OB Exam 2

A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior? A. demonstrates pleasure when touching or holding the newborn B. identifies imperfections in the newborn's appearance C. is able to distinguish his newborn from others in the nursery D. shows feelings of pride with the birth of the newborn

B

A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching? A. introducing solid foods immediately to increase sleep cycle B. demonstrating comfort measures to quiet a crying infant C. encouraging daily outings to the shopping mall with the newborn D. allowing the infant to cry for at least an hour before picking him or her up

B

A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection? A. placing a cap on a newborn's head B. working inside an isolette as much as possible C. placing the newborn skin-to-skin with the mother D. using a radiant warmer to transport a newborn

B

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern? A. hemoglobin 19 g/dL B. platelets 75,000/μL C. white blood cells 20,000/mm3 D. hematocrit 52%

B

A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? A. substance use disorder B. diabetes C. preeclampsia D. infection

B

A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed? A. allowing unlimited visiting hours on maternity units B. offering round-the-clock nursery care for all infants C. promoting rooming-in D. encouraging infant contact immediately after birth

B

A nurse is teaching a new mother about her newborn's immune status. The nurse determines that the teaching was successful when the mother states which immunoglobulin as having crossed the placenta? A. IgA B. IgG C. IgM D. IgE

B

A nurse is teaching a postpartum client and her partner about caring for their newborn's umbilical cord site. Which statement by the parents indicates a need for additional teaching? A. "We can put him in the tub to bathe him once the cord falls off and is healed." B. "The cord stump should change from brown to yellow." C. "Exposing the stump to the air helps it to dry." D. "We need to call the primary care provider if we notice a funny odor."

B

A woman with gestational hypertension develops eclampsia and experiences a seizure. Which intervention would the nurse identify as the priority? A. fluid replacement B. oxygenation C. control of hypertension D. birth of the fetus

B

A pregnant woman at 31-weeks' gestation calls the clinic and tells the nurse that she is having contractions sporadically. Which instructions would be most appropriate for the nurse to give the woman? Select all that apply. A. "Walk around the house for the next half hour." B. "Drink two or three glasses of water." C. "Lie down on your back." D. "Try emptying your bladder." E. "Stop what you are doing and rest."

B, D, E

A group of nurses are reviewing information about the changes in the newborn's lungs that must occur to maintain respiratory function. The nurses demonstrate understanding of this information when they identify which event as occurring first? A. expansion of the lungs B. increased pulmonary blood flow C. initiation of respiratory movement D. redistribution of cardiac output

C

A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate? A. "If he seems content after feeding, that should be a sign." B. "Make sure he drinks at least 5 minutes on each breast." C. "He should wet between 6 to 10 diapers each day." D. "If his lips are moist, then he's okay."

C

A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? A. prophylactic heparin administration B. compression stockings C. early ambulation D. warm compresses

C

A nurse is preparing a presentation for a group of young adult pregnant women about common infections and their effect on pregnancy. When describing the infections, which infection would the nurse include as the most common congenital and perinatal viral infection in the world? A. rubella B. hepatitis B C. cytomegalovirus D. parvovirus B19

C

A nurse is preparing an inservice education program for a group of nurses about dystocia involving problems with the passenger. Which problem would the nurse likely include as the most common? A. macrosomia B. breech presentation C. persistent occiput posterior position D. multifetal pregnancy

C

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response? A. reduces lochia B. promotes uterine involution C. improves pelvic floor tone D. alleviates perineal pain

C

A nurse is teaching a pregnant woman with preterm prelabor rupture of membranes about caring for herself after she is discharged home (which is to occur later this day). Which statement by the woman indicates a need for additional teaching? A. "I need to keep a close eye on how active my baby is each day." B. "I need to call my doctor if my temperature increases." C. "It's okay for my husband and me to have sexual intercourse." D. "I can shower, but I shouldn't take a tub bath."

C

A pregnant woman is diagnosed with iron-deficiency anemia and is prescribed an iron supplement. After teaching her about her prescribed iron supplement, which statement indicates successful teaching? A. "I should take my iron with milk." B. "I should avoid drinking orange juice." C. "I need to eat foods high in fiber." D. "I'll call the primary care provider if my stool is black and tarry."

C

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal? A. two fingerbreadths above the umbilicus B. at the level of the umbilicus C. two fingerbreadths below the umbilicus D. four fingerbreadths below the umbilicus

C

A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? A. "Express some milk from your breasts every so often to relieve the distention." B. "Remove your bra to relieve the pressure on your sensitive nipples and breasts." C. "Apply ice packs to your breasts to reduce the amount of milk being produced." D. "Take several warm showers daily to stimulate the milk let-down reflex."

C

A woman gave birth to a newborn via vaginal birth with the use of a vacuum extractor. The nurse would be alert for which possible effect in the newborn? A. asphyxia B. clavicular fracture C. cephalhematoma D. central nervous system injury

C

A woman with hyperemesis gravidarum asks the nurse about suggestions to minimize nausea and vomiting. Which suggestion would be most appropriate for the nurse to make? A. "Make sure that anything around your waist is quite snug." B. "Try to eat three large meals a day with less snacking." C. "Drink fluids in between meals rather than with meals." D. "Lie down for about an hour after you eat."

C

After teaching a group of nurses working at the women's health clinic about the impact of pregnancy on the older woman, which statement by the group indicates that the teaching was successful? A. "The majority of women who become pregnant over age 35 experience complications." B. "Women over the age of 35 who become pregnant require a specialized type of assessment." C. "Women over age 35 and are pregnant have an increased risk for spontaneous abortions." D. "Women over age 35 are more likely to have a substance use disorder."

C

Assessment of a newborn reveals transient tachypnea. The nurse reviews the newborn's medical record. Which factor in the newborn's history would the nurse identify as playing a role in this this condition? A. vaginal birth B. shortened labor C. central nervous system depressant during labor D. maternal hypertension

C

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation? A. respiratory rate of 54 breaths/minute B. abdominal breathing C. nasal flaring D. acrocyanosis

C

When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? A. reciprocity B. engrossment C. bonding D. attachment

C

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as: A. molding. B. microcephaly. C. caput succedaneum. D. cephalhematoma

C

A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply. A. There is flaccid muscle tone of the affected limb. B. Respiration rate is 52 breaths per minute. C. Heart rate is 180 beats per minutes. D. Oxygen saturation level is 88%. E. The infant has facial grimacing and quivering chin

C, D, E

A nurse is providing teaching to a new mother about her newborn's nutritional needs. Which suggestions would the nurse include in the teaching? Select all that apply. A. Supplement with iron if the woman is breastfeeding. B. Provide supplemental water intake with feedings. C. Feed the newborn every 2 to 4 hours during the day. D. Burp the newborn frequently throughout each feeding. E. Use feeding time for promoting closeness

C, D, E

A nurse is reviewing the medical record of a pregnant client. The nurse suspects that the client may be at risk for dystocia based on which factors? Select all that apply. A. plan for pudendal block anesthetic use B. multiparity C. short maternal stature D. Body mass index 30.2 E. breech fetal presentation

C, D, E

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn? A. symmetrical chest movements B. periodic breathing C. respirations of 40 breaths/minute D. sternal retractions

D

A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate intervention? A. fetal heart rate of 150 beats/minute B. contractions every 2 minutes, lasting 45 seconds C. uterine resting tone of 14 mm Hg D. urine output of 20 mL/hour

D

A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect? A. uterine hyperstimulation B. headache C. blurred vision D. hypotension

A

A macrosomic infant in the newborn nursery is being observed for a possible fractured clavicle. For which would the nurse assess? Select all that apply. A. facial grimacing with movement B. bruising over area C. asymmetrical movement D. edema present E. positive Babinski reflex

A, B, C, D

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply. A. history of diabetes B. labor of 12 hours C. rupture of membranes for 16 hours D. hemoglobin level 10 mg/dL E. placenta requiring manual extraction

A, D, E

A nurse is conducting an in-service presentation to a group of perinatal nurses about sexually transmitted infections and their effect on pregnancy. The nurse determines that the teaching was successful when the group identifies which infection as being responsible for ophthalmia neonatorum? A. syphilis B. gonorrhea C. chlamydia D. HPV

B

A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After reviewing a client's history, which factor would the nurse identify as placing her at risk for preeclampsia? A. Her mother had preeclampsia during pregnancy. B. Client has a twin sister. C. Her sister-in-law had gestational hypertension. D. This is the client's second pregnancy.

A

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn? A. infection B. hemorrhage C. trauma D. hypovolemia

A

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates: A. normal progression of behavior. B. probable hypoglycemia. C. physiological abnormality. D. inadequate oxygenation.

A

A client has given birth to a full-term infant weighing 10 pounds 5 ounces (4678 grams). What priority assessment should be completed by the nurse? A. Blood glucose B. Temperature control C. Feeding difficulty D. Perfusion

A

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority? A. hemorrhage B. jaundice C. edema D. infection

A

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available? A. calcium gluconate B. potassium chloride C. ferrous sulfate D. calcium carbonate

A

A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately? A. dyspnea, diaphoresis, hypotension, and chest pain B. dyspnea, bradycardia, hypertension, and confusion C. weakness, anorexia, change in level of consciousness, and coma D. pallor, tachycardia, seizures, and jaundice

A

A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which cause when responding to the new mother? A. insufficient calorie intake B. shift of water from extracellular space to intracellular space C. increase in stool passage D. overproduction of bilirubin

A

A newborn infant has been diagnosed with persistent pulmonary hypertension of the newborn (PPHN). In providing care for this newborn what intervention should be the nurse's priority? A. Measure blood pressure B. Obtain arterial blood gases C. Monitor oxygen saturation D. Suction the newborn

A

A newborn is exhibiting symptoms of withdrawal and toxicology test have been prescribed. Which type of specimen should the nurse collect to obtain the most accurate results? A. Meconium B. Blood C. Urine D. Sputum

A

A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which measure would the nurse anticipate as possibly necessary for this newborn? A. extracorporeal membrane oxygenation (ECMO) B. respiratory support with a ventilator C. insertion of a laryngoscope for deep suctioning D. replacement of an endotracheal tube via X-ray

A

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex? A. Babinski B. tonic neck C. stepping D. plantar grasp

A

A nurse is conducting a review class for a group of perinatal nurses working at the local clinic. The clinic sees a high population of women who are HIV positive. After discussing the recommendations for antiretroviral therapy with the group, the nurse determines that the teaching was successful when the group identifies which rationale as the underlying principle for the therapy? A. reduction in viral loads in the blood B. treatment of opportunistic infections C. adjunct therapy to radiation and chemotherapy D. can cure acute HIV/AIDS infections

A

A nurse is developing the plan of care for a small-for-gestational-age newborn. Which action would the nurse determine as a priority? A. Preventing hypoglycemia with early feedings B. Observing for newborn reflexes C. Promoting bonding between the parents and the newborn D. Monitoring vital signs every 2 hours

A

A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to suspect that a woman is experiencing postpartum psychosis? A. delirium B. feelings of guilt C. sadness D. insomnia

A

A nurse is preparing a teaching program for a group of pregnant women about preventing infections during pregnancy. When describing measures for preventing cytomegalovirus infection, which measure would the nurse include as a priority? A. frequent handwashing B. immunization C. prenatal screening D. antibody titer screening

A

A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding? A. The client states, "He has my eyes and nose." B. The client shows interest in caring for the newborn. C. The client performs self-care independently. D. The client confidently cares for the newborn.

A

A nurse is teaching a group of new parents about their newborns' sensory capabilities. The nurse would identify which sense as being well-developed at birth? A. hearing B. touch C. taste D. vision

A

A nurse is teaching a woman about measures to prevent preterm labor in future pregnancies because the woman just experienced preterm labor with her most recent pregnancy. The nurse determines that the teaching was successful based on which statement by the woman? A. "I'll make sure to limit the amount of long distance traveling I do." B. "Stress isn't a problem that is related to preterm labor." C. "Separating pregnancies by about a year should be helpful." D. "I'll need extra iron in my diet so I have extra for the baby."

A

A pregnant client at 24 weeks' gestation comes to the clinic for an evaluation. The client called the clinic earlier in the day stating that she had not felt the fetus moving since yesterday evening. Further assessment reveals absent fetal heart tones. Intrauterine fetal demise is suspected. The nurse would expect to prepare the client for which testing to confirm the suspicion? A. Ultrasound B. Amniocentesis C. Human chorionic gonadotropin (hCG) level D. Triple marker screening

A

A pregnant woman comes to the clinic for her first evaluation. The woman is screened for hepatitis B (HBV) and tests positive. The nurse would anticipate administering which agent? A. HBV immune globulin B. HBV vaccine C. acylcovir D. valacyclovir

A

A pregnant woman gives birth to a small for gestational age neonate who is admitted to the neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which substance would the nurse suspect the women of using during pregnancy? A. alcohol B. cocaine C. heroin D. methamphetamine

A

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome? A. congenital anomalies B. incompetent cervix C. placenta previa D. placental abruption (abruptio placentae)

A

A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. When reviewing the results, the nurse determines that the woman is achieving good glucose control based on which result? A. 88 mg/dL B. 100 mg/dL C. 110 mg/dL D. 120 mg/dL

A

A preterm newborn has received large concentrations of oxygen therapy during a 3-month stay in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist? A. ophthalmologist B. nephrologist C. cardiologist D. neurologist

A

A woman who gave birth to a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence? A. estrogen B. hCG C. hPL D. progesterone

A

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take? A. Document the finding, as it is a normal finding at this time. B. Contact the primary care provider, as it indicates early DIC. C. Contact the primary care provider, as it is a first sign of postpartum eclampsia. D. Obtain a prescription for a CBC, as it suggests postpartum anemia

A

A young adult woman comes to the clinic for a routine check-up. During the visit, the woman who works in a day care facility tells the nurse that she and her partner are considering having a baby. "We are concerned that I might be exposed to common childhood illnesses." The woman undergoes testing and finds out that she is not immune from chickenpox. Based on this information, which information would the nurse give to the client? A. "You will need to be vaccinated now and wait at least 1 month before getting pregnant." B. "It is very likely that you will need to quit your job if you do get pregnant." C. "Because chickenpox is so rare nowadays, there is nothing to worry about." D. "You will need to take a leave of absence during winter and spring months."

A

After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful? A. "I will be sure to avoid getting pregnant for at least 1 year." B. "My intake of iron will have to be closely monitored for 6 months." C. "My blood pressure will continue to be increased for about 6 more months." D. "I won't use my birth control pills for at least a year or two."

A

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation? A. Dry the newborn thoroughly. B. Put a hat on the newborn's head. C. Check the newborn's temperature. D. Wrap the newborn in a blanket.

A

Assessment of a newborn reveals a heart rate of 180 beats per minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know? A. How many hours old is this newborn? B. How long ago did this newborn eat? C. What was the newborn's birthweight? D. Is acrocyanosis present?

A

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also reports significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? A. hematoma B. laceration C. bladder distention D. uterine atony

A

On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? A. delusional beliefs B. feelings of anxiety C. sadness D. insomnia

A

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess? A. respiratory rate 45 breaths/minute, irregular B. costal breathing pattern C. nasal flaring, rate 65 breaths/minute D. crackles on auscultation

A

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism? A. evaporation B. conduction C. convection D. radiation

A

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority? A. placing the call light within her reach B. teaching her how the sitz bath works C. telling her to use the sitz bath for 30 minutes D. cleaning the perineum with the peri-bottle

A

The nurse is inspecting the external genitalia of a male newborn. Which finding would alert the nurse to a possible problem? A. limited rugae B. large scrotum C. palpable testes in scrotal sac D. negative engorgement

A

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus? A. cannot be palpated B. 2 cm below the umbilicus C. 6 cm below the umbilicus D. 10 cm below the umbilicus

A

The nurse is providing care to several pregnant women who may be scheduled for labor induction. The nurse identifies the woman with which Bishop score as having the best chance for a successful induction and vaginal birth? A. 11 B. 7 C. 5 D. 3

A

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as: A. a good time to initiate breast-feeding. B. the period of decreased responsiveness preceding sleep. C. a sign that the infant is being overstimulated. D. evidence that the newborn is becoming chilled

A

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority? A. hypothermia B. impaired parenting C. deficient fluid volume D. risk for infection

A

When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because: A. these measurements may not change until after the blood loss is large. B. the body's compensatory mechanisms activate and prevent any changes. C. they relate more to change in condition than to the amount of blood lost. D. maternal anxiety adversely affects these vital signs

A

When describing the neurologic development of a newborn to parents, the nurse would explain that it occurs in which fashion? A. head-to-toe B. lateral-to-medial C. outward-to-inward D. distal-caudal

A

When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure? A. early parent-infant contact following birth B. expert medical care for the labor and birth C. good nutrition and prenatal care during pregnancy D. grandparent involvement in infant care after birth

A

When teaching a class of pregnant women about the effects of substance use during pregnancy, the nurse would include which effect? A. low-birthweight infants B. excessive weight gain C. higher pain tolerance D. longer gestational periods

A

Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth? A. Show the newborn to the parents as soon as possible while explaining the defect. B. Remove the newborn from the birthing area immediately. C. Inform the parents that there is nothing wrong at the moment. D. Tell the parents that the newborn must go to the nursery immediately

A

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next? A. Document this as pseudo menstruation. B. Notify the primary care provider immediately. C. Obtain a culture of the discharge. D. Inspect for engorgement

A

While reviewing a newborn's medical record, the nurse notes that the chest X-ray shows a ground glass pattern. The nurse interprets this as indicative of: A. respiratory distress syndrome. B. transient tachypnea of the newborn. C. asphyxia. D. persistent pulmonary hypertension

A

A nurse is taking a history on a woman who is at 20 weeks' gestation. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply. A. dull low backache B. viscous vaginal discharge C. dysuria D. constipation E. occasional crampinG

A, B, C

A postpartum woman is diagnosed with endometritis. The nurse interprets this as an infection involving which area? Select all that apply. A. endometrium B. decidua C. myometrium D. broad ligament E. ovaries F. fallopian tubes

A, B, C

A pregnant client has received dinoprostone. Following administration of this medication, the nurse assesses the client and determines that the client is experiencing an adverse effect of the medication based on which client report? Select all that apply. A. headache B. nausea C. diarrhea D. tachycardia E. hypotension

A, B, C

A premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply. A. increased serum bilirubin levels B. clay-colored stools C. tea-colored urine D. cyanosis E. Mongolian spots

A, B, C

A preterm newborn is admitted to the neonatal intensive care with the diagnosis of an omphalocele. What nursing actions would the nurse perform? Select all that apply. A. The abdominal contents are protected. B. Fluid loss of the neonate will be minimized. C. Perfusion to the exposed abdominal contents will be maintained. D. Neonatal weight loss will be prevented. E. Assessment of hyperbilirubinemia will be monitored

A, B, C

After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse determines that the teaching was successful when the woman identifies which foods as being good sources of iron in her diet? Select all that apply. A. dried fruits B. peanut butter C. meats D. milk E. white bread

A, B, C

A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply. A. Obtain hemoglobin and hematocrit laboratory tests B. Provide early feedings to prevent hypoglycemia C. Maintain oxygen saturation parameters D. Monitor urinary output E. Insert a peripheral IV

A, B, C, D

A 33 weeks' gestation neonate is being assessed for necrotizing enterocolitis (NEC). Which nursing actions would the nurse implement? Select all that apply. A. Perform hemoccult tests on stools. B. Monitor abdominal girth. C. Measure gastric residual before feeds. D. Assess bowel sounds before each feed. E. Assess urine output

A, B, C, D

A client expresses concerns that her grandmothers had complicated pregnancies. What principle(s) should the nurse discuss to allay the fears of the client? Select all that apply. A. "We work to ensure that birth of high-risk infants happens in settings where we are able to care for them." B. "We will work with you to identify prenatal risk factors early and take actions to reduce their impact." C. "We support those at risk of having a preterm births with the goal of delaying early births." D. "We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death." E. "We allow families to grieve the loss of a newborn, should it occur."

A, B, C, D

A neonate is born at 42 weeks' gestation weighing 4.4 kg (9 lb, 7 oz) with satisfactory Apgar scores. Two hours later birth the neonate's blood sugar indicates hypoglycemia. Which symptoms would the baby demonstrate? Select all that apply. A. poor sucking B. respiratory distress C. weak cry D. jitteriness E. blood glucose >40 mg/dl

A, B, C, D

A term neonate has been admitted to the observational newborn nursery with the diagnosis of being small for gestational age. Which factors would predispose the neonate to this diagnosis? Select all that apply. A. The mother had chronic placental abruption. B. At birth the placenta was noted to be decreased in weight. C. On assessment the placenta had areas of infarction. D. At birth the placenta was a shiny Schultz presentation. E. Placental talipes was present at birth

A, B, C, D

At a preconception counseling class, a client expresses concern and wonders how Healthy People 2030 will improve maternal-infant outcomes. Which response(s) by the nurse is appropriate? Select all that apply. A. Healthy People 2030 will reduce the rate of fetal and infant deaths. B. Healthy People 2030 will decrease the number of all infant deaths (within 1 year). C. Healthy People 2030 will decrease the number of neonatal deaths (within the first year). D. Healthy People 2030 will foster early and consistent prenatal care

A, B, C, D

The nurse in the neonatal intensive care unit is caring for a neonate she suspects is at risk for an intraventricular hemorrhage (IVH). Which nursing actions would be priorities? Select all that apply. A. Maintain fetal flexed position. B. Administer fluids slowly. C. Assess for bulging fontanel. D. Measure head circumference daily. E. Assess Moro reflex. F. Measure intake and output

A, B, C, D

A nurse is reading a journal article about cesarean births and the indications for them. Place the indications for cesarean birth below in the proper sequence from most frequent to least frequent. All options must be used. A. Labor dystocia B. Abnormal fetal heart rate tracing C. Fetal malpresentation D. Multiple gestation E. Suspected macrosomia

A, B, C, D, E

A neonate is admitted to the newborn observation nursery with the possible diagnosis of polycythemia. The nurse would be observing for which findings? Select all that apply. A. ruddy skin color B. respiratory distress C. cyanosis D. pink gums and tongue E. jitteriness

A, B, C, E

A nurse is conducting an in-service program for a group of labor and birth unit nurses about cesarean birth. The group demonstrates understanding of the information when they identify which conditions as appropriate indications? Select all that apply. A. active genital herpes infection B. placenta previa C. previous cesarean birth D. prolonged labor E. fetal distress

A, B, C, E

A pregnant client at 30 weeks' gestation calls the clinic because she thinks that she may be in labor. To determine if the client is experiencing labor, which question(s) would be appropriate for the nurse to ask? Select all that apply. A. "Are you feeling any pressure or heaviness in your pelvis?" B. "Are you having contractions that come and go, off and on?" C. "Have you noticed any fluid leaking from your vagina?" D. "Are you having problems with heartburn?" E. "Have you been having any nausea or vomiting?"

A, B, C, E

A 42-year-old woman is 26 weeks' pregnant. She lives at a shelter for female victims of intimate partner violence. Her blood pressure is 170/90 mm Hg, the fetal heart rate is 140 bpm, TORCH studies are positive, and she is bleeding vaginally. What findings put her at risk of giving birth to a small-for-gestational-age (SGA) infant? Select all that apply. A. the age of the client B. living in a shelter for victims of intimate partner violence C. vaginal bleeding D. fetal heart rate E. blood pressure F. positive test for TORCH

A, B, C, E, F

A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care unit with respiratory distress syndrome and underwent an exchange transfusion for anemia. Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply A. preterm birth B. respiratory distress syndrome C. low Apgar scores D. hyperthermia E. hyperglycemia F. exchange transfusion

A, B, C, F

A small-for-gestational age infant is admitted to the observational care unit with the nursing diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. Which are appropriate nursing interventions? Select all that apply. A. Assess the axillary temperature every hour. B. Review maternal history. C. Assess environment for sources of heat loss. D. Bathe the neonate with warmer water. E. Minimize kangaroo care. F. Encourage skin-to-skin contact

A, B, C, F

A 2-hour-old neonate born via caesarean birth has begun having a respiratory rate of 110 breaths/min and is in respiratory distress. What intervention(s) is a priority for the nurse to include in this neonates's care? Select all that apply. A. Keep the head in a "sniff" position B. Administer oxygen C. Insert an orogastric tube D. Ensure thermoregulation E. Obtain an arterial blood gas

A, B, D

A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply. A. cephalhematoma B. molding C. closed fontanels D. caput succedaneum E. posterior fontanel diameter 1.5 cm

A, B, D

While assessing a pregnant woman, the nurse suspects that the client may be at risk for hydramnios. Which information would the nurse use to support this suspicion? Select all that apply. A. history of diabetes B. reports of shortness of breath C. identifiable fetal parts on abdominal palpation D. difficulty obtaining fetal heart rate E. fundal height below that for expected gestational age

A, B, D

A nurse is providing care to a woman of Latin American culture who delivered a healthy neonate 6 hours ago. When developing a plan of care that is culturally congruent for this client, which information would be important for the nurse to obtain initially? Select all that apply. A. Meanings associated with touch and gestures B. Woman's beliefs about the postpartum period C. Plans for care of the newborn after discharge D. Amount of help the partner is expected to provide E. Preferences for measures to relieve discomforts

A, B, D, E

A nurse is conducting a review course on tocolytic therapy for perinatal nurses. After teaching the group, the nurse determines that the teaching was successful when they identify which drugs as being used for tocolysis? Select all that apply. A. nifedipine B. magnesium sulfate C. dinoprostone D. misoprostol E. indomethacin

A, B, E

A nurse is obtaining a medication history from a pregnant client with a history of systemic lupus erythematosus (SLE). Which medication(s) would the nurse expect the woman to report to be currently using? Select all that apply. A. Ibuprofen B. Hydroxychloroquine C. Methotrexate D. Leflunomide E. Prednisone

A, B, E

A nurse is providing a refresher class for a group of postpartum nurses. The nurse reviews the risk factors associated with postpartum hemorrhage. The group demonstrates understanding of the information when they identify which risk factors associated with uterine tone? Select all that apply. A. rapid labor B. retained blood clots C. hydramnios D. operative birth E. fetal malpostion

A, C

The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which measures would the nurse most likely include in this teaching plan? Select all that apply. A. taking the prescribed antibiotic until it is finished B. checking temperature once a week C. washing hands before and after perineal care D. handling perineal pads by the edges E. directing peribottle to flow from back to front

A, C, D

A nurse is preparing a class on newborn adaptations for a group of soon-to-be parents. When describing the change from fetal to newborn circulation, which information would the nurse include? Select all that apply. A. Decrease in right atrial pressure leads to closure of the foramen ovale. B. Increase in oxygen levels leads to a decrease in systemic vascular resistance. C. Onset of respirations leads to a decrease in pulmonary vascular resistance. D. Increase in pressure in the left atrium results from increases in pulmonary blood flow. E. Closure of the ductus venosus eventually forces closure of the ductus arteriosus

A, C, D, E

The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. When reporting this suspicion, which finding(s) would the nurse include in the report? Select all that apply. A. significant difficulty breathing B. hypertension C. tachycardia D. pulmonary edema E. bleeding with bruising

A, C, D, E

A 32-year-old black woman in her second trimester has come to the clinic for an evaluation. While interviewing the client, she reports a history of fibroids and urinary tract infection. The client states, "I know smoking is bad and I have tried to stop, but it is impossible. I have cut down quite a bit though, and I do not drink alcohol." Complete blood count results reveal a low red blood cell count, low hemoglobin, and low hematocrit. When planning this client's care, which factor(s) would the nurse identify as increasing the client's risk for preterm labor? Select all that apply. A. African heritage B. Maternal age C. History of fibroids D. Cigarette smoking E. History of urinary tract infections F. Complete blood count results

A, C, D, E, F

A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks' gestation, a blood pressure of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few times. The client has been pregnant before and indicates she "loses them early." What characteristic(s) place the client in the high-risk pregnancy category? Select all that apply. A. BMI 17.5 B. blood pressure 110/70 mm Hg C. prenatal history D. homelessness E. age F. prenatal care

A, C, D, F

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply. A. respiratory distress B. decreased oxygen needs C. hypoglycemia D. metabolic alkalosis E. jaundice

A, C, E

A nurse is teaching a woman with mild preeclampsia about important areas that she needs to monitor at home. The nurse determines that the teaching was successful based on which statements by the woman? Select all that apply. A. "I should check my blood pressure twice a day." B. "I will weigh myself once a week." C. "I should complete a fetal kick count each day." D. "I will check my urine for protein four times a day." E. "I'll call my health care provider if I have burning when I urinate."

A, C, E

A nurse has been invited to speak at a local high school about adolescent pregnancy. When developing the presentation, the nurse would incorporate information related to which aspects? Select all that apply. A. peer pressure to become sexually active B. rise in teen birth rates over the years. C. Asian Americans as having the highest teen birth rate D. loss of self-esteem as a major impact E. about half occurring within a year of first sexual intercourse

A, D

Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which finding would the nurse expect to assess? Select all that apply. A. diaphoresis B. tachycardia C. oliguria D. cool extremities E. confusion

A, D

A new parent is talking with the nurse about feeding the newborn. The parent has chosen to use formula. The parent asks, "How can I make sure that my baby is getting what is needed?" Which response(s) by the nurse would be appropriate? Select all that apply. A. "Make sure to use an iron-fortified formula until your baby is about 1 year old." B. "Start giving your baby fluoride supplements now so your baby develops strong teeth." C. "Since you are not breastfeeding, your baby needs a baby multivitamin each day." D. "Your baby gets enough fluid with formula, so you do not need to give extra water." E. "It is important to give your baby vitamin D each day."

A, D, E

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply. A. dark red vaginal bleeding B. insidious onset C. absence of pain D. rigid uterus E. absent fetal heart tones

A, D, E

A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels "lousy." Which finding would lead the nurse to suspect endometritis? Select all that apply. A. lower abdominal tenderness B. urgency C. flank pain D. breast tenderness E. anorexia

A, E

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000 grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer? Record your answer using one decimal place.

Answer: 0.3 Rationale: Epinephrine should be given if heart rate is 60 after 30 seconds of compressions and ventilation. epinephrine: 1:10,000 concentration 0.1 to 0.3 mL/kg IV 3000 grams = 3 kg 3 kg x 0.1 mL/kg = 0.3 mL

The pediatrician prescribes morphine sulphate 0.2 mg/kg orally q 4 hour for a neonate suffering from drug withdrawal. The neonate weighs 3,800 grams. How much of drug will the nurse give in 24 hours? Record your answer using two decimal places.

Answer: 4.56 Rationale: 3800 grams = 3.8 kg 3.8 kg/kg x 0.20 mg x 6 doses = 4.56 mg in 24 hours

A client at 33 weeks' gestation comes to the emergency department with vaginal bleeding. Assessment reveals the following: • Onset of slight vaginal bleeding at 29 weeks with spontaneous cessation • Recent onset of bright red vaginal bleeding, more than with previous episode • No uterine contractions at present • Fetal heart rate within normal range • Uterus soft and nontender Based on the assessment findings, which condition would the nurse likely suspect? A. Placental abruption B. Placenta previa C. Ruptured ectopic pregnancy D. Polyhydramnios

B

A client comes to the emergency department with moderate vaginal bleeding. She says, "I have had to change my pad about every 2 hours and it looks like I may have passed some tissue and clots." The woman reports that she is 9 weeks' pregnant. Further assessment reveals the following: • Cervical dilation • Strong abdominal cramping • Low hCG) levels • Ultrasound positive for products of conception The nurse suspects that the woman is experiencing which type of spontaneous abortion? A. Threatened B. Inevitable C. Incomplete D. Complete

B

A client who has experienced an incomplete abortion is prescribed mifepristone to assist in removing the retained products of conception. Which medication would the nurse expect to adminster if prescribed before administering mifepristone? A. Opioid analgesic for relief of cramping B. Antiemetic to minimize nausea C. VItamin K to reduce bleeding D. Diuretic to promote fluid loss

B

A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A. expectations B. transition to mastery C. reality D. taking-in

B

A group of nurses are reviewing information about mastitis and its causes in an effort to develop a teaching program on prevention for postpartum women. The nurses demonstrate understanding of the information when they focus the teaching on ways to minimize risk of exposure to which organism? A. E. coli B. S. aureus C. Proteus D. Klebsiella

B

A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement? A. "We will call 911 if we start to see that our newborn's lips or skin are looking bluish." B. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." C. "If our newborn does not have a wet diaper in 12 hours, we will call our pediatrician." D. "We will let the pediatrician know if our newborn's temperature goes above 100.4°F (38°C)."

B

A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. What is the nurse's first observation about the infant? A. The neonate is average for its gestational age. B. The neonate is small for its gestational age. C. The neonate is large for its gestational age. D. The neonate is fetal growth restricted

B

A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate? A. "You probably took iron during your pregnancy and that is what causes this type of stool." B. "This is meconium stool and is normal for a newborn." C. "I'll take a sample and check it for possible bleeding." D. "This is unusual, and I need to report this to your pediatrician

B

A newborn has an Apgar score of 6 at 5 minutes. Which action would be the priority? A. initiating IV fluid therapy B. beginning resuscitative measures C. promoting kangaroo care D. obtaining a blood culture

B

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU). The nurse prepares to obtain the blood sample from the newborn's: A. finger. B. heel. C. scalp vein. D. umbilical vein

B

A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? A. Apply warm soaks to the area. B. Notify the health care provider. C. Massage the uterine fundus. D. Encourage the client to void

B

A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? A. "I just feel so overwhelmed and tired." B. "I'm feeling so guilty and worthless lately." C. "It's strange, one minute I'm happy, the next I'm sad." D. "I keep hearing voices telling me to take my baby to the river."

B

A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrates understanding when they make which statement about this condition? A. "Postpartum blues is a long-term emotional disturbance." B. "Getting some outside help for housework can lessen feelings of being overwhelmed." C. "The mother loses contact with reality." D. "Extended psychotherapy is needed for treatment."

B

A nurse is conducting a presentation for a group of pregnant women about measures to prevent toxoplasmosis. The nurse determines that additional teaching is needed when the group identifies which measure as preventive? A. washing raw fruits and vegetables before eating them B. cooking all meat to an internal temperature of 125° F (52° C) C. wearing gardening gloves when working in the soil D. avoiding contact with a cat's litter boX

B

A nurse is conducting a program for pregnant women with gestational diabetes about reducing complications. The nurse determines that the teaching was successful when the group identifies which factor as being most important in helping to reduce complications associated with pregnancy and diabetes? A. stability of the woman's emotional and psychological status B. degree of blood glucose control achieved during the pregnancy C. reduction in retinopathy risk by frequent ophthalmologic evaluations D. control of blood urea nitrogen (BUN) levels for optimal kidney function

B

A nurse is describing the advantages and disadvantages of circumcision to a group of expectant parents. Which statement by the parents indicates effective teaching? A. "Sexually transmitted infections are more common in circumcised males." B. "The rate of penile cancer is less for circumcised males." C. "Urinary tract infections are more easily treated in circumcised males." D. "Circumcision is a risk factor for acquiring HIV infection."

B

A nurse is describing the risks associated with post-term pregnancies as part of an inservice presentation. The nurse determines that more teaching is needed when the group identifies which factor as an underlying reason for problems in the fetus? A. aging of the placenta B. increased amniotic fluid volume C. meconium aspiration D. cord compression

B

A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? A. administering broad-spectrum antibiotics B. inspecting the placenta after delivery for intactness C. manually removing the placenta at birth D. applying pressure to the umbilical cord to remove the placenta

B

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description? A. The cardiac murmur heard at birth disappears by 48 hours of age. B. Pulmonary vascular resistance (PVR) is decreased as lungs begin to function. C. Heart rate remains elevated after the first few moments of birth. D. Breath sounds will have rhonchi for at least the first day of life as fluid is absorbed

B

A nurse is explaining to a group of nurses new to the labor and birth unit about methods used for cervical ripening. The group demonstrates understanding of the information when they identify which method as a mechanical one? A. herbal agents B. laminaria C. membrane stripping D. amniotomy

B

A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as: A. involution. B. engorgement. C. mastitis. D. engrossment

B

A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: A. determines that the procedure is effective. B. helps support the lower uterine segment. C. aids in expressing accumulated clots. D. prevents uterine muscle fatigue

B

A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn? A. "You have your daddy's eyes." B. "He looks like a frog to me." C. "Where did you get all that hair?" D. "He seems to sleep a lot.

B

A nurse is observing a postpartum client interacting with her newborn and notes that the mother is engaging with the newborn in the en face position. Which behavior would the nurse be observing? A. mother placing the newborn next to bare breast B. mother making eye-to-eye contact with the newborn C. mother gently stroking the newborn's face D. mother holding the newborn upright at the shoulder

B

A nurse is providing care to a newborn who is receiving phototherapy. Which action would the nurse most likely include in the plan of care? A. keeping the newborn in the supine position B. covering the newborn's eyes while under the bili lights C. ensuring that the newborn is covered or clothed D. reducing the amount of fluid intake to 8 ounces daily

B

A nurse is reviewing a journal article on the causes of postpartum hemorrhage. Which condition would the nurse most likely find as the most common cause? A. labor augmentation B. uterine atony C. cervical or vaginal lacerations D. uterine inversion

B

A nurse is teaching new parents about bathing their newborn. The nurse determines that the teaching was successful when the parents make which statement? A. "We can put a tiny bit of lotion on his skin, and then rub it in gently." B. "We should avoid using any kind of baby powder." C. "We need to bathe him at least four to five times a week." D. "We should clean his eyes after washing his face and hair."

B

A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse determines that additional teaching is needed when the mother identifies which action as appropriate for her newborn? A. wrapping the newborn snugly in a blanket B. waking the newborn every hour C. checking the newborn's fontanels D. offering a pacifier

B

A nurse is visiting a postpartum woman who gave birth to a healthy newborn 5 days ago. Which finding would the nurse expect? A. bright red discharge B. pinkish brown discharge C. deep red mucus-like discharge D. creamy white discharge

B

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding? A. Conduction heat loss is a problem in the baby. B. The supply of brown adipose tissue is not developed. C. Axillary temperatures are not accurate. D. This is a normal temperature.

B

A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? A. nonpalpable fundus B. moderate lochia serosa C. bruising on arms and legs D. fever

B

A postpartum client is prescribed medication therapy as part of the treatment plan for postpartum hemorrhage. Which medication would the nurse expect to administer in this situation? A. Magnesium sulfate B. methylergonovine C. Indomethacin D. nifedipine

B

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? A. "It's difficult to say, but it will probably return in about 2 to 3 weeks." B. "It varies, but you can estimate it returning in about 7 to 9 weeks." C. "You won't have to worry about it returning for at least 3 months." D. "You don't have to worry about that now. It'll be quite a while."

B

A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? A. "I will use a soft toothbrush to brush my teeth." B. "I can take ibuprofen if I have any pain." C. "I need to avoid drinking any alcohol." D. "I will call my health care provider if my stools are black and tarry."

B

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? A. "You'll notice that this will fade to silvery lines." B. "Exercise will help to improve the muscles." C. "Expect the color to lighten somewhat." D. "You'll notice that your shoe size will increase."

B

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding? A. 1 to 2 ounces B. 2 to 4 ounces C. 4 to 6 ounces D. 6 to 8 ounces

B

A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition? A. a low-lying placenta B. fetopelvic disproportion C. contraction ring D. uterine bleeding

B

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected? A. two fingerbreadths above the umbilicus B. at the level of the umbilicus C. two fingerbreadths below the umbilicus D. four fingerbreadths below the umbilicus

B

A woman gave birth to a healthy term neonate today at 1330. It is now 1430 and the nurse has completed the client's assessment. At which time would the nurse next assess the client? A. 1445 B. 1500 C. 1530 D. 1830

B

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result? A. 3.3 mEq/L B. 6.1 mEq/L C. 8.4 mEq/L D. 10.8 mEq/L

B

A woman pregnant with twins comes to the clinic for an evaluation. While assessing the client, the nurse would be especially alert for signs and symptoms for which potential problem? A. oligohydramnios B. preeclampsia C. post-term labor D. chorioamnionitis

B

A woman receives magnesium sulfate as treatment for preterm labor. The nurse assess and maintains the infusion at the prescribed rate based on which finding? A. Respiratory rate-16 breaths/minute B. Decreased fetal heart rate variability C. Urine output 22 mL/hour D. Absent deep tendon reflexes

B

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? A. "You must have an infection, so let me get a urine specimen." B. "Your body is undergoing many changes that cause your bladder to fill quickly." C. "Your uterus is not contracting as quickly as it should." D. "The anesthesia that you received is wearing off and your bladder is working again."

B

A woman with a history of systemic lupus erythematosus comes to the clinic for evaluation. The woman tells the nurse that she and her partner would like to have a baby but that they are afraid her lupus will be a problem. Which response would be most appropriate for the nurse to make? A. "It's probably not a good idea for you to get pregnant since you have lupus." B. "Be sure that your lupus is stable or in remission for 6 months before getting pregnant." C. "Your lupus will not have any effect on your pregnancy whatsoever." D. "If you get pregnant, we'll have to add quite a few medications to your normal treatment plan

B

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate? A. "My mother lives next door and can drive me here if necessary." B. "I have a toddler and preschooler at home who need my attention." C. "I know to call my health care provider right away if I start to bleed again." D. "I realize the importance of following the instructions for my care."

B

A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately? A. respiratory rate of 16 breaths per minute B. 1+ deep tendon reflexes C. urine output of 45 mL/hour D. alert level of consciousness

B

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? A. presence of lochia serosa B. frequent scant voidings C. fundus firm, below umbilicus D. milk filling in both breasts

B

After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching? A. "Holding a pillow against my incision will help me when I cough." B. "I'm going to have to wait a few days before I can start breastfeeding." C. "I guess the nurses will be getting me up and out of bed rather quickly." D. "I'll probably have a tube in my bladder for about 24 hours or so."

B

After teaching a postpartum woman about breastfeeding, the nurse determines that the teaching was successful when the woman makes which statement? A. "I should notice a decrease in abdominal cramping during breast-feeding." B. "I should wash my hands before starting to breastfeed." C. "The baby can be awake or sleepy when I start to feed him." D. "The baby's mouth will open up once I put him to my breast."

B

After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? A. "I need to call my doctor if my temperature goes above 100.4° F (38° C)." B. "When I put on a new pad, I'll start at the back and go forward." C. "If I have chills or my discharge has a strange odor, I'll call my doctor." D. "I'll point the spray of the peri-bottle so it the water flows front to back."

B

After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production? A. convection B. nonshivering thermogenesis C. cold stress D. bilirubin conjugation

B

After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify which concept as reflecting the enduring nature of their relationship, one that involves placing the infant at the center of their lives and finding their own way to assume the parental identity? A. reciprocity B. commitment C. bonding D. attachment

B

After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A. "We'll make sure to cover both of his eyes to protect them." B. "Our newborn could develop a learning disability later on." C. "Once the bleeding ceases, there won't be any more worries." D. "We need to get family members to donate blood for transfusion."

B

As part of an education program for a group of pregnant women, the nurse teaches them about the changes that occur in the respiratory system during the postpartum period. The women demonstrate understanding of the information when they identify which occurrence as a postpartum adaptation? A. continued shortness of breath B. relief of rib aching C. diaphragmatic elevation D. decrease in respiratory rate

B

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating: A. habituation. B. motor maturity. C. orientation. D. social behaviors

B

Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a "clunk" when the Ortolani maneuver is performed. What would the nurse suspect? A. slipping of the periosteal joint B. developmental hip dysplasia C. normal newborn variation D. overriding of the pelvic bone

B

Assessment of a newborn's head circumference reveals that it is 34 cm. The nurse would suspect that this newborn's chest circumference would be: A. 30 cm. B. 32 cm. C. 34 cm. D. 36 cm.

B

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as: A. milia B. Mongolian spots C. stork bites D. birth trauma

B

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate? A. Assess the newborn's gestational age. B. Rewarm the newborn gradually. C. Observe the newborn every hour. D. Notify the primary care provider if the temperature goes lower

B

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rhpositive newborn based on the understanding that this drug will prevent her from: A. becoming Rh positive. B. developing Rh sensitivity. C. developing AB antigens in her blood. D. becoming pregnant with an Rh-positive fetus.

B

The nurse is assessing a newborn of a woman who is suspected of abusing alcohol. Which newborn finding would provide additional evidence to support this suspicion? A. wide, large eyes B. thin upper lip C. protruding jaw D. elongated nose

B

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description? A. scant B. light C. moderate D. large

B

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse interprets this finding as indicating which amount of blood loss? A. 10 mL B. 10 to 25 mL C. 25 to 50 mL D. over 50 mL

B

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location? A. just superior to the nipple, at the mid sternum B. lateral to the midclavicular line at the fourth intercostal space C. at the fifth intercostal space to the left of the sternum D. directly adjacent to the sternum at the second intercostals space

B

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: A. preterm. B. late preterm. C. term. D. postterm

B

The nurse is teaching a group of parents about the similarities and differences between newborn skin and adult skin. Which statement by the group indicates that additional teaching is needed? A. "The newborn's skin and that of an adult are similar in thickness." B. "The newborn's sweat glands function fully, just like those of an adult." C. "Skin development in the newborn is not complete at birth." D. "The newborn has fewer fibrils connecting the dermis and epidermis."

B

The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect? A. greenish black, tarry stool B. yellowish-brown, seedy stool C. yellow-gold, stringy stool D. yellowish-green, pasty stool

B

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism? A. evaporation B. conduction C. convection D. radiation

B

The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary because: A. lactase enzymatic activity is not adequate. B. oxygen demands need to be reduced. C. renal solute lead must be considered. D. hyperbilirubinemia is likely to develop

B

The nurse prepares to assess a newborn who is considered to be large-for-gestational-age (LGA). Which characteristic would the nurse correlate with this gestational age variation? A. strong, brisk motor skills B. difficulty in arousing to a quiet alert state C. birthweight of 7 lb, 14 oz (3,572 g) D. wasted appearance of extremities

B

The nurse reviews the medical record of a woman who has come to the clinic for an evaluation. The client has a history of mitral valve prolapse and is listed as risk class II. During the visit, the woman states, "We want to have a baby, but I know I am at higher risk. But what is my risk, really?" Which response by the nurse would be appropriate? A. "If you do get pregnant, you will need to be seen by a cardiologist every other month for monitoring." B. "Your risk during pregnancy is small, but you should see your cardiologist first before getting pregnant." C. "Your heart disease would put too much strain on your heart if you were to get pregnant." D. "Your pregnancy would be uneventful, but you would need specialized care for labor and birth."

B

The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which stage? A. expectations B. reality C. transition to mastery D. taking-hold

B

When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding? A. elevated white blood cell count B. acute decrease in hematocrit C. increased levels of clotting factors D. pulse rate of 60 beats/minute

B

When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage? A. Regular contractions B. Cervical dilation C. Fetal movement through the birth canal D. Placental separation

B

When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is some soft bedding material, and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching for which reason? A. The newborn should not be sleeping on his back B. Soft bedding material should not be in areas where infants sleep C. The bulb syringe should not be kept in the bassinet D. This newborn should be sleeping in a crib

B

When preparing a schedule of follow-up visits for a pregnant woman with chronic hypertension, which schedule would be most appropriate? A. monthly visits until 32 weeks, then bi-monthly visits B. bi-monthly visits until 28 weeks, then weekly visits C. monthly visits until 20 weeks, then bi-monthly visits D. bi-monthly visits until 36 weeks, then weekly visitS

B

Which assessment finding will alert the nurse to be on the lookout for possible placental abruption during labor? A. macrosomia B. gestational hypertension C. gestational diabetes D. low parity

B

Which information would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice? A. Physiologic jaundice results in kernicterus. B. Pathologic jaundice appears within 24 hours after birth. C. Both are treated with exchange transfusions of maternal O- blood. D. Physiologic jaundice requires transfer to the NICU

B

Which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A. Avoid using the terms "death" or "dying." B. Provide opportunities for them to hold the newborn. C. Refrain from initiating conversations with the parents. D. Quickly refocus the parents to a more pleasant topic

B

A nurse is assessing a newborn who is about 4½ hours old. The nurse would expect this newborn to exhibit which behavior? Select all that apply. A. sleeping B. interest in environmental stimuli C. passage of meconium D. difficulty arousing the newborn E. spontaneous Moro reflexes

B, C

A nurse is preparing a presentation about changes in the various body systems during the postpartum period and their effects for a group of new mothers. The nurse explains which event as influencing a postpartum woman's ability to void? Select all that apply. A. use of an opioid anesthetic during labor B. generalized swelling of the perineum C. decreased bladder tone from regional anesthesia D. use of oxytocin to augment labor E. need for an episiotomy

B, C, D

The nurse is assessing a newborn's eyes. Which findings would the nurse identify as normal? Select all that apply. A. slow blink response B. able to track object to midline C. transient deviation of the eyes D. involuntary repetitive eye movement E. absent red reflex

B, C, D

A set of newborn twins has been admitted to the neonatal intensive care unit with the diagnosis of fetal growth restriction (FGR). Which maternal factors would predispose the newborn to this diagnosis? Select all that apply. A. hemoglobin 15 g/dl (150 g/l) B. A1C levels of 8% (0.08) C. heroin use disorder D. blood pressure baseline of 170/90 mm Hg E. age 39 years F. multiple gestation

B, C, D, E, F

A neonate is exhibiting signs of neonatal abstinence syndrome. Which findings would confirm this diagnosis? Select all that apply. A. adequate rooting and sucking B. frequent sneezing C. persistent fever D. shrill, high-pitched cry E. hypotonic reflexes F. frequent yawning

B, C, D, F

At the breech forceps birth of a 32 weeks' gestation neonate, the nurse notes olygohydramnios with green thick amniotic fluid. The maternal history reveals a mother of Hispanic ethnicity with marked hypertension, who admits to using cocaine daily. Which factor(s) may contribute to meconium aspiration syndrome (MAS)? Select all that apply. A. the preterm pregnancy B. the forceps breech birth C. maternal cocaine use D. maternal hypertension E. Hispanic ethnicity F. oligohydramnios present

B, C, D, F

A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply. A. resumption of sexual intercourse about two weeks after birth B. possible experience of fluctuations in sexual interest C. use of a water-based lubricant to ease vaginal discomfort D. use of combined hormonal contraceptives for the first three weeks E. possibility of increased breast sensitivity during sexual activity

B, C, E

A nurse is reviewing an article about preterm prelabor rupture of membranes. Which factors would the nurse expect to find placing a woman at high risk for this condition? Select all that apply. A. high body mass index B. urinary tract infection C. low socioeconomic status D. single gestations E. smoking

B, C, E

A pregnant woman is admitted with premature rupture of the membranes. The nurse is assessing the woman closely for possible infection. Which findings would lead the nurse to suspect that the woman is developing an infection? Select all that apply. A. fetal bradycardia B. abdominal tenderness C. elevated maternal pulse rate D. decreased C-reactive protein levels E. cloudy malodorous fluid

B, C, E

A pregnant woman with chronic hypertension is entering her second trimester. The nurse is providing anticipatory guidance to the woman about measures to promote a healthy outcome. The nurse determines that the teaching was successful based on which client statement(s)? Select all that apply. A. "I will need to schedule follow-up appointments every 2 weeks until I reach 32 weeks' gestation." B. "I should try to lie down and rest on my left side for about an hour each day." C. "I will start doing daily counts of my baby's activity at about 24 weeks' gestation." D. "I will need to have an ultrasound at each visit beginning at 28 weeks' gestation." E. "I should take my blood pressure frequently at home and report any high readings."

B, C, E

A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which behavior? Select all that apply. A. frequently ask for the newborn to be taken from the room B. identify common features between themselves and the newborn C. refer to the newborn as having a monkey-facE D. make direct eye contact with the newborn E. refrain from checking out the newborn's features

B, D

A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply. A. Advise the parents that the hospital can make the arrangements. B. Offer to pray with the family if appropriate. C. Leave the parents to talk through their next steps. D. Initiate spiritual comfort by calling the hospital clergy, if appropriate. E. Respect variations in the family's spiritual needs and readiness

B, D, E

After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply. A. prolonged labor B. placenta previa C. null parity D. hydramnios E. labor augmentation

B, D, E

A neonate born to a mother who was abusing heroin is exhibiting signs and symptoms of withdrawal. Which signs would the nurse assess? Select all that apply. A. low whimpering cry B. hypertonicity C. lethargy D. excessive sneezing E. overly vigorous sucking F. tremors

B, D, F

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding? A. urinary output of 20 mL per hour B. respiratory rate of 10 breaths/minute C. deep tendons reflexes 2+ D. difficulty in arousing

C

A client is experiencing postpartum hemorrhage, and the nurse begins to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus? A. Place the hands on the sides of the abdomen to grasp the uterus. B. Use an up-and-down motion to massage the uterus. C. Wait until the uterus is firm to express clots. D. Continue massaging the uterus for at least 5 minutes

C

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? A. Offer warm blankets. B. Encourage the woman to void. C. Apply an ice pack to the site. D. Offer a warm sitz bath

C

A client with hyperemesis gravidarum is admitted to the facility after being cared for at home without success. What would the nurse expect to include in the client's plan of care? A. clear liquid diet B. total parenteral nutrition C. nothing by mouth D. administration of labetalol

C

A newborn is suspected of developing persistent pulmonary hypertension. The nurse would expect to prepare the newborn for which procedure to confirm the suspicion? A. chest X-ray B. blood cultures C. echocardiogram D. stool for occult blood

C

A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse expect to assess? A. bradypnea B. hydrocephaly C. flattened maxilla D. hypoactivity

C

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which event would the nurse expect to occur first? A. reestablishing relationships with others B. demonstrating increasing confidence in care of the newborn C. assuming a passive role in meeting her own needs D. becoming preoccupied with the present

C

A nurse is assessing a postterm newborn. Which finding would the nurse correlate with this gestational age variation? A. moist, supple, plum skin appearance B. abundant lanugo and vernix C. thin umbilical cord D. absence of sole creases

C

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? A. lochia rubra with a fleshy odor B. respiratory rate of 16 breaths per minute C. temperature of 101° F (38.3° C) D. pain rating of 2 on a scale from 0 to 10

C

A nurse is conducting an in-service program for a group of nurses working at the women's health facility about the causes of spontaneous abortion. The nurse determines that the teaching was successful when the group identifies which condition as the most common cause of first trimester abortions? A. maternal disease B. cervical insufficiency C. fetal genetic abnormalities D. uterine fibroids

C

A nurse is providing care to a newborn. The nurse suspects that the newborn is developing sepsis based on which assessment finding? A. increased urinary output B. interest in feeding C. temperature instability D. wakefulness

C

A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy? A. use of oral contraceptives for 5 years B. ovarian cyst 2 years ago C. recurrent pelvic infections D. heavy, irregular menses

C

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as: A. puerperium. B. lactation. C. attachment. D. engrossment

C

A nurse suspects that a client may be developing disseminated intravascular coagulation. The woman has a history of placental abruption (abruptio placentae) during birth. Which finding would help to support the nurse's suspicion? A. severe uterine pain B. board-like abdomen C. appearance of petechiae D. inversion of the uterus

C

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? A. ferrous sulfate B. methylergonovine C. docusate D. bromocriptine

C

A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding? A. pouring warm water over her perineal area B. having her hear the sound of water running nearby C. placing her hand in a basin of cool water D. standing her in the shower with the warm water on

C

A postpartum woman is prescribed oxytocin to stimulate the uterus to contract. Which action would be most important for the nurse to do? A. Administer the drug as an IV bolus injection. B. Give as a vaginal or rectal suppository. C. Piggyback the IV infusion into a primary line. D. Withhold the drug if the woman is hypertensive

C

A postpartum woman who is breastfeeding tells the nurse that she is experiencing nipple pain. After teaching the woman about possible suggestions, the nurse determines that more teaching is needed when the woman makes which statement? A. "I use a mild analgesic about 1 hour before breastfeeding." B. "I apply expressed breast milk to my nipples." C. "I apply glycerin-based gel to my nipples." D. "My baby latches on."

C

A pregnant client with iron-deficiency anemia is prescribed an iron supplement. After teaching the woman about using the supplement, the nurse determines that more teaching is needed based on which client statement? A. "Taking the iron supplement with food will help with the side effects." B. "I will need to avoid coffee and tea when I take this supplement." C. "I will take the iron with milk instead of orange or grapefruit juice." D. "If I happen to miss a dose, I will take it as soon as I remember."

C

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer? A. sedatives B. tocolytics C. uterine stimulants D. corticosteroids

C

A woman with a history of crack cocaine use disorder is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also reports acute abdominal pain that is continuous. Which condition would the nurse suspect? A. amniotic fluid embolism B. shoulder dystocia C. uterine rupture D. umbilical cord prolapse

C

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition? A. retained placental fragments B. hypertension C. thrombophlebitis D. uterine subinvolution

C

The health care provider prescribes PGE2 for a woman to help evacuate the uterus following a spontaneous abortion. Which action would be most important for the nurse to do? A. Use clean technique to administer the drug. B. Keep the gel cool until ready to use. C. Maintain the client supine for 30 minutes after administration. D. Administer intramuscularly into the deltoid area

C

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason? A. reduce lochia B. promote uterine involution C. improve pelvic floor tone D. alleviate perineal pain

C

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? A. to aid in maturing the newborn's sucking reflex B. to encourage the development of maternal antibodies C. to facilitate maternal-infant bonding D. to enhance the clearing of the newborn's respiratory passages

C

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of: A. inability to clear fluids. B. immature respiratory control center. C. deficiency of surfactant. D. smaller respiratory passages

C

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as: A. harlequin sign. B. nevus flames. C. erythema toxicum. D. port wine stain

C

The nurse is developing a plan of care for a neonate experiencing symptoms of drug withdrawal. What should be included in this plan? A. Administer glucose between feedings. B. Schedule feedings every 4 to 6 hours. C. Swaddle the infant between feedings. D. Rock horizontally

C

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful? A. "I'll basically follow the same diet that I was following before I became pregnant." B. "Because I need extra protein, I'll have to increase my intake of milk and meat." C. "Pregnancy affects insulin production, so I'll need to make adjustments in my diet." D. "I'll adjust my diet and insulin based on the results of my urine tests for glucose."

C

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A. Suggest that the parents stay for just a few minutes to reduce their anxiety. B. Reassure them that their newborn is progressing well. C. Encourage the parents to touch their preterm newborn. D. Discuss the care they will be giving the newborn upon discharge

C

Upon entering the room of a client who has had a spontaneous abortion, the nurse observes the client crying. Which response by the nurse would be most appropriate? A. "Why are you crying?" B. "Will a pill help your pain?" C. "I'm sorry you lost your baby." D. "A baby still wasn't formed in your uterus."

C

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A. greater than after a vaginal birth. B. about the same as after a vaginal birth. C. less than after a vaginal birth. D. saturated with clots and mucus.

C

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes? A. gastrointestinal and hepatic B. urinary and hematologic C. respiratory and cardiovascular D. neurological and integumentary

C

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area? A. superficial structures above the muscle B. through the perineal muscles C. through the anal sphincter muscle D. through the anterior rectal wall

C

When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation? A. deep red, fleshy-smelling lochia B. voiding of 350 cc C. blood pressure 90/50 mm Hg D. profuse sweating

C

Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? A. multiparity, age of mother, operative birth B. size of placenta, small baby, operative birth C. uterine atony, placenta previa, operative procedures D. prematurity, infection, length of labor

C

Which method would be most effective in evaluating the parents' understanding about their newborn's care? A. Demonstrate all infant care procedures. B. Allow the parents to state the steps of the care. C. Observe the parents performing the procedures. D. Routinely assess the newborn for cleanliness

C

While observing the interaction between a newborn and the mother, the nurse notes the newborn nestling into the arms of the mother. The nurse identifies this as which behavior? A. habituation B. self-quieting ability C. social behaviors D. orientation

C

A client in her first trimester comes to the clinic for an evaluation. Assessment reveals reports of fatigue, anorexia, and frequent upper respiratory infections. The client's skin is pale and the client is slightly tachycardic. The client also reports drinking about 6 cups of coffee on average each day. A diagnosis of iron-deficiency anemia is suspected. The client is scheduled for laboratory testing and the results are as follows: • Hemoglobin 11.5 g/dL (115 g/L) • Hematocrit 35% (0.35) • Serum iron 32 µg/dL (5.73 µmol/L) • Serum ferritin 90 ng/dL (90 µg/L) Which laboratory finding would the nurse correlate with the suspected diagnosis? A. Hemoglobin B. Hematocrit C. Serum iron level D. Serum ferritin level

D

A client who is HIV-positive is in her second trimester and remains asymptomatic. She voices concern about her newborn's risk for the infection. Which statement by the nurse would be most appropriate? A. "You'll probably have a cesarean birth to prevent exposing your newborn." B. "Antibodies cross the placenta and provide immunity to the newborn." C. "Wait until after the infant is born, and then something can be done." D. "Antiretroviral medications are available to help reduce the risk of transmission."

D

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A. "Your uterus is still shrinking in size; that's why you're feeling this pain." B. "Let me check your vaginal discharge just to make sure everything is fine." C. "Your body is responding to the events of labor, just like after a tough workout." D. "The baby's sucking releases a hormone that causes the uterus to contract."

D

A neonate born addicted to cocaine is now being treated with medication for acute neonatal abstinence syndrome. Which medication will be prescribed to relieve withdrawal symptoms? A. meperidine B. adrenalin C. naloxone D. morphine sulphate

D

A neonate is diagnosed with Erb's palsy after birth. The parents are concerned about their neonate's limp arm. The nurse explains the neonate will be scheduled to receive what recommended treatment for this condition first? A. Physical therapy to the joint and extremity B. Nothing but time and let nature take its course C. Surgery to correct the joint and muscle alignment D. Immobilization of the shoulder and arm

D

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. Which factor would the nurse integrate into the response? A. newborn being placed prone after feeding B. limited ability of digestive enzymes C. underdeveloped pyloric sphincter D. relaxed cardiac sphincter

D

A newborn has been diagnosed with a group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause? A. improper hand washing B. contaminated formula C. nonsterile catheter insertion D. mother's birth canal

D

A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which behavior? A. habituation B. motor maturity C. social behavior D. orientation

D

A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? A. leg pain on ambulation with mild ankle edema B. calf pain with dorsiflexion of the foot C. perineal pain with swelling along the episiotomy D. sharp, stabbing chest pain with shortness of breath

D

A nurse is assessing a pregnant woman with gestational hypertension. Which finding would lead the nurse to suspect that the client has developed severe preeclampsia? A. urine protein 300 mg/24 hours B. blood pressure 150/96 mm Hg C. mild facial edema D. hyperreflexia

D

A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a preterm newborn is in pain? A. bradycardia B. oxygen saturation level of 94% C. decreased muscle tone D. sudden high-pitched cry

D

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM? A. yellow-green fluid B. blue color on Nitrazine testing C. ferning D. foul odor

D

A nurse is counseling a pregnant woman with rheumatoid arthritis about medications that can be used during pregnancy. The nurse would emphasize the need to avoid which medication at this time? A. hydroxychloroquine B. nonsteroidal anti-inflammatory drugs C. glucocorticoid D. methotrexate

D

A nurse is providing care to several pregnant women at different weeks of gestation. The nurse would expect to screen for group B streptococcus infection in the client who is at: A. 16 weeks' gestation. B. 28 weeks' gestation. C. 32 weeks' gestation. D. 36 weeks' gestation

D

A nurse is providing education to a woman who is experiencing postpartum hemorrhage and is to receive a uterotonic agent. The nurse determines that additional teaching is needed when the woman identifies which drug as possibly being prescribed as treatment? A. oxytocin B. methylergonovine C. carboprost D. magnesium sulfate

D

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down? A. prolactin B. estrogen C. progesterone D. oxytocin

D

A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman makes which statement? A. "I'll sit down to rest for 30 minutes." B. "I'll try to move my bowels." C. "I'll lie down with my legs raised." D. "I'll drink several glasses of water."

D

A nurse suspects that a client is developing HELLP syndrome. The nurse notifies the health care provider based on which finding? A. hyperglycemia B. elevated platelet count C. disseminated intravascular coagulation (DIC) D. elevated liver enzymes

D

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk? A. increase in clotting factors B. vessel damage C. immobility D. increase in red blood cell production

D

A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A. shapeless. B. circular. C. triangular. D. slit-like

D

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which factor would the nurse identify as being a significant contributor to this condition? A. early ambulation B. short duration of labor C. breastfeeding D. use of anesthetics

D

A pregnant client with preeclampsia is being treated with intravenous magnesium sulfate. The nurse assesses the client's deep tendon reflexes and grades them as 4+. The nurse notifies the health care provider about this finding, describing them using which term to ensure accurate communication? A. Absent B. Average C. Brisk D. Clonus

D

A pregnant woman asks the nurse, "I'm a big coffee drinker. Will the caffeine in my coffee hurt my baby?" Which response by the nurse would be most appropriate? A. "The caffeine in coffee has been linked to birth defects." B. "Caffeine has been shown to restrict growth in the fetus." C. "Caffeine is a stimulant and needs to be avoided completely." D. "If you keep your intake to less than 200 mg/day, you should be okay."

D

A preterm newborn is receiving enteral feedings. Which finding would alert the nurse to suspect that the newborn is developing NEC? A. irritability B. sunken abdomen C. clay-colored stools D. feeding intolerance

D

A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of <87%. The nurse interprets these findings as: A. cardiac distress. B. respiratory alkalosis. C. bronchial pneumonia. D. respiratory distress

D

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? A. an inverted nipple on the affected breast B. no breast milk in the affected breast C. an ecchymotic area on the affected breast D. hardening of an area in the affected breast

D

A woman who is experiencing postpartum hemorrhage is extremely apprehensive and diaphoretic. The woman's extremities are cool and her capillary refill time is increased. Based on this assessment, the nurse suspects that the client is experiencing approximately how much blood loss? A. 20% B. 30% C. 40% D. 60%

D

A woman with a history of asthma comes to the clinic for evaluation for pregnancy. The woman's pregnancy test is positive. When reviewing the woman's medication therapy regimen for asthma, which medication would the nurse identify as problematic for the woman now that she is pregnant? A. ipratropium B. albuterol C. salmeterol D. Prednisone

D

After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position? A. supine B. side-lying C. sitting D. knee-chest

D

As part of an in-service program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn? A. in the first week B. within the first 2 weeks C. in approximately 1 month D. within the first 6 weeks

D

Assessment of a pregnant woman and her fetus reveals tachycardia and hypertension. There is also evidence suggesting vasoconstriction. The nurse would question the woman about use of which substance? A. marijuana B. alcohol C. heroin D. cocaine

D

It is determined that a client's blood Rh is negative and her partner's is Rh positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time? A. at 32 weeks' gestation and immediately before discharge B. 24 hours before birth and 24 hours after birth C. in the first trimester and within 2 hours of birth D. at 28 weeks' gestation and again within 72 hours after birth

D

Rapid assessment of a newborn indicates the need for resuscitation. The newborn has copious secretions. The newborn is dried and placed under a radiant warmer. Which action would the nurse do next? A. Intubate with an appropriate-sized endotracheal tube. B. Give chest compressions at a rate of 80 times per minute. C. Administer epinephrine intravenously. D. Clear the airway with a bulb syringe

D

The nurse administers vitamin K intramuscularly to the newborn based on which rationale? A. Stop Rh sensitization. B. Increase erythropoiesis. C. Enhance bilirubin breakdown. D. Promote blood clotting.

D

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they: A. have a smaller body surface compared to body mass. B. lose more body heat when they sweat than adults. C. have an abundant amount of subcutaneous fat all over. D. are unable to shiver effectively to increase heat production

D

The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth? A. fracture of the tibia B. fracture of the femur C. fracture of a rib D. midclavicular fracture

D

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest? A. 38 breaths per minute B. 46 breaths per minute C. 54 breaths per minute D. 68 breaths per minute

D

The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after birth. The nurse determines that the women understood the description when they identify the condition as postpartum: A. depression. B. psychosis. C. bipolar disorder. D. blues

D

The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation? A. encouraging the woman to manually express milk B. suggesting that she take frequent warm showers to soothe her breasts C. telling her to limit the amount of fluids that she drinks D. instructing her to apply ice packs to both breasts every other hour

D

The nurse is providing an in-service education program to a group of home health care nurses who provide care to postpartum women. After teaching the group about the process of involution, the nurse determines that additional teaching is needed when the group identifies which process as being involved? A. catabolism B. muscle fiber contraction C. epithelial regeneration D. vasodilation

D

The nurse is reviewing the laboratory test results of a pregnant client. Which finding would alert the nurse to the development of HELLP syndrome? A. hyperglycemia B. elevated platelet count C. leukocytosis D. elevated liver enzymes

D

The nurse is reviewing the physical examination findings for a client who is to undergo labor induction. Which finding would indicate to the nurse that a woman's cervix is ripe in preparation for labor induction? A. posterior position B. firm C. closed D. shortened

D

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? A. fewer visible blood vessels through the skin B. more subcutaneous fat in the neck and abdomen C. well-developed flexor muscles in the extremities D. greater body surface area in proportion to weight

D

The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days old. What would the nurse expect to find? A. greenish black, tarry stool B. yellowish-brown, seedy stool C. yellow-gold, stringy stool D. yellowish-green, pasty stool

D

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal? A. Prevent cold stress B. Increase surfactant levels in the lungs C. Promote respiratory stability D. Decrease the serum bilirubin level

D

When assessing a newborn's reflexes, the nurse strokes the newborn's cheek, and the newborn turns toward the side that was stroked and begins sucking. The nurse documents which reflex as being positive? A. palmar grasp reflex B. tonic neck reflex C. Moro reflex D. rooting reflex

D

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature? A. hearing B. touch C. taste D. vision

D

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging and turning bluish. What would the nurse do first? A. Alert the primary care provider stat, and turn the newborn to her right side. B. Administer oxygen via facial mask by positive pressure. C. Lower the newborn's head to stimulate crying. D. Aspirate the oral and nasal pharynx with a bulb syringe

D