab report of a newborn who has a blood type of B-. The mother's blood type is O+. Lab results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? - hyperbilirubinemia - central cyanosis - intracranial hemorrhage - cardiomyopathy
hyperbilirubinemia - central cyanosis in newborns is d/t certain congenital cardiac defects - risk factors for intracranial hemorrhage: forceps or vacuum assisted birth, precipitous or prolonged second stage of labor, increased fetal size - cardiomyopathy generally occurs in newborns d/t poor control of maternal DM
A nurse is caring for a client in labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? - nausea and vomiting - tachycardia - hypotension - resp depression
hypotension - adverse effect. administer IV fluid bolus prior to epidural placement to decrease likelihood - tachycardia is an adverse effect of opioid agonist-antagonists like butorphanol - resp depress is not an adverse effect
A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of these statements indicates a need for further instruction? - i can continue to breastfeed - i still need to have my provider perform a rubella titer check during my next pregnancy - i cannot receive the rubella immunization during pregnancy - i can conceive anytime i want after 10 days
i can conceive anytime i want after 10 days - patient must wait at least 28 days/1 month after receiving rubella immunization to prevent fetal injury
A nurse is providing teaching for a PP client who is breastfeeding. Which of the following indicates an understanding of the teaching? - i should feed my baby 8-12 times a day, based on feeding cues - my baby should have 6 or 7 wet diapers a day during the first week - i should switch my baby to the other breast after 15 minutes of feeding - my nipple pain should go away after a few weeks of breastfeeding
i should feed my baby 8-12 times a day, based on cues - during the first week, newborns should have a min. of 1 wet diaper for every day of their age. 3 day old = 3 wet diapers, 6-8 heavy wet diapers at the end of the week - switch breasts based on cues from infant, wait til they take a break + breast has softened, offer other breast - nipple pain is not an expected finding, see lactation consultant
A nurse is providing teaching for a client at 7 weeks gestation who is experiencing nausea and vomiting. Which of the following client statements indicates an understanding of the teaching? - i should eat fatty foods to increase my caloric intake - i should brush my teeth right after eating - acupressure bands on my elbows might help me feel better - i should have a small snack before bedtime
i should have a small snack before bedtime - can relieve N/V through the night and prevent client from feeling too hungry in the morning - fatty foods can increase N/V - this can trigger N/V - acupressure bands on the WRISTS can reduce N/V
A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates and understanding of the teaching? - i will limit breastfeeding to 5 minutes per breast - i will not breastfeed if I start to have flu-like symptoms - i will shop for an underwire nursing bra today - i will avoid any of my family members who are ill
i will avoid any of my family members who are ill - decrease risk of mastitis and exposure, compromise of immune system - adequate emptying reduces risk of developing mastitis - flu-like symptoms could indicate maternal illness or early mastitis but client should continue breastfeeding to promote emptying - underwire bras can prevent adequate emptying, predispose to mastitis
A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include? - this test is an invasive procedure that presents minimal risk to the fetus - if the test is reactive, that means your baby's heart rate is healthy - when your baby moves, the test should record the baby's heart rate decreasing by about 15 beats per minute - the results of the test will be recorded as positive if no fetal movement occurs during the 20-min testing period
if the test is reactive, that means your baby's heart rate is healthy - reactive: at least 2 15 bpm accelerations lasting 15 seconds or more within 20 minute time frame - nonreactive: absence of accels, or accelerations of insufficient amplitude to meet criteria after 40 minutes - noninvasive
A nurse is reviewing lab results for a client who is at 37 weeks gestation. The client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O-. Which of the following actions should the nurse take? - admin a dose of Rho(D) immune globulin - request a prescription or an antibiotic until delivery - instruct the client to obtain a rubella immunization after delivery - inform the client that she will need to deliver via cesarean birth
instruct the client to obtain a rubella immunization after delivery - Rh-negative patients should receive rhogam at 28 weeks, then 72 hours after if the newborn is positive - they will receive IV antibx during labor to prevent transmission to the newborn
A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should assess the newborn for which of the following potential complications? - intraventricular hemorrhage - hyperglycemia - hyperthermia - meconium aspiration syndrome
intraventricular hemorrhage - babies before 34 weeks have fragile vessels in the brain + premature babies have impaired coag processes and fluctuating blood pressure -> increase risk of bleeding + subsequent neuro damage - premie has increased risk of hypoglycemia - " " hypothermia - MAS is typically a complication of post-term infants
A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider? - jaundice of the sclera - resp rate 50/min - acrocyanosis - blood glucose 50 mg/dL
jaundice of the sclera - jaundice w/in the first 24 hours is pathological - 50/min is within range - acrocyanosis is expected - 60 mg/dL within range, treat hypoglycemia when blood glucose levels are <40-50 mg/dL
A nurse is teaching a client about the use of a dinoprostone vaginal insert pouch to stimulate labor. Which of the following statements should the nurse include in the teaching? - it's inserted using a catheter - one pouch is given every 4 hours until labor occurs - lie on your back for at least 2 hour without getting up - if labor doesn't occur within 6 hours, a second dose can be administered
lie on your back for at least 2 hours without getting up - slow release - dinoprostone GEL is administered by endocervical catheter (they stay supine for at least 30 minutes to prevent leakage) - released slowly until active labor occurs or is removed after 12 hours - the gel may require 2-3 doses in the 12 hour window
A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? - measure the newborn's length from anterior fontanel to the heel - measure the newborn's weight while he is wearing a clean diaper - measure the circumference of the newborn's head with a tape measure just above the eyebrows - measure the circumference of the newborn's chest with a tape measure 2 cm below the nipple line
measure the circumference of the newborn's head with a tape measure just above the eyebrows - this occipitofrontal area of the head has the largest diameter - measure length from the top of the head to the heel - remove the diaper and clothing to measure weight - measure chest circum. at the nipple line, not below
A nurse is providing teaching about formula feeding to the guardian of a newborn. Which of the following pieces of information should the nurse include? - boil bottles and nipples for 20 minutes after each use - mix 1 scoop of powdered formula with 2 oz water - store prepared bottles in the refrigerator for up to 4 days - warm formula by heating bottles in the microwave on the lowest setting
mix 1 scoop of formula w 2 oz of water - use sterile water that has been boiled for 2 minutes when mixing formula; 1 scoop in 2 oz - boil nipples and bottles for 5 minutes before using them the first time, then they can be handwashed in hot, soapy water or in dishwasher - prepared bottles should be in the fridge and used within 48 hours d/t bacterial contamination - warm cold bottles by placing under warm running water, give the formula at or slightly above room temp
A nurse is preparing to admin an IV infusion of oxytocin for labor induction to a client at 41 weeks gestation. Which of the following actions should the nurse plan to take? - administer the oxytocin with manual IV tubing - monitor the FHR every 15 minutes initially - begin the infusion at 10 milliunits/min - titrate the dosage until the client has 1 contraction every minute
monitor the FHR every 15 minutes initially - monitor FHR every 15 min during the first stage of labor, then every 5 minutes in the second stage. document the FHR with every change of the oxytocin dose - use an infusion pump to ensure accurate flow rate - begin the infusion at 1 milliunit/min, increase the infusion slowly every 30-60 minutes and by no more than 1-2 milliunit/min until the desired response is achieved - titrate dosage until client has one contraction every 2-3 minutes
A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? - monitor the client's intake and output - initiate a high-fiber diet for the client - monitor the client's weight weekly - initiate bedrest with the head of the bed elevated
monitor the client's weight weekly - should be weighed daily for fluid overload - yes, blood flow to and from the heart increases for the first 24+ hours after birth - yes, high-fiber to prevent straining with BM, valsalva can result in cardiac stress - yes, promote rest and decrease O2 consumption
A nurse is teaching a client who had vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information? - my baby's head will be cone-shaped for about 2 months - my doctor did this procedure because i didn't dilate past 6 cm - the doctor performed this because my hemoglobin was low - my baby has a higher risk of developing jaundice
my baby has a higher risk of developing jaundice - jaundice occurs as bruises caused by device dissipate - the procedure will result in caput succedaneum, resolves without treatment 3-4 days - doctors choose vacuum-assisted birth for prolonged second stage of labor or for fetal distress, the mom must be fully dilated before vaginal birth
A nurse is caring for a client who is 38 weeks gestation and is receiving oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? - place the client in a side-lying position - discontinue the oxytocin infusion - apply oxygen to the client via a face mask - check for umbilical cord prolapse
place the client in a side-lying position - variable decels reflect cord prolapse, help shift pressure off the presenting part of the cord - discontinue oxytocin but not first - administer O2 to prevent fetal hypoxia but not first - perform or assist with vag exam for cord prolapse but not first
A nurse is assessing a 4-hour old newborn prior to breastfeeding and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? - apply an O2 hood over the newborn's head and neck - check the newborn's temp using a temporal thermometer - place the naked newborn on the mother's bare chest and cover both with a blanket - give the newborn glucose water between feedings
place the naked baby on the mother's chest and cover both w/a blanket - cool environments cause vasoconstriction, skin-to-skin helps stabilize newborn's temp and promotes bonding - blue lips and mucus membranes can indicate central cyanosis and resp depression, which might require supp. O2 - temporal and intra-auricular thermometers are not effective for newborn temp, use axillary - no, this can cause newborn to become full and not suck enough to ensure adequate milk production from mom
A nurse is teaching the guardian of a newborn about car sear safety. Which of the following pieces of information should the nurse include? - position the child's car seat forward-facing at 1 year of age - place the retainer clip 2 inches about the newborn's umbilicus - place the shoulder harness in the slots that are level with the newborn's shoulders - position the newborn's car seat at a 20 degree angle in the vehicle
place the shoulder harness in the slots level w the newborn's shoulders - the seat should be rear-facing until the child is 2 years old or later, per manufacturer - retainer clip should be at the level of the newborns armpits - the car seat should be at a 45 degree angle, prevents slumping and decrease risk of airway obstruction w weak newborn neck muscles
A nurse is caring for a client who is attempting a trial of labor after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the FHR tracing. Which of the following actions should the nurse take? - assist the client to the bathroom to empty her bladder - place the client in a knee-chest position - plan to administer calcium gluconate - prepare the client for an emergency cesarean delivery
prepare the client for an emergency cesarean delivery - abd pain, c-section hx, prolonged decels are manifestations of uterine rupture - not appropriate - knee-chest position is an intervention for variable decels or prolapse cord, not uterine rupture - this is for mag toxicity
A nurse is reviewing the medical record of a client who is at 20 weeks gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy? - report of fetal movement by the client - auscultation of the FHR with Doppler - presence of the Chadwick's sign on pelvic exam - report of Braxton-Hicks contractions by the client
report of fetal movement by the client - quickening occurs around 18-20 weeks and is considered a presumptive sign of preg - FHR can be auscultated at 10-12 weeks, is a positive sign of preg - Chadwick's sign (violet coloration of cervix) visible at 6 weeks, probably sign of preg - BH contractions can be reported as early as 20 weeks, probably sign of preg
A nurse is planning care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan? - reposition every 3 hours - apply lotion to the newborn's exposed skin twice daily - feed the newborn 1 oz of glucose water every 2 hours - dress the newborn in a diaper and a thin cotton tee
reposition every 3 hours - reposition every 2-3 hours to maximize exposure - lotions, creams, ointments absorb heat and can cause burns - newborn should be breastfed or bottle-fed every 2-3 hours, glucose water has no nutritional value and doesn't promote bilirubin excretion - dress only in a diaper
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? - resp depression - hypothermia - hypoglycemia - jaundice
respiratory depression - mag can cause resp and neuromuscular depression in the newborn - mag does not cause hypothermia, preterm babes can have thermoregulation issues d/t immature mechanisms - does not affect newborn's BG; premature babes can have hypoglycemia d/t prematurity - mag does not cause jaundice, premature babes can have jaundice r/t prematurity
A postpartum nurse is providing care for a client who is breastfeeding and has a peritoneal hematoma. The nurse should recommend that the client use which of the following breastfeeding positions? - side lying - clutch hold - across the lap - cross cradle
side-lying - allows access to baby, latching, reduces pressure on hematoma - clutch is particularly good for clients who had a c-section - across the lap is recommended for parents who have smaller babies, let's them latch on easier - cross-cradle is useful for small, young babies, allows parents to easily position the baby to latch
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? - continuous lochia flow and flaccid uterus - report of increasing pain and pressure in the perineal area - slow trickle of bright vaginal bleeding and a firm fundus - gush of rubra lochia when the uterus is massaged
slow trickle of bright vaginal bleeding + firm uterus - can also be oozing or outright bleeding - monitor for excessive bleeding in the presence of a flaccid uterus to identify that the blood is coming from the uterus. common with a full bladder or retained placental fragments - increasing pain + pressure in the perineal area points to hematoma - massaging moves pooled blood in the uterus to the vaginal opening with contractions
A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? - gently retract the foreskin to wash the glans w soap and water - sponge bathe the newborn every other day - use an antimicrobial soap for bathing - bathe the newborn with water between 46-48 C (115-120 F)
sponge bathe the newborn every other day - daily baths can disrupt pH of newborn's skin and alter skin integrity, sponge bathe until the cord stump has detached and the area has healed - do not attempt to retract the foreskin before the age of 3 years, wash penis with soap and water - avoid antimicrobial soaps, use soap with a neutral pH and no preservative - keep water temp between 38-40 C (100-104 F)
A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? - urinary hesitancy - hematuria - stress incontinence - increased vaginal moisture
stress incontinence - d/t shrinking of the uterus, vulva, distal parts of urethra. common age-related changes, not necessarily menopause - urinary frequency can occur, not hesitancy - hematuria, irritation to bladder mucosa, might indicate UTI - vaginal dryness is expected as walls become thinner and dryer
While assessing a client who is in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention? - the fundus is at midline - the fundus is below the umbilicus - the bladder is resonant with percussion - the bladder fluctuates with percussion
the bladder fluctuates with percussion - with distention, bladder is suprapubic, round, bulging, dull to percussion, fluctuates like a balloon filled with water - the uterus is usually displaced to the right, boggy, and located well above the umbilicus
A nurse is caring for a client who is at 20 weeks gestation. The client asks the nurse what the baby looks like at this point. Which of the following answers by the nurse provides an accurate response? - lanugo has disappeared - the fetus resembles a human - the arm and leg buds are noticeable - subcutaneous fat gives the body a wrinkled appearance
the fetus resembles a human - lanugo covers the body at this stage - arm and leg buds are noticeable between 5-6 weeks - lack of subq fat makes the body look wrinkly
A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide? - the fundus is approx. 2 cm above the level of the umbilicus at the end of the third stage of labor - the fundus is approx. 3 cm above the umbilicus within 12 hours after delivery - the fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum - the fundus is not palpable abdominally at 2 weeks postpartum
the fundus is not palpable abdominally at 2 weeks postpartum - at the end of the 3rd stage, fundus is 2 cm below umbilicus - within 12 hours PP, the fundus rises to 1 cm above the umbilicus - the fundus descends 1-2 cm every 24 hours and is not palpable after the sixth PP day - fundus is approx 2 cm below umbilicus at the end of the 3rd stage
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? - this is an attempt by your body to retain the fluid gained during pregnancy - this is caused by an increase in your estrogen levels - this is caused by the increased pressure on your veins in your lower legs - this is a source of your fluid loss after delivery
this is a source of your fluid loss after delivery - PP diuresis is the loss of the remaining preg-induced increase in blood volume. loss of excess tissue begins 12 hours after birth. fluid loss by urination and sweat causes weight loss of approx 5 lb. during early PP period - pp diuresis is d/t decreased estrogen levels, removal of increased venous pressure in lower limbs, loss of preg-induced increase of bl. volume - urine output can exceed 3000 mL/day during first 2-3 PP days
A nurse is performing a nonstress test on a client is 41 weeks gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide? - this test will determine if you are likely to deliver within the next week - this test will help determine if your baby is healthy - this test can see how your baby responds when you have contractions - this test will determine if your baby's lungs are mature
this test will help determine if your baby is healthy - tracks FHR patterns expected w fetal movement, can help identify fetal distress - does not evaluate uterine relaxation - fetal lung maturity is assessed by amniocentesis
A nurse is assessing a 2-day-old newborn and notes and egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? - this will resolve in 3-6 weeks without treatment - this will resolve on its own within 3-4 days - the provider might drain this area with a syringe - this appearance is expected at birth, so you don't need to worry
this will resolve in 3-6 weeks w/o treatment - cephalohematoma results from a collection of blood between the skull and periosteum - caput succedaneum crosses suture lines, present at birth, edema of the scalp that resolves in 3-4 days - do not aspirate d/t risk of infection
A newborn is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? - weak cry - absent Moro reflex - constipation - tremors
tremors - neonatal abstinence syndrome can cause tremors, tachypnea, nasal flaring, apnea, retractions, incessant crying, frequent yawning and sneezing, mottling of the skin, excessive sucking, vomiting, and fevers - NAS newborns have a shrill cry - NAS newborns have an exaggerated Moro reflex - NAS newborns can have diarrhea
A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? - true contractions will begin irregularly and then become regular in timing - true contractions will go away w ambulation - false contractions increase in frequency and duration the closer you are to your due date - false contractions are first felt in the pelvic area and then in the lower back and abdomen
true contractions will begin irregularly and then become regular in time - false contractions begin and remain irregular - false contrax usually go away with ambulation or sleep, true contrax continue regardless of activity - false contrax don't increase in freq, duration, or intensity. if this is happening, they are considered true contrax - false contrax are felt in the abdomen and remain in the abdominal and groin area, true contrax begin in the lower back and spread around to the abd
A nurse is planning care for a newborn who is receiving phototherapy. Which of the following interventions should the nurse include in the plan of care? - apply lotion to the skin during phototherapy - supplement feedings with oral glucose water - cover the nares with an opaque mask - turn and reposition the newborn every 2 hours during phototherapy
turn and reposition the newborn every 2 hours during phototherapy - allows maximum exposure of skin surfaces - creams and lotions can absorb heat and cause burns - hydrating the newborn during phototherapy with breast milk or formula is important; glucose and water don't promote excretion of bilirubin - covering the nares can interfere w respiration, opaque eye masks are appropriate
A nurse is caring for a client in the third trimester who reports difficulty sleeping. Which of the following instructions should the nurse provide? - eat a high-fat snack before bed - exercise in the evening before bed - sleep in the supine position - use additional pillows to support extremities and abdomen
use additional pillows to support extremities and abdomen - finding comfy positions for sleep in the last 3 months of preg is difficult d/t fetal growth - high-fat snack may increase heartburn - encourage client to decrease activity and use relaxation techniques - avoid the supine position late in pregnancy d/t supine hypotension syndrom (decrease cardiac output and placental blood flow)
A nurse at a family-planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse include? - use spermicide jelly whenever you use your diaphragm - insert the diaphragm about 8 hours before sexual activity - you should remove the diaphragm 30 min. after intercourse - a diaphragm comes in a single size and does not require fitting
use spermicide jelly whenever you use your diaphragm - it's a barrier device, not 100& effective but use of spermicide jelly increases effectiveness - insert diaphragm up to 6 hours before vaginal intercourse - wait at least 6 hours after vaginal intercourse to remove, semen can still enter uterus - comes in several sizes and must be fitted to work correctly, may require size change with weight change
A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? - bilirubin 5 mg/dL - weight loss 12% of birth weight - loose, green stools - axillary temp of 36.6 (97.9)
weight loss 12% of birth weight - acceptable weight loss over the first 3-5 days is 10% - 5 mg/dL, provider should discontinue treatment - loose stools are common with phototherapy, green stools are also common and transition to yellow - within range of ax temperature for newborns 36.5-37.5 (97.7 - 99.5)
The nurse is teaching a client who is postpartum about the rubella vaccine. Which of the following teachings should the nurse include? - you must not take this immunization if you've had the chickenpox - you must not become pregnant for 28 days after receiving this immunization - you must not breastfeed because the virus is passed in breastmilk - you must not receive other vaccines at the same time as the rubella vaccine
you must not become pregnant for 28 days after
A nurse in a clinic is providing education to a client at 32 weeks gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? - you should slightly increase your exposure to sunlight - you will need extensive dermatological treatment for this condition after you deliver - your provider will schedule weekly lab testing to monitor your liver function - your provider will prescribe isotretinoin cream
you should slightly increase your exposure to sunlight - the condition causes generalized itching w/o rash d/t stretching of skin, sunlight helps - no excessive treatment after deliery - no affect on liver - isotretinoin is for acne, containdicated in preg patients d/t teratogenic effects (retinoid)
