PN Maternal/Newborn A & B

A nurse is reinforcing teaching w/ a pt who is pregnant & will undergo a 1-hr oral glucose tolerance test. Which of the following instructions should the nurse include? a) Provide a urine sample at the start of the test. b) Fast for 12 hr before the test. c) Avoid caffeine the morning of the test. d) Eat a low-carbohydrate diet 24 hr prior to the test.

a) It is not necessary to provide a urine sample at the start of this test, although it is a requirement for a 3-hr glucose tolerance test. b) It is not necessary for the client to fast prior to this test, although it is a requirement for a 3-hr glucose tolerance test. c) The client should avoid caffeine the morning of the test because it can increase glucose levels. d) Eating a low-carbohydrate diet 24 hr prior to the test is not necessary. However, for a 3-hr glucose tolerance test, clients should ingest an adequate amount of carbohydrates for at least 3 days before the test, except for the overnight fast immediately prior to the test.

A nurse is planning to administer terbutaline to a pt who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? a) IM b) Intradermal c) SubQ d) Topical

a) Terbutaline cannot be administered intramuscularly. b) Terbutaline cannot be administered intradermally. c) Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication should be administered subcutaneously every 4 hr. d) Terbutaline cannot be administered topically.

A nurse is caring for a pt who is at 32 weeks of gestation & has a Rx for nifedipine. Which of the following outcomes should the nurse expect from this medication? a) Fetal lung matury b) Maternal blood glucose control c) Cessation of uterine contractions d) Resolution of maternal nausea

a) The nurse should expect a glucocorticoid, such as dexamethasone, to promote the acceleration of fetal lung maturity. b) The nurse should expect an oral hypoglycemic agent, such as glyburide, to help control blood glucose. c) Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the smooth muscle of the uterus. d) The nurse should expect an antiemetic, such as metoclopramide, to decrease maternal nausea.

A nurse is preparing to administer clindamycin 450 mg PO to a pt who has endometritis. The amount variable is clindamycin 150/capsule. How many capsules should the nurse administer?

3 capsules Step 1: What is the unit of measurement the nurse should calculate? capsule(s) Step 2: What is the dose the nurse should administer? 450 mg (desired) Step 3: What is the dose available? 150 mg (have) Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 capsule Step 6: Set up an equation and solve for X. Have / Desired = Quantity (x) 150 mg / 450 mg = 1 capsule(x) (x) capsule(s) = 3 capsules

Graphic Record: BP: - Week 16: 120/70 mm Hg - Week 20: 130/80 mm Hg Weight: - Week 16: 61.7 kg (136 lb) - Week 20: 63 kg (138.9 lb) Nurse's Notes: Fundal Height: - Week 16: 16 cm - Weeks 20: 25 cm Fetal Heart Rate: - Week 16: 156/min - Weeks 20: 160/min Diagnostic Results: - Week 16: Urine negative for albumin & glucose - Week 20: Urine negative for albumin & glucose ----------------------------------------------------------------------------- A nurse is caring for a pt who is at 20 weeks of gestation & is in the clinic for a routine prenatal visit. Which of the following findings in the data from the pt's MR should the nurse report to the provider? a) Weight b) Fundal height c) FHR d) BP

a) A client in the second trimester of pregnancy should gain approximately 0.45 kg (1 lb) per week. Therefore, a weight gain of 1.3 kg (2.9 lb) in 4 weeks is an expected finding. b) The height of the fundus in centimeters at 20 weeks of gestation is approximately the same as the number of weeks of gestation plus or minus 2 cm. Therefore, a fundal height of 25 cm is greater than the expected finding for 20 weeks of gestation. c) A fetal heart rate of 160/min at 20 weeks of gestation is within the expected reference range of 110 to 160/min. d) A maternal blood pressure of 130/80 mm Hg is below the reportable value of 140/90 mm Hg.

A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in newborns w/ a group of pts who are pregnant. Which of the following risk factors should the nurse include? a) Cord compression b) Chronic HTN c) Alcohol use during pregnancy d) Prematurity

a) Cord compression during pregnancy can result in fetal anoxia. However, it is not a risk factor for RDS. b) Chronic hypertension is not a risk factor for RDS. c) Alcohol use during pregnancy can result in fetal alcohol syndrome, developmental delay, and birth defects. However, it is not a risk factor for RDS. d) A newborn who is premature has inadequate surfactant production, which can lead to RDS.

A nurse in a maternal/newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the newborn to his daughter's room. Which of the following responses should the nurse make? a) "I'll first need to see your photo ID before I can release the baby to you." b) "Let me wash my hands and then I'll take the baby to his mother." c) "Please wash your hands first, then I'll allow you to carry the baby to your daughter's room." d) "Have your daughter call the nursery so that the staff can release the baby to you."

a) Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns. b) Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns. c) Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns. In addition, transport of the newborn must be in a designated bassinet. d) Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns.

A nurse is caring for a newborn who has a high-pitched cry & does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect the complete? a) Apgar score b) Newborn Hearing Screen c) Critical Congenital Heart Disease screen (CCHD) d) Neonatal Abstinence Scoring System

a) The Apgar score is completed at 1 and 5 min following birth and is not indicated for a newborn who is inconsolable and has a high-pitched cry. Components of the Apgar score include heart rate, respiratory effort, muscle tone, reflex irritability, and skin color. b) The Newborn Hearing Screen is included in the Recommended Uniform Screening Panel (RUPS), but it is not indicated for a newborn who is inconsolable and has a high-pitched cry. The Newborn Hearing Screen should be completed before the newborn is discharged from the hospital. c) The CCHD is included in the RUPS, but it is not indicated for a newborn who is inconsolable and has a high-pitched cry. The CCHD should be completed 24 to 48 hr following birth and before the newborn is discharged from the hospital. d) This newborn is exhibiting manifestations of opioid withdrawal and should be screened using the Neonatal Abstinence Scoring System. Some additional manifestations of withdrawal include restlessness, tremors, increased muscle tone, and an exaggerated Moro reflex.

A nurse is reinforcing family planning options w/ a pt who is requesting info about contraceptives. Which of the following pt statements indicates an understanding of the teaching? a) "The diaphragm should be removed 2 hrs after having intercourse." b) "I can use water-soluble lubricant when my partner wears a latex condom." c) "It is okay for me to remove the birth control sponge within 2 hrs after having intercourse." d) "When I use the birth control patch, it must be changed once a month."

a) The diaphragm should be left in place for at least 6 hr following intercourse in order to be effective. b) Water-soluble lubricants should be used with male latex condoms, because the use of any other lubricant can compromise the integrity of the condom. c) The contraceptive sponge should be left in place for at least 6 hr after intercourse in order to be effective. d) The contraceptive patch is changed weekly for 3 weeks, followed by 1 week in which the client does not wear the patch.

A nurse is caring for a pt who is at 11 weeks of gestation & reports frequent vomiting. Which of the following findings should the nurse identify as an indication that the pt has hyperemesis gravidarum? a) Ketonuria b) Bradycardia c) Bradypnea d) Proteinuria

a) The nurse should identify that ketonuria is an indication of hyperemesis gravidarum. Ketonuria occurs due to the breakdown of fat secondary to malnutrition or starvation. b) The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachycardia due to dehydration. c) The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachypnea due to dehydration. d) The nurse should identify that proteinuria is an indication of preeclampsia, rather than hyperemesis gravidarum.

A nurse is caring for a pt who delivered vaginally 6 hrs ago. Which of the following findings should the nurse report to the provider? a) Labial edema b) Fundus firm at the umbilicus c) WBC count 15,000/mm³ d) Perineal pad soaked in 15 mins

a) The nurse should identify that labial edema is an expected finding following a vaginal birth. The nurse can apply ice packs to minimize edema and pain. b) The nurse should identify that a firm fundus at the level of the umbilicus 6 hr following birth is an expected finding. c) The nurse should identify that a WBC count of 15,000/mm3 is an expected finding 6 hr following birth. d) The nurse should identify that soaking a perineal pad in 15 min or less is a manifestation of postpartum hemorrhage. Therefore, the nurse should report this finding to the provider.

A nurse in an antepartum clinic is reviewing laboratory test results for a group of pts. The nurse should notify the provider of which of the following results? a) Hemoglobin 14 g/dL b) WBC count 14,000/mm³ c) Hematocrit 31% d) Platelets 200,000/mm³

a) This is within the expected reference range for a pt who is pregnant. b) This is within the expected reference range for a pt who is pregnant. c) This is below the expected reference range for a pt who is pregnant & requires reporting to the provider. d) This is within the expected reference range for a pt who is pregnant.

A nurse is assisting w/ the care of a pt who is postpartum & is receiving lactated Ringer's 1,500 mL IV to infused over 10 hr. The nurse should verify that the IV pump's settings will deliver how many mL/hr?

150 mL/hr Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the volume the nurse should infuse? 1,500 mL Step 3: What is the total infusion time? 10 hr Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for X. Volume (mL) / (x) mL/hr = Time (hr) 1,500 mL / (x) mL/hr = 10 hr (x) mL/hr = 150 mL/hr

A nurse is reinforcing teaching about a non-stress test w/ a pt who is at 33 weeks of gestation. Which of the following statements should the nurse include? a) "You will receive IV fluids throughout the test." b) "You will press a button when you feel the baby move." c) "You will need to avoid eating for 4 hrs prior to the test." d) "You will be prompted to massage your nipples for the test."

a) "You will receive IV fluids throughout the test." The nurse should instruct the client that a non-stress test is noninvasive and does not require an IV infusion. A contraction stress test might require an IV infusion for the administration of oxytocin. b) The nurse should instruct the client that a non-stress test monitors for accelerations in the FHR with fetal movement. The client will have a handheld button to push when they feel fetal movements. c) The nurse should instruct the client to eat and drink as usual prior to the test. A non-stress test is noninvasive and does not require fasting. d) The nurse should instruct the client that a non-stress test monitors for accelerations in the FHR with fetal movement. A contraction stress test might require the client to perform nipple stimulation to initiate contractions.

A nurse is reinforcing teaching about food sources that are high in folate w/ a group of pts who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? a) 1 cup dried prunes b) 1/2 cup boiled potatoes c) 1/2 cup dried peas d) 1 cup grapes

a) 1 cup of dried prunes contains 3 mcg of folate. Therefore, there is another food the nurse should recommend. b) 1/2 cup of boiled potatoes contains 4 mcg of folate. Therefore, there is another food the nurse should recommend. c) Clients who are pregnant should consume 400 mcg of folate per day. 1/2 cup of dried green split peas provides 127 mcg of folate and is the best of these sources of folate for the nurse to recommend. d) 1 cup of grapes contains 3 mcg of folate. Therefore, there is another food the nurse should recommend.

A nurse is collecting data from a 28 yo pt who is requesting an Rx for an oral contraceptive. Which of the following info in the pt's Hx should the nurse identify as a contraindication for the use of oral contraceptives? a) Hx of mononucleosis 1 yr ago b) Frequent headaches w/ visual changes c) Reports of occasional heartburn in the evening d) Irregular menstrual cycles w/ dysmenorrhea

a) A Hx of mononucleosis is not a contraindication for oral contraceptive use. Although infection is not a contraindication, the pt will need to know that there are some antibiotic & antiviral meds that can reduce the effectiveness of oral contraceptives. b) Frequent headaches w/ visual changes can indicate a cardiovascular condition, such as HTN. A cardiovascular disorder is a contraindication for oral contraceptive use b/c the combination can increase the risks of cerebrovascular accident, myocardial infarction, & thromboembolism. c) Occasional heartburn in the evening is not contraindication for oral contraceptive use as long as it is not a manifestation of a more serious disorder. Gallbladder disease and liver cirrhosis, for example, are contraindications for oral contraceptive use, and both these disorders can cause indigestion. d) Irregular menstrual cycles w/ dysmenorrhea are not a contraindication for using oral contraceptives. In fact, non-contraceptive advantages of oral contraceptive use include regulation of irregular cycles & relief of menstrual pain.

A nurse is assisting w/ the care of a pt who is postpartum & is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity? (SATA) a) Hyperreflexia b) Decreased RR c) Polyuria d) Decreased LOC e) Double vision

a) Absent deep tendon reflexes are an early manifestation of magnesium sulfate toxicity. b) Respiratory depression is a manifestation of magnesium sulfate toxicity. c) Oliguria, a urine output of less than 30 mL/hr, is an indication of magnesium sulfate toxicity. d) A decreased level of consciousness is a manifestation of magnesium sulfate toxicity. e) Double vision is a manifestation of magnesium sulfate toxicity.

A nurse is assisting w/ collecting data from a newborn who is born 2 hrs ago & has respiratory distress. Which of the following findings should the nurse report to the provider? (SATA) a) Acrocyanosis b) Tachypnea c) Nasal flaring d) Retractions e) Expiratory grunting

a) Acrocyanosis is a bluish discoloration of the hands and feet of the newborn and is an expected finding during the first 48 hr after birth. b) Tachypnea is a respiratory rate greater than 60/min and is a finding associated with respiratory distress in the newborn. c) Nasal flaring is a finding associated with respiratory distress in the newborn. d) Retractions are a finding associated with respiratory distress in the newborn. e) Expiratory grunting is a finding associated with respiratory distress in the newborn.

A nurse is caring for a pt 6 hrs after a vaginal birth who is going to breastfeed her newborn. The pt reports perineal pain of 6 on a scale from 0-10. The nurse also notes mild perineal edema & ecchymosis, w/ a fundus that is 2 cm above the umbilicus w/ deviation to the R. Which of the following actions is the nurse's priority? a) Administer analgesics. b) Apply an ice pack to the perineum. c) Assist the pt w/ breastfeeding. d) Help the pt ambulate to the toilet.

a) Administer analgesics. The nurse should administer analgesics to relieve the client's pain; however, another action is the nurse's priority. b) The nurse should apply an ice pack to the client's perineum to reduce swelling and relieve the client's pain; however, another action is the nurse's priority. c) The nurse should assist the client with breastfeeding to promote uterine involution; however, another action is the nurse's priority. d) The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the priority intervention by the nurse is to assist the client to urinate and completely empty the bladder, which will allow the uterus to contract.

A nurse is assisting w/ monitoring a newborn who is 3 days old & has received phototherapy. Which of the following laboratory values should the nurse recognize as an indication that the therapy has been effective? a) Glucose 45 mg/dL b) WBC count 10,000/mm³ c) Total bilirubin 5 mg/dL d) Hgb 16 g/dL

a) Although a glucose of 45 mg/dL is within the expected reference range of 30 to 60 mg/dL, it is not an indication that the phototherapy has been effective. b) Although a WBC count of 10,000/mm3 is within the expected reference range of 9,000 to 30,000/mm3, it is not an indication that the phototherapy has been effective. c) The nurse should identify that phototherapy is used to treat newborns who have hyperbilirubinemia. Therefore, the nurse should monitor the newborn's bilirubin level before, during, and after phototherapy. A total bilirubin of 5 mg/dL is within the expected reference range of 1 to 12 mg/dL, which indicates the phototherapy has been effective. d) Although a hemoglobin level of 16 g/dL is within the expected reference range of 14 to 24 g/dL, it is not an indication that the phototherapy has been effective.

A nurse is assisting w/ the care of a pt who is in the active phase of the 1st stage of labor. Which of the following findings should the nurse report to the charge nurse? a) FHR 155/min b) Uterine contractions 70 seconds in duration c) Green fluid from the vagina d) Early decelerations

a) An FHR of 155/min is an expected finding during the active phase of the first stage of labor. The expected reference range for a term fetus is 110 to 160/min. b) Uterine contractions lasting 40 to 90 seconds during the active phase of the first stage of labor is an expected finding. c) Green fluid from the vagina indicates that the fetus has passed a meconium stool. This places the fetus at risk for developing meconium aspiration syndrome. d) Fetal head compression can result in early decelerations, which are an expected finding during the active phase of the first stage of labor.

A nurse is assisting w/ monitoring a pt after an amniocentesis. Which of the following findings should the nurse expect? a) FHR 120/min b) Vaginal bleeding c) Temperature of 39°C (102.2°F) d) Leakage of amniotic fluid

a) An amniocentesis is a procedure used to evaluate amniotic fluid for congenital abnormalities during pregnancy. Before & after an amniocentesis, the nurse should assist w/ obtaining vital signs & FHR. A FHR of 120/min is an expected finding & is within the expected reference range of 110-160/min. The nurse should also monitor the pt for complications such as infection, hemorrhage, leakage of amniotic fluid, placental abruption, and fetal death & report any unexpected findings to the charge nurse or provider immediately. b) Vaginal bleeding is an unexpected finding that could indicate hemorrhage & the nurse should report this finding to the charge nurse or provider immediately. c) A temperature of 39°C (102.2°F) is an unexpected finding that could indicate infection. The nurse should report this finding to the charge nurse or provider immediately. d) The leakage of amniotic fluid is an expected finding that could indicate rupture of the amniotic sac during the procedure. The nurse should report this finding to the charge nurse or provider immediately.

A nurse is reinforcing teaching w/ a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching? a) "Some assistive personnel might not have name badges." b) "A nurse will carry my baby back to the nursery in their arms for routine care when it is needed." c) "I will ask the nurse to take my baby back to the nursery if I need to leave my room." d) "I can remove my baby's security band before giving her a bath."

a) Assistive personnel caring for newborns should always wear identification. The parent should not allow anyone without proper identification to care for or remove the newborn from the room. b) A newborn should always be transported in a bassinet when moved from one location to another to prevent the risk for injury and abduction. c) The nurse should instruct the parent not to leave the newborn unattended. If the parent needs to leave the room, the parent should call the nurse to transport the newborn back to the nursery. d) The parent should always make sure the newborn's security band is in place because the band helps to ensure the safety of the newborn. If the security band is removed, the alarm will sound immediately.

A nurse is reinforcing teaching w/ a pt who is trying to become pregnant. Which of the following foods should the nurse recommend as the best source of folate? a) 1 cup cooked spinach b) 1 medium apple c) 240 mL (8 oz) 2% milk d) 1 large hard-boiled egg

a) Clients who are pregnant should consume 400 mcg of folate per day. According to evidence-based practice, 1 cup of cooked spinach provides 230 mcg of folate and is the best of these nutritional sources for the nurse to recommend. b) 1 medium apple only contains 4 mcg of folate. Therefore, this is not the best of these nutritional sources for the nurse to recommend. c) 240 mL of 2% milk only contains 12 mcg of folate. Therefore, this is not the best of these nutritional sources for the nurse to recommend. d) 1 large hard-boiled egg only contains 22 mcg of folate. Therefore, this is not the best of these nutritional sources for the nurse to recommend.

A nurse is collecting data from a pt who is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider? a) Flushed skin b) Respiratory rate 22/min c) Absent deep-tendon reflexes d) Urinary output 35 mL/hr

a) Flushed skin is the initial response when a client receives magnesium sulfate. This is an expected finding & does not require reporting to the provider. b) This RR is within the expected reference range & does not require reporting to the provider. c) The nurse should recognize that absent deep-tendon reflexes are an indication of magnesium toxicity & report this finding to the provider. Magnesium toxicity can lead to respiratory or cardiac arrest. d) This urinary output is within the expected reference range & does not require reporting to the provider. The nurse should report a urinary output of < 25-30 mL/hr.

A nurse is reinforcing teaching about breastfeeding w/ a pt who has a 12-hr old newborn. Which of the following statements should the nurse identify as an indication that the pt understands the instructions? a) "I will wipe the colostrum off my nipple before my baby feeds." b) "I should wake up my baby to feed during the night." c) "Since I am breastfeeding, I won't need to give my baby iron supplements until he's a yr old." d) "I should start to pump my breasts after each feeding when I get home."

a) Colostrum contains immunoglobulins, which provide passive immunity to the newborn. Therefore, the pt should not remove the colostrum from her nipple prior to breastfeeding. b) Parents should awaken the newborn to feed every 3 hrs at night for the first 24-48 hrs after birth. Once the newborn is gaining weight, adequately progressing to demand feedings is safe. c) After 6 months of age, all infants need to ingest iron-fortified cereal & other foods rich in iron. d) Pumping after breastfeeding can lead to an oversupply of breastmilk. The pt should use the breast pump if the newborn is not able to feed at the breast. After breastfeeding is well-established, the pt can pump intermittently to establish a reserve supply of breast milk if desired.

A nurse is reinforcing teaching w/ a pt who is at 20 weeks of gestation & reports having constipation. Which of the following info should the nurse include? a) Conused 28 g of fiber per day. b) Decrease daily protein intake. c) Use laxatives daily. d) Drink 1 L of fluid per day.

a) Consuming 28 g of fiber per day will help relieve constipation. b) The client should not decrease dietary protein during pregnancy. Protein consumption does not decrease constipation during pregnancy. c) The client should not take laxatives or use enemas during pregnancy unless these interventions have been prescribed by the provider. d) The client should consume 2 to 3 L of fluid daily to maintain adequate hydration and decrease constipation.

A nurse is contributing to the POC for a pt who is pregnant & has intermittent constipation. Which of the following interventions should the nurse recommend in the plan? a) Take 2 docusate calcium capsules each evening. b) Use a hypertonic enema when episodes occur. c) Consume 10 mL (2 tsp) of mineral oil each morning. d) Drink 2 L of water per day.

a) Daily use of docusate can lead to dependence and electrolyte imbalances. Stool softeners should only be used intermittently. b) Using a hypertonic enema during pregnancy could cause injury to the client or the fetus. The action of an enema might trigger labor and should be avoided during pregnancy. c) The client should not consume mineral oil during pregnancy because it depletes stores of fat-soluble vitamins A, D, E, and K, which are necessary for fetal development. d) The client should drink 2 L of water (67.6 oz) per day to decrease reabsorption of fluid and prevent drying of stool, which causes constipation.

Provider Rx: - Norgestrel 0.075mg PO daily - Metronidazole 500mg PO BID for 7 days Hx & PE: - Spontaneous vaginal birth 6 months ago - Hx of HTN - Pt reports vaginal discharge w/ a fish-like odor - Thin, watery vaginal secretions noted on pelvic exam Diagnostic Results: - pH 5.0 - Whiff test positive - Positive microscopic screening for bacterial vaginosis ----------------------------------------------------------------------------- A nurse in a provider's office is reinforcing teaching w/ a pt. Which of the following statements should the nurse include? a) "You should d/c your medication if your urine appears dark in color." b) "You should douche every other day for 1 week while taking your medication." c) "You might experience a metallic taste in your mouth while taking your medication." d) "Your partner will require medication Tx for this condition as well."

a) Dark urine is a common adverse effect of metronidazole. The client should not d/c taking their medications if this occurs. b) Douching can increase the risk of contracting bacterial vaginosis. A general recommendation for preventing genital tract infections is to avoid douching. Other recommendations include limiting time in damp clothing after exercise & urinating before and after vaginal intercourse. c) A metallic taste in the mouth is a common adverse effect of metronidazole & does not warrant notification of the provider. d) Bacterial vaginosis is not an STI. Therefore, the pt's partner will not need Tx.

A nurse is assisting w/ the care of a pt who is at 39 weeks of gestation. Which of the following statements should alert the nurse as a sign of a potential complication? a) "I have pain in my upper right abdomen." b) "My feet & ankles are swollen." c) "I feel like I can't breathe when I'm lying down." d) "I have occasional numbness in my fingers."

a) Epigastric pain can indicate hepatic involvement and severe preeclampsia. b) Non-pitting pedal edema is an expected finding in the third trimester due to an enlarging uterus that decreases blood return to the heart. c) Shortness of breath is an expected finding in the third trimester of pregnancy due to an enlarging uterus that limits movement of the diaphragm. d) Some clients who are pregnant develop brachial plexus traction syndrome during pregnancy as a result of their shoulders drooping from the weight of the fetus. Carpal tunnel syndrome can also cause these manifestations.

A nurse is reinforcing teaching w/ a pt who is at 20 weeks of gestation & has gestational DM. Which of the following info should the nurse include in the teaching? a) Exercise before meals. b) Consume at least 2,000 cal/day. c) Avoid consuming an evening snack. d) Maintain a fasting blood glucose of 110-120 mg/dL.

a) Exercise should be done after meals to prevent hypoglycemia. b) A client who has gestational diabetes should consume at least 2,000 kcal/day which is about 35 cal/kg/day. This will ensure adequate glucose intake and prevent hypoglycemia. c) Clients who have gestational diabetes mellitus should consume snacks to maintain blood glucose throughout the day. The final snack of the day should include a protein and a simple carbohydrate to prevent hypoglycemia during the night. d) A client who has gestational diabetes should maintain a fasting blood glucose of less than 95 mg/dL.

A nurse in a clinic is collecting data from a pt who is at 12 weeks of gestation. Which of the following actions should the nurse take? a) Use an ultrasound stethoscope to listen to fetal heart tones. b) Obtain a blood sample for the maternal serum alpha-fetoprotein (MSAFP) screen. c) Collect a vaginal and an anal specimen for a group B Streptococus (GBS). d) Measure fundal height for gestational age.

a) Fetal heart tones are audible w/ an US stethoscope at the end of the first trimester. b) The nurse should obtain a blood sample for the MSAFP screen between 16-18 weeks of gestation. c) The nurse should collect a vaginal & anal specimen for GBS between 35-37 weeks of gestation. d) The nurse should measure fundal height regularly b/t 18-30 weeks of gestation.

A nurse is caring for a pt who is planning to become pregnant. The pt asks the nurse why folic acid supplements are necessary. The nurse should inform the pt that the purpose of the folic acid supplement is to do which of the following? a) Facilitate the storage of iron in the fetus' liver b) Prevent certain kinds of birth defects c) Inhibit premature labor d) Aid in the absorption of other important nutrients

a) Folic acid supplements are used to prevent neural tube defects in the newborn. Maternal supplemental iron facilitates the storage of iron in the fetus' liver. b) The nurse should inform the client that adequate folic acid intake prior to and early during pregnancy is necessary to help prevent neural tube defects. c) Folic acid will not inhibit preterm labor, but it prevents the development of neural tube defects in the newborn. d) Folic acid will not aid in the absorption of other important nutrients, but it prevents neural tube defects in the newborn.

A nurse is collecting data from a pt who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider? a) Glycosuria b) Leg cramps c) Insomnia d) Leukorrhea

a) Glycosuria is a potential complication of gestational DM & the nurse should report this finding to the provider. b) Leg cramps are an expected finding during the 3rd trimester of pregnancy d/t poor peripheral circulation. c) Insomnia is an expected finding during the 3rd trimester of pregnancy d/t the physical discomforts of pregnancy. d) Leukorrhea is an expected finding throughout pregnancy d/t an increased amount of cervical mucus resulting from hormonal changes.

A nurse in a prenatal clinic is caring for a pt who is at 16 weeks of gestation & has a positive hepatitis B test result. Which of the following actions should the nurse take? a) Instruct the pt to avoid crowds until a repeat hepatitis B test is negative. b) Tell the pt that they will need to start the hepatitis B vaccine series after birth. c) Explain to the pt that they will receive the hepatitis B immune globulin immediately. d) Inform the pt that hepatitis B cannot be transmitted to the fetus.

a) Hepatitis B is not spread through casual contact; therefore, the nurse should not instruct the client to avoid crowds. The nurse should instruct the client to decrease the risk of transmission of the virus by practicing thorough hand washing techniques, not sharing razors and toothbrushes, using a latex condom for intercourse, and not sharing drinking glasses and silverware. b) The nurse should instruct the client to begin receiving the hepatitis B vaccine series within 14 days of the last known exposure to the virus or following a positive test result. Immunization is safe during pregnancy. c) The nurse should explain to the client the need to receive the hepatitis immune globulin to decrease the risk of transmission to the fetus. The nurse should also instruct the client that all sexual partners and members of the client's household should see their providers to begin prophylactic treatment. d) The nurse should inform the client that hepatitis B can cross the placenta and cause an infection in the fetus. This risk is reduced when the infection occurs before the end of the third trimester.

A nurse is reinforcing teaching w/ a pt who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include? a) "You must be at least 37 weeks of gestation before you can use hydrotherapy." b) "You will receive an injection of sterile water into your lower back during hydrotherapy." c) "You can continue to use hydrotherapy as long as you do not develop a fever > 101°F." d) "You should keep the water temperature > 100°F during hydrotherapy."

a) Hydrotherapy uses warm water as a non-pharmacological pain measure to help provide comfort during labor. It is contraindicated for clients who are at less than 37 weeks of gestation due to the risk of preterm labor. b) Hydrotherapy does not involve injecting sterile water into the client's lower back. Rather, this is the procedure for an intradermal injection water block, which can alleviate back discomfort during labor. c) During hydrotherapy, the client's temperature should be monitored. Hydrotherapy is contraindicated for clients who have a fever greater than 37° C (100.4° F). d) The water temperature should be kept between 35° to 37.8° C (95° to 100° F) during hydrotherapy to prevent the client from overheating. The client's shoulders should also remain out of the water during hydrotherapy to allow dissipation of heat.

A nurse is caring for a pt who is experiencing postpartum hemorrhage. Which of the following medications should the nurse expect the provider to prescribe? a) Indomethacin b) Terbutaline c) Methylergonovine d) Betamethasone

a) Indomethacin is an NSAID that relaxes smooth muscle of the uterus by inhibiting the production of prostaglandins. Indomethacin is used in the treatment of preterm labor. b) Terbutaline is a tocolytic medication used in the treatment of preterm labor by relaxing the smooth muscle of the uterus. c) Methylergonovine is used to treat postpartum hemorrhage. Methylergonovine is an oxytocic medication that causes contraction of the smooth muscle of the uterus, which assists in decreasing the lochia. This medication should not be administered to clients who have preeclampsia or hypertension. d) Betamethasone is a glucocorticoid that is administered to promote fetal lung maturity in clients who are experiencing preterm labor.

A nurse is collecting data from pt who is a primigravida & has hyperthyroidism. Which of the following findings should the nurse expect? a) Lethargy b) Hoarseness c) Diaphoresis d) Cold intolerance

a) Lethargy is an expected finding with hypothyroidism. b) Hoarseness is an expected finding with hypothyroidism. c) Diaphoresis, heat intolerance, and tachycardia are expected findings with hyperthyroidism. d) Cold intolerance is an expected finding with hypothyroidism.

A nurse is collecting data from a pt who is in the 2nd trimester of pregnancy. Which of the following findings should the nurse report to the provider? a) Increase leukorrhea b) Hyperpigmentation of the face c) Varicose veins d) Frequent uterine contractions

a) Leukorrhea is a whitish discharge which is an expected finding due to the hormonal changes that occur during pregnancy. b) Hyperpigmentation of the face is also known as the "mask of pregnancy" and is an expected finding due to the hormonal changes during pregnancy that stimulate melanocytes. c) Varicose veins are an expected finding during pregnancy due to hormonal influence on the smooth muscle walls of veins. The growing fetus can exacerbate varicose veins. d) The nurse should report frequent uterine contractions during the second trimester to the provider because these contractions can cause the cervix to open early and subject the client to preterm labor.

A nurse is contributing to the POC for a newborn following a vaginal birth. Which of the following information should the nurse include when helping to develop the newborn's POC? (SATA) a) Maternal group B stretococcus (GBS) status b) Apgar score c) Maternal urinary output d) Type of birth e) Maternal weight

a) Maternal GBS status is relevant information from the prenatal record that the nurse should include in the newborn's plan of care. If the mother is GBS positive and has not received antibiotic therapy, the newborn is at risk for neonatal morbidity and mortality. b) The nurse or birth attendant documents an Apgar score at 1 and 5 min following birth to determine how the newborn has adjusted to extrauterine life and whether intervention is necessary. c) The nurse should monitor maternal urinary output during labor. However, this information is not relevant for the newborn's plan of care. d) The type of labor and birth is relevant information to include in the newborn's plan of care for planning essential data collection and intervention. e) Maternal weight is not relevant to the newborn's plan of care.

A nurse is assisting w/ the admission of a newborn who has respiratory distress. While collecting data, which of the following should the nurse report to the provider? (SATA) a) Nasal flaring b) RR 60/min c) Intercostal retractions d) Grunting e) HR 120/min

a) Nasal flaring is a manifestation of respiratory distress in newborns. b) A respiratory rate of 60/min is within the expected reference range for newborns. c) Intercostal retractions are a manifestation of respiratory distress in newborns. d) Grunting is a manifestation of respiratory distress in newborns. e) A heart rate of 120/min is within the expected reference range for newborns.

A nurse is reinforcing d/c teaching w/ a pt who has mastitis of the L breast. Which of the following instructions should the nurse include? a) Use a nipple shell on the unaffected breast. b) Formula-feed the newborn until mastitis subsides. c) Pump the affected breast frequently. d) Apply cabbage leaves to reduce pain.

a) Nipple shells can be used to promote healing and relieve discomfort from sore nipples. This intervention is not necessary to use on the unaffected breast, as there is no risk of the mastitis spreading from one breast to another. b) The nurse should reinforce that the client should continue breastfeeding or pumping breast milk from the affected breast, because frequently emptying the breast promotes comfort and maintains milk supply. Mastitis does not contaminate the milk supply. c) Keeping the breast empty through breastfeeding or pumping will help to prevent the growth of bacteria due to milk stasis and increase comfort. d) Frequent application of cold cabbage leaves to the breasts can relieve engorgement during lactation suppression in clients who bottle-feed their newborns. This intervention does not assist with the pain from mastitis.

A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this Rx by which of the following routes? a) Ophthalmic b) IM c) SubQ d) Rectal

a) Phytonadione is not available in an ophthalmic formulation. b) The nurse should administer phytonadione intramuscularly to the newborn to prevent hemorrhage until the newborn's GI system can produce its own vitamin K. c) Although older infants receive phytonadione subcutaneously to treat bleeding problems, this is not the route for routine newborn prophylaxis. d) Phytonadione is not available in a rectal formulation.

A nurse is observing a pt bathe her 1-day old newborn. Which of the following actions should the nurse identify as an indication that the pt understands how to bathe the newborn? a) The pt shakes powder from the container onto the newborn's skin. b) The pt uses a cotton-tipped swab to clean the newborn's ears. c) The pt washes the newborn's hair before unwrapping them. d) The pt rinses the newborn under warm, running water.

a) The client should avoid shaking powder onto the newborn's skin due to the possible risk of inhalation, resulting in respiratory distress or potential allergic reaction to the powder. b) Cotton-tipped swabs can cause injury to the newborn's ears. Instead, the parent should use moistened cotton or a washcloth to wipe the newborn's ears. c) Keeping the newborn wrapped while washing their hair helps prevent heat loss. d) Rinsing the newborn under running water can result in a scalding injury or hypothermia in the newborn because the water temperature could change.

A nurse on a postpartum unit is contributing to the d/c teaching plan for a pt. Which of the following instructions should the nurse suggest for the plan? a) Apply powder to the newborn's skin after baths. b) Use a firm mattress in the newborn's crib. c) Cover the newborn w/ a crib comforter. d) Place the newborn on their stomach to sleep.

a) The client should avoid using any type of powder with the newborn because it increases the risks of aspiration and respiratory distress. b) Use a firm mattress in the newborn's crib. The client should use a firm mattress in the newborn's crib to decrease the risk of sudden infant death syndrome. c) The client should avoid using comforters, pillows, and soft bedding in the newborn's crib because they increase the risk of sudden infant death syndrome. d) The client should place the newborn in the supine position to decrease the risk of sudden infant death syndrome.

A nurse is reinforcing teaching w/ a pt who has asked about continuing routine exercise during pregnancy. Which of the following responses should the nurse make? a) "Drink plenty of water after exercising." b) "Lie on your back for 5 mins after exercising." c) "You should limit exercise to once per week." d) "Increase your exercise intensity as your pregnancy progresses."

a) The client should drink plenty of water during and after exercising to decrease the risk of dehydration from diaphoresis. b) The client should lie on their side and rest for 10 min after exercising to promote return circulation from the extremities to the heart. c) The client should exercise on a regular basis, at least three times per week for 30 min each time, because sporadic exercising increases muscle strain. d) The client should decrease their exercise intensity as their pregnancy progresses.

A nurse is reviewing the laboratory results of a pt who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? a) BUN 14mg/dL b) Platelet count 200,000/mm³ c) Hematocrit 30% d) Creatinine 1.0 mg/dL

a) The nurse should identify that a BUN of 14 mg/dL is within the expected reference range of 10 to 20 mg/dL. b) The nurse should identify that a platelet count of 200,000/mm³ is within the expected reference range of 150,000 to 400,000/mm³. c) The nurse should identify that a hematocrit of 30% is below the expected reference range of greater than 33% for a client who is pregnant. A low Hct is an indication of anemia. Therefore, the nurse should report this finding to the provider. d) The nurse should identify that a creatinine of 1.0 mg/dL is within the expected reference range of 0.5 to 1.0 mg/dL for a female client aged 18 to 40 years.

A nurse is reinforcing d/c teaching about methods to prevent engorgement during lactation suppression w/ a pt who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the pt understands the instructions? a) "I will massage my breasts while I take a shower." b) "I should wear an underwire bra during the day." c) "I should use a breast pump several times a day to relieve discomfort." d) "I will apply cold cabbage leaves to my breasts throughout the day."

a) The client should not massage her breasts to treat engorgement during lactation suppression. Breast stimulation through massage can promote milk production. b) The client should not wear an underwire bra to treat engorgement during lactation suppression because it can cause plugged milk ducts, which can result in a breast infection. c) The client should not pump her breasts to treat engorgement during lactation suppression because it can cause an increase in milk production. d) Frequent application of cold cabbage leaves to the breasts can prevent engorgement during lactation suppression for a client who is bottle-feeding her newborn. The client should also apply ice packs or cold compresses to her breasts, take mild analgesics, and wear a well-fitting and supportive bra.

A nurse is reinforcing education about the prevention of newborn abduction w/ a pt who recently gave birth. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a) "I can carry my baby back to the nursery in my arms." b) "An alarm will sound if someone removes my baby's safety device." c) "The nurse is not required to show their ID when taking my baby back to the nursery." d) "I can leave my baby in the bassinet while I take a shower."

a) The client should only transport their newborn between the nursery and their room in a bassinet. b) An alarm will sound if someone removes the newborn's safety device, or if someone transports the newborn past an established facility parameter. c) The client should always request ID from any healthcare personnel that is removing their newborn from the room. Only facility personnel w/ badges indicating that the individual works specifically in the maternal/newborn unit should transport newborns. This is a safety precaution to prevent newborn abduction. d) Leaving a newborn unattended while showering places the newborn at risk for abduction.

A pt requests info about the use of a diaphragm for birth control. Which of the following statements should the nurse make? a) "You will need to replace your diaphragm every 2 yrs." b) "You can use an oil-based lubricant w/ your diaphragm." c) "You should have a full bladder when you insert diaphragm." d) "You should remove your diaphragm 1 hr after intercourse to clean it."

a) The client should replace the diaphragm every 2 years. b) The client should avoid using oil-based products such as baby oil, vaginal lubricants, mineral oil, and body lubricants because these can weaken the rubber of the diaphragm and reduce its effectiveness. c) The client should urinate and empty their bladder completely prior to inserting the diaphragm. d) The client should leave the diaphragm in place for at least 6 hr after intercourse because sperm remain viable in the vagina for that length of time.

A nurse is reinforcing teaching about newborn umbilical cord care w/ a pt who is postpartum. Which of the following statements should the nurse identify as an indication that the pt understands the instructions? a) "I will report any drainage from my baby's umbilical cord." b) "I will wash my baby's umbilical cord w/ soapy water." c) "I will expect my baby's umbilical cord to fall off in 2-3 days." d) "I will secure the diaper over my baby's umbilical cord."

a) The client should report any drainage or foul odor from the umbilical cord because these are manifestations of infection. b) The client should use only warm water to wash the umbilical cord and dry thoroughly. c) The umbilical cord should fall off within 10 to 14 days. d) The client should secure the diaper below the newborn's umbilical cord to prevent infection and promote drying.

A nurse is caring for a newborn who is LGA & is jittery. Which of the following actions should the nurse take first? a) Check the newborn's blood glucose level. b) Place the newborn under a radiant warmer. c) Provide non-nutritive sucking. d) Swaddle the newborn.

a) The first action the nurse should take using the nursing process is to collect data from the client; therefore, the first action the nurse should take is to check the newborn's blood glucose level. b) The nurse might need to place the newborn under a radiant warmer to prevent cold stress. However, there is another action the nurse should take first. c) The nurse might need to provide nonnutritive sucking to help the newborn conserve energy. However, there is another action the nurse should take first. d) The nurse might need to swaddle the newborn to minimize energy expenditure. However, there is another action the nurse should take first.

A nurse is collecting data from a pt who gave birth 18 hrs ago. Which of the following findings should the nurse identify as an indication of a postpartum complication? a) Fundus is palpable at 2 cm above the umbilicus. b) Temperature is 38°C (100.4°F). c) Lochia increases after breastfeeding. d) The perineal pad contains several small blood clots.

a) The fundus should be located at the level of the umbilicus during the first 24 hrs postpartum and decrease 1 cm each day after that. A fundus that is palpable at a higher than expected level could be an indication of uterine atony, which can result in maternal hemorrhage. b) The temperature is an expected finding in the first 24 hr postpartum d/t dehydration. c) Increased lochia after breastfeeding is an expected finding. Maternal oxytocin is released during breastfeeding, which causes uterine contractions. The contractions decrease the risk of postpartum hemorrhage and expel lochia which has pooled in the uterus. d) Lochia containing small blood clots is an expected finding in the first 24 hrs postpartum. Lochia that is bright red or contains large blood clots indicates excessive bleeding.

A nurse is reinforcing home care safety w/ the guardian of a newborn prior to d/c. Which of the following statements by the guardian indicates understanding of the teaching? a) "I can place a pillow in my baby's crib." b) "I can allow my toddler to sleep in the bed w/ my baby." c) "I should place my baby's crib away from windows." d) "I should keep my baby's bath water at 97°F."

a) The guardian should keep pillows, toys, and other objects out of the newborn's crib due to the risk of suffocation. b) Bed sharing is not recommended during the first year because of the risk of suffocation and SIDS. c) The guardian should place the newborn's crib away from windows to prevent drafts or entanglement in blinds or drapery. d) The guardian should keep the newborn's bath water temperature at 38° to 40°C (100.4° - 104°F) to prevent heat loss.

A nurse is reinforcing teaching about car seat safety w/ the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching? a) "I will place the baby's car seat in a rear-facing position until she is 1 yr old." b) "I will position the retainer clip at the level of the baby's armpits." c) "I will place the shoulder harness straps in a slot 2 in above the baby's shoulders." d) "I will position the baby at a 60° angle in the car seat."

a) The guardian should position the newborn's car seat rear-facing in the middle of the back seat from birth for as long as possible until they meet the height and weight restrictions set by the car seat's manufacturer. b) The guardian should position the retainer clip at the level of the newborn's axillae & not over the neck or abdomen. c) The guardian should place the shoulder harness straps in the slots at or below the level of the newborn's shoulders. d) The guardian should position the newborn in the car seat at a 45° angle to prevent the newborn's head from falling forward, which can lead to airway obstruction & suffocation.

A nurse is planning to reinforce d/c teaching about formula feeding w/ the guardian of a newborn. Which of the following instructions should the nurse plan to include? a) Provide the newborn w/ 6-8 feedings during a 24-hr period. b) Ensure that the newborn receives 45-60 mL of formula per feeding during the first 48 hrs. c) Offer water to the newborn b/t feedings. d) Delay burping the newborn until the feeding is complete.

a) The guardian should schedule the newborn's feedings every 3-4 hrs. b) A newborn will typically drink 15-30 mL of formula per feeding during the first 24-48 hrs. c) Formula contains enough water to meet a newborn's fluid needs. Offering water b/t feedings can lead to an inadequate caloric intake. d) The nurse or guardian should burp the newborn a few times during the feeding to reduce spitting up. Burping the newborn several times throughout the feeding can decrease episodes of regurgitation after the feeding.

A nurse is planning to perform a blood collection via heel stick on a newborn. After performing hand hygiene & donning gloves, which of the following actions should the nurse plan to take next? a) Cleanse the newborn's heel w/ antiseptic & allow it to dry. b) Wrap the newborn's heel w/ a cloth moistened w/ warm water. c) Cuddle & comfort the newborn. d) Apply pressure to the newborn's heel by using a dry gauze square.

a) The nurse should cleanse the lateral side of the newborn's heel with an antiseptic solution and allow it to dry to disinfect the skin and avoid diluting the specimen. However, evidence-based practice indicates that the nurse should take a different action first. b) According to evidence-based practice, the nurse should first warm the newborn's heel by applying a cloth moistened with warm water for 5 to 10 min. This will allow dilation of the vessels in the area in order to obtain an adequate sample. c) The nurse should cuddle and comfort the newborn. However, evidence-based practice indicates that the nurse should take a different action first. d) After obtaining the heel stick blood specimen, the nurse should apply pressure to the site using a dry gauze square to stop the bleeding. However, evidence-based practice indicates that the nurse should take a different action first.

A nurse is collecting data from the parent of a newborn immediately following birth. The parent states, "She is so tiny. We don't know how to pick her up without hurting her." Which of the following action should the nurse take first to promote parent-newborn attachment? a) Encourage rooming-in with the newborn during the hospital stay. b) Reinforce the need for all adult family members to engage in newborn care. c) Demonstrate to the parent how to hold the newborn. d) Provide privacy for the parent to examine the newborn.

a) The nurse should encourage rooming-in with the newborn during the hospital stay b/c this fosters an environment of family-centered care; however, there is another action the nurse should take first. b) The nurse should reinforce the need for all adult family members to engage in newborn care activities, such as bathing, dressing, and changing diapers, b/c these activities cultivate a family-centered environment; however, there is another action the nurse should take first. c) The first action the nurse should take is to demonstrate to the parent how to hold the newborn. Evidence-based practice has shown benefits of skin-to-skin contact b/t the parent & the newborn in the minutes & hours after birth. Therefore, the nurse should first demonstrate how to hold the newborn & then place her in the parent's arms, ensuring the safety of the newborn. d) The nurse should provide a private environment for the parent to spend time alone w/ the newborn b/c this special time enhances the parent-newborn relationship & improves the overall attachment process; however, there is another action the nurse should take first.

A nurse is collecting data from a pt who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? a) Leg cramps b) Tingling of fingers c) Varicose veins d) Epigastric pain

a) The nurse should identify leg cramps as a common discomfort during pregnancy caused by compression of the nerves by the enlarged uterus. b) The nurse should identify tingling of the fingers as a common discomfort of pregnancy caused by traction on the brachial plexus due to slumping of the shoulders. c) The nurse should identify that varicose veins are a common discomfort of pregnancy caused by increased blood volume and relaxation of vascular smooth muscle. d) The nurse should identify epigastric pain as a potential complication of pregnancy. Epigastric pain is a manifestation of preeclampsia.

A nurse is caring for a pt who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider? a) 2+ urinary protein b) Leukorrhea c) Spider nevi d) 30 cm fundal height

a) The nurse should identify that 2+ proteinuria is a manifestation of preeclampsia. Therefore, the nurse should report this finding to the provider. b) The nurse should identify that leukorrhea is a greyish, mucus-like discharge and is an expected finding throughout pregnancy due to hormonal changes that cause the cervix to produce this mucoid fluid. c) The nurse should identify that spider nevi, or vascular spiders, are an expected finding during pregnancy due to an increase in estrogen production. d) The nurse should identify that a fundal height of 30 cm is an expected finding for a client who is at 30 weeks of gestation.

A nurse is reviewing the laboratory results of a 4 hr old newborn. Which of the following findings should the nurse report to the provider? a) Hemoglobin 20 g/dL b) Platelet count 120,000/mm³ c) Glucose 50 mg/dL d) WBC count 20,000/mm³

a) The nurse should identify that a Hgb level of 20 g/dL is within the expected reference range of 14 to 24 g/dL for a newborn. b) The nurse should identify that a platelet count of 120,000/mm³ is below the expected reference range of 150,000 to 300,000/mm³ for a newborn. Therefore, the nurse should report this finding to the provider. c) The nurse should identify that a glucose level of 50 mg/dL is within the expected reference range of 30 to 60 mg/dL for a newborn. d) The nurse should identify that a WBC count of 20,000/mm3 is within the expected reference range of 9,000 to 30,000/mm3 for a newborn.

A nurse is collecting data from a newborn whose mother had gestational DM. Which of the following findings should the nurse report to the provider? a) Calcium 9.2 mg/dL b) HR 160/min c) Blood glucose 28 mg/dL d) Axillary temperature 36.5°C (97.7°F)

a) The nurse should identify that a calcium level of 9.2 mg/dL is within the expected reference range of 7.6 to 10.4 mg/dL for a newborn. b) The nurse should identify that a heart rate of 160/min is within the expected reference range of 110 to 160/min for a newborn. A heart rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn. c) The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 40 to 45 mg/dL for a newborn. Therefore, the nurse should report this finding to the provider. d) The nurse should identify that a temperature for a healthy newborn averages 37° C (98.6° F), with a range of 36.5° to 37.5°C (97.7° - 99.5°F).

A nurse is assisting w/ the care of a pt who is at 40 weeks of gestation & is in active labor. Which of the following findings should the nurse report to the charge nurse? a) Maternal temperature of 37.5°C (99.5°F) b) Contractions every 3 mins c) Presence of blood show d) Prolonged deceleration of FHR

a) The nurse should identify that a maternal temperature greater than 38° C (100.4° F) is elevated and indicative of complications such as infection. b) The nurse should identify that contractions occurring every 3 to 5 min is an expected finding for a client who is in active labor. c) The nurse should identify that bloody show is an expected finding for a client who is in active labor. Bloody show can increase as labor progresses. d) The nurse should report a prolonged deceleration of the FHR to the charge nurse because it can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord prolapse. The charge nurse should notify the provider about this change in FHR pattern.

A nurse is reviewing the prenatal record of a pt who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome? a) Negative rubella titer b) Reactive non-stress test c) 1-hr glucose tolerance screening test result of 150 mg/dL d) Hemoglobin 9.5 g/dL

a) The nurse should identify that a negative rubella titer indicates that the client is not immune to rubella and will require immunization in the postpartum period. b) The nurse should identify that a reactive non-stress test indicates fetal well-being and is a desirable outcome. c) The nurse should identify that a glucose value of 140 mg/dL or higher 1 hr after ingesting 50 g of glucose indicates the need for further testing to determine if the client has gestational diabetes mellitus. d) The nurse should identify that a hemoglobin level of 9.5 g/dL indicates anemia, which is an undesirable test result and will require treatment.

A nurse is caring for a pt who has received methylergonovine. Which of the following should the nurse identify & document as an adverse effect of the medication? a) Hyperglycemia b) HTN c) Urinary retention d) Hyporeflexia

a) The nurse should identify that hyperglycemia is not an adverse effect of methylergonovine. b) Methylergonovine is an oxytocic agent that stimulates uterine contractions and is used for postpartum hemorrhage. It can cause nausea, vomiting, cramping, headache, and dizziness. The nurse should report changes in blood pressure to the provider because methylergonovine can cause both hypertension and hypotension. c) The nurse should identify that urinary retention is not an adverse effect of methylergonovine. d) The nurse should identify that hyporeflexia is not an adverse effect of methylergonovine.

A nurse is collecting data from a pt who is at 37 weeks of gestation. Which of the following findings should the nurse report to the provider? a) Leukorrhea b) Non-pitting ankle edema c) Tingling in fingers d) Blurred vision

a) The nurse should identify that leukorrhea, or vaginal discharge, is an expected finding during pregnancy. b) The nurse should identify that non-pitting ankle edema is an expected finding during the third trimester of pregnancy. c) The nurse should identify that tingling in fingers is an expected finding during pregnancy due to traction on the brachial plexus nerves. d) The nurse should identify that blurred vision or double vision are manifestations of gestational hypertension or preeclampsia. The nurse should report this finding to the provider.

A nurse on a postpartum unit is assisting w/ the care of a pt who has a hypotonic uterus & excessive vaginal bleeding. Which of the following actions should the nurse take first? a) Provide fundal massage for the pt. b) Insert an indwelling urinary catheter for the pt. c) Administer methylergonovine IM to the pt. d) Administer oxygen via nonrebreather face mask to the pt.

a) The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should take is to provide fundal massage to increase uterine muscle tone and express blood clots from the uterus, which will decrease bleeding. b) Inserting an indwelling urinary catheter is important to eliminate bladder distention and monitor urinary output. However, this is not the first action the nurse should take. c) Administering methylergonovine to enhance uterine contractions is an action the nurse should take to manage postpartum hemorrhage. However, this is not the first action the nurse should take. d) Administering oxygen via nonrebreather face mask is an action the nurse should take to enhance oxygenation to the cells. However, this is not the first action the nurse should take.

A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider? a) Vernix in the skin folds b) Positive Moro reflex c) Apneic episode of 10 seconds d) Apical HR of 90/min while crying

a) The nurse should identify that vernix in the skin folds is an expected finding in a newborn. It is a normal protective substance that is present at birth. b) The nurse should identify that a positive Moro reflex is an expected finding in a newborn which is present from birth up to 8 weeks. c) The nurse should identify that an apneic episode of 20 seconds or less is an expected finding in a newborn. Newborns' respirations are normally shallow and irregular. d) The nurse should identify that an apical heart rate of 90/min while crying is below the expected reference range of 110 to 160/min for a newborn. A heart rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn.

A nurse is assisting in the care of a newborn immediately following birth. Which of the following should the nurse identify as an indication that the newborn has a myelomeningocele? a) Occurs when the neural tube fails to close, and the meninges and spinal cord herniate b) Occurs from abnormal development of the abdominal wall, symphysis pubis, and bladder c) Occurs when abdominal organs herniate through the umbilical ring at the base of the umbilical cord d) A collection of blood between the skull bone and the periosteum

a) The nurse should identify this as a myelomeningocele. A myelomeningocele occurs when the neural tube fails to close, and the meninges and spinal cord herniate. This defect most often occurs in the lumbar area and may be covered by a thin membranous sac. b) The nurse should identify this as exstrophy of the bladder. This occurs from abnormal development of the abdominal wall, symphysis pubis, and bladder. The bladder is visible in the suprapubic area and requires surgical intervention soon after birth. c) The nurse should identify this as an omphalocele. An omphalocele occurs when abdominal organs herniate through the umbilical ring at the base of the umbilical cord. The organs are covered by a peritoneal sac and require surgical intervention soon after birth. d) The nurse should identify this as a cephalohematoma. A cephalohematoma is a collection of blood between the skull bone and its covering, the periosteum. A cephalohematoma does not cross the suture lines of the newborn's skull and will spontaneously resolve in 2 to 8 weeks.

A nurse is assisting w/ the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the following indicates a characteristic response of the tonic neck reflex? a) The newborn's head is quickly turned to one side, the arm and leg on the same side extend, while the arm and leg on the opposite side flex. b) When the newborn is placed on the abdomen, they will appear to make crawling movements with the arms and legs. c) The newborn will push against the examiner's hands when pressure is applied to the soles of the newborn's feet. d) When the newborn hears a loud noise, they will abduct then extend the arms with the fingers widely open and the thumb and index finger form a "C" shape. The lower extremities might also extend then abduct toward the abdomen.

a) The nurse should identify this as the tonic neck reflex. b) The nurse should identify this as the crawling reflex. c) The nurse should identify this as the magnet reflex. d) The nurse should identify this as the Moro reflex.

A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension w/ a pt who is at 16 weeks of gestation. Which of the following responses by the pt indicates an understanding of the teaching? a) "I will apply support stockings 30 mins after getting out of bed." b) "I will lie on my L side w/ my head elevated on a pillow." c) "I will cross my legs when sitting." d) "I will limit my salt intake."

a) The nurse should instruct a client who has varicose veins to apply support stockings before getting out of bed. b) The nurse should instruct the client to avoid lying supine during pregnancy to prevent supine hypotension. The uterus compresses the inferior vena cava in the supine position, which decreases blood pressure and causes dizziness and fainting. Lying on the left side prevents compression of the vena cava and subsequent hypotension. c) The nurse should instruct the client to avoid crossing the legs while sitting to prevent varicose veins. d) The nurse should instruct the client to maintain an adequate intake of sodium during pregnancy. The client should consume 1.5 to 2.3 g of salt per day.

A nurse is reinforcing teaching about preventing UTIs w/ a pt who is at 25 weeks of gestation. Which of the following instructions should the nurse include? a) "You should perform Kegel exercises 4x/day." b) "You should empty your bladder before you go to bed at night." c) "You should wipe from back to front after urinating." d) "You should wear underwear made from nylon."

a) The nurse should instruct a pt who has urinary incontinence to perform Kegel exercises to strengthen the muscles of the pelvic floor. b) The nurse should instruct the pt to urinate & empty the bladder completely before going to bed at night to prevent stasis of urine. A full bladder provides an environment that fosters bacterial growth. c) The nurse should instruct the pt to wipe from front to back after voiding to avoid transferring fecal bacterial to the urethra. d) The nurse should instruct the pt to wear all cotton undergarments to avoid trapping heat & moisture in the genital area.

A nurse is reinforcing teaching w/ a pt who is at 9 weeks of gestation & reports frequent episodes of nausea & vomiting. Which of the following instructions should the nurse include? a) Eat foods that are served hot. b) Drink 360 mL (12 oz) of fluids during mealtimes. c) Consume small meals frequently each day. d) Eat a high-protein snack before getting out of bed.

a) The nurse should instruct the client that it will be easier to tolerate foods that are served cold or at room temperature. b) The client should avoid drinking liquid with meals because this increases the risk for nausea. The client should alternate consumption of fluids and foods every 2 to 3 hr throughout the day. c) The nurse should instruct the client to eat five to six small meals throughout the day. The client should avoid an empty stomach, as this increases nausea. d) The nurse should instruct the client to consume a snack high in carbohydrates, such as crackers, before getting out of bed in the morning to decrease nausea.

A nurse is caring for a pt following a c-section. Which of the following actions should the nurse take to decrease the client's risk of developing thrombophlebitis? a) Have the pt ambulate several times each day. b) Administer aspirin 80 mg orally once per day. c) Tell the pt to expect leg pain for 48 hrs. d) Apply warm compresses to the pt's legs.

a) The nurse should instruct the client to ambulate several times each day to increase circulation in the lower extremities and prevent thrombophlebitis. b) The nurse should not administer aspirin to a client following a cesarean birth. Aspirin increases the risk of postpartum bleeding. c) The nurse should instruct the client to report any pain or tenderness in the legs because this could be an indication of thrombophlebitis. d) The nurse should apply warm compresses to the legs if the client develops thrombophlebitis. The nurse should apply sequential compression device boots to prevent blood clot formation.

A nurse is assisting w/ the POC for a pt who is breastfeeding & has mastitis. Which of the following recommendations should the nurse include? a) Instruct the pt to d/c feeding from the affected breast. b) Tell the pt to wear an underwire bra. c) Instruct the pt to apply warm compresses to the affected breast. d) Administer an antiviral mdeication.

a) The nurse should instruct the client to continue breastfeeding from both breasts, because that will assist in emptying the breasts and decreasing pressure on the infected area. Emptying the breasts also prevents milk stasis, which decreases bacterial growth. b) The nurse should discourage the use of underwire and poorly fitting bras because they can cause plugged milk ducts, increasing the risk of mastitis. c) The nurse should instruct the client to apply warm compresses to the breast, which will decrease inflammation and edema. This will enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth. d) The nurse should plan to administer an antibiotic medication to a client who has mastitis. The client should take the antibiotic for 10 to 14 days to eradicate the infection.

A nurse is reinforcing d/c teaching about home care w/ the parent of a newborn. Which of the following instructions should the nurse include? a) "Dress your newborn w/ 2 extra layers for the 1st week at home." b) "Give your newborn a bath once a day in the morning." c) "Cover your newborn w/ a lightweight blanket during naps." d) "Ensure the water temperature during your newborn's bath is maintained at 100°F."

a) The nurse should instruct the parent to dress the newborn as they dress themselves, adding no more than 1 additional light layer of clothing. The parent can apply a cap to the newborn's head if the weather is cool. b) The nurse should instruct the parent to bathe the newborn not more than every other day to avoid impairing the newborn's skin integrity. The parent should cleanse the newborn's diaper area & face daily. The parent should shampoo the newborn's hair 1-2 times a week. c) The nurse should instruct the parent to avoid covering the newborn w/ blankets or comforters during sleep. Covering the newborn increases the risk for SIDS. The parent should dress the newborn in a one-piece sleeper or sleep sack for sleep. d) The nurse should instruct the parent to keep the water temperature at 38°C (100°F) when bathing the newborn. A water temperature below this value can cause cold stress in the newborn, and a water temperature above this value increases the risk of burn injuries.

A nurse is contributing to the POC for a pt who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend? a) Encourage fluids w/ meals. b) Obtain a specimen for uric acid level. c) Initiate a high-fat & low-protein diet. d) Monitor intake & output.

a) The nurse should instruct the pt to consume liquid & solid foods separately to prevent the stomach from overfilling. b) The nurse should obtain specimens for a urinalysis & CBC, as well as electrolytes, liver enzymes, & bilirubin levels. A uric acid level is a laboratory test essential for clients who have preeclampsia. c) The nurse should initiate a low-fat & high-protein diet. d) The nurse should monitor intake & output to evaluate the pt's hydration status & determine whether other interventions are necessary.

A nurse is assisting w/ the care of a pt who is pregnant & has preeclampsia. While the nurse is collecting data, the pt has a seizure. Which of the following actions should the nurse take first? a) Monitor fetal heart tones b) Measure the pt's BP c) Insert indwelling urinary catheter d) Turn the pt on their side

a) The nurse should monitor fetal heart tones after the seizure to determine fetal well-being. However, there is another action the nurse should take first. b) The nurse should obtain the client's vital signs frequently after the seizure until the client is stable. However, there is another action the nurse should take first. c) The nurse should insert an indwelling urinary catheter after the seizure. However, there is another action the nurse should take first. d) The greatest risk to the client is airway obstruction. Therefore, the first action the nurse should take is to turn the client on one side to keep their airway patent.

A nurse is collecting data from a pt who is 32 hrs postpartum. Which of the findings should the nurse expect? a) Saturation of 1 perineal pad every 15 mins b) Fundus 2 cm above the umbilicus c) Temperature of 39°C (102.2°F) d) Urine output of 3,000 mL in 24 hrs

a) The nurse should not expect saturation of one perineal pad every 15 min as this indicates postpartum hemorrhage, which could lead to hypovolemic shock. b) At 32 hr postpartum, the client's fundus should be 1 to 2 cm below the umbilicus. The fundus should descend 1 cm per day after birth. c) The nurse should identify that a temperature higher than 38° C (100.4° F) after the first 24 hr postpartum can indicate infection. d) The nurse should expect postpartum diuresis to begin approximately 12 hr after birth. Therefore, a urine output of 3,000 mL in 24 hr is an expected finding for this client.

A nurse is assisting in the care of a pt during the active phase of labor. Which of the following actions should the nurse take to promote the pt's comfort? a) Prepare the pt for a pudendal nerve block. b) Administer a sedative to the pt. c) Encourage the pt to push. d) Have the pt perform relaxing breathing techniques.

a) The nurse should not prepare the client for a pudendal nerve block during the active phase of labor. A pudendal nerve block should be administered during the second stage of labor, 10 to 20 min before the birth of the newborn. b) The nurse should not administer a sedative to the client during the active phase of labor, as it can cause respiratory depression in the newborn. Sedatives should be administered no less than 12 hr prior to birth of the newborn. c) The nurse should encourage the client to push during the second stage of labor, when the cervix is dilated to 10 cm. d) The nurse should encourage the client to perform relaxation techniques to promote comfort during the active phase of labor.

A nurse on a postpartum unit is assisting in the care of a pt who is experiencing hypovolemic shock. Which of the following actions should the nurse take? a) Place the pt in high-Fowler's position. b) Administer terbutaline subcutaneously. c) Apply oxygen at 2 L/min via nasal cannula. d) Insert an indwelling urinary catheter.

a) The nurse should place the client in a side-lying position or lying with the right hip elevated. The client's legs should be elevated to at least a 30° angle to increase venous return. b) The nurse should administer an oxytocic medication, such as oxytocin or methylergonovine, to increase uterine contraction. Terbutaline is a tocolytic that causes uterine relaxation, which will increase bleeding. c) The nurse should apply oxygen at 10 L/min via a nonrebreather face mask to improve the client's oxygenation. d) The nurse should insert an indwelling urinary catheter to monitor output closely. Decreased kidney perfusion caused by shock can lead to oliguria.

A nurse is contributing to the POC for a pt who is at 18 weeks gestation & has just learned that the fetus has trisomy 21. Which of the following resources should the nurse recommend for the pt? a) Physical therapy b) Occupational therapy c) Palliative services d) Genetic counseling

a) The nurse should recommend physical therapy for a client who has mobility issues. b) The nurse should recommend occupational therapy for a client who has impairment with performing activities of daily living. c) The nurse should recommend palliative services for a client who is in need of end-of-life services. d) A fetus that has trisomy 21 (Down Syndrome) has an extra chromosome. Therefore, the nurse should recommend genetic counseling to provide the client further education about the prognosis and treatment of the condition, as well as offer support and guidance.

A nurse is reinforcing teaching about car seat safety w/ the parent of a newborn. Which of the following pt statements indicates an understanding of the teaching? a) "My baby should be in a rear-facing car seat until he is 6 months old & 15 lbs." b) "If my baby rides in a car w/ no back seat, the passenger air bag must be turned off." c) "It is dangerous to secure the car seat using the vehicles seat belts." d) "I will place my baby's car seat at a 90° angle in the back seat."

a) The nurse should reinforce to the parent that the current recommendations include keeping infants in a rear-facing car seat until they exceed the maximum height and weight for the car seat or are a minimum of 2 years of age. b) The nurse should reinforce to the parent that in the event that a newborn cannot ride in the rear seat, the parent must disable the front passenger air bag to prevent potential injuries caused by air bag deployment. c) The nurse should reinforce to the parent to use the vehicle's seat belts to secure the newborn's car seat and provide adequate protection in a motor-vehicle crash. d) The nurse should reinforce to the parent to avoid placing the car seat at a 90° angle because it can compromise the newborn's airway. The parent should position the seat so that the newborn is at a 45° angle.

A nurse is reinforcing teaching about formula feeding a newborn w/ a group of new parents. Which of the following instructions should the nurse include? a) Begin giving approximately 240 mL (8 oz) per feeding after the 1st week. b) Position the bottle at a 45° angle during feedings. c) Ensure that the newborn empties the bottle. d) Wait to burp the newborn until the end of the feeding.

a) The nurse should reinforce with the parents that newborns will drink 15 to 30 mL (0.5 to 1 oz) of formula per feeding during the first 24 hr while gradually increasing intake as they grow. By the end of the second week of life, most newborns consume 90 to 150 mL (3 to 5 oz) of formula at each feeding. b) The nurse should reinforce with the parents to position the bottle at a 45° angle during feedings to allow the newborn to have more control during feedings and prevent the swallowing of air. c) The nurse should reinforce with the parents to allow the newborn to self-regulate formula intake. Forcing intake can cause vomiting due to overeating. d) Wait to burp the newborn until the end of the feeding. The nurse should reinforce with the parents to burp the newborn several times throughout the feeding as well as at the end of the feeding to relieve gas and decrease the risk for vomiting.

A nurse is caring for a pt who is 48 hr postpartum following a vaginal birth. Which of the following findings should the nurse report to the provider? (SATA) a) Warm, tender area on the calf b) Orthostatic hypotension c) Moderate lochia rubra d) Dysuria e) Cracked nipples

a) The nurse should report a warm, tender area on the calf, because this can indicate deep-vein thrombosis. b) Orthostatic hypotension is an expected finding during the first 48 hr postpartum and is due to the splanchnic engorgement that occurs after birth. Therefore, the nurse does not need to report this finding to the provider. c) Moderate lochia rubra is an expected finding 48 hr after birth. Therefore, the nurse does not need to report this finding to the provider. d) The nurse should report dysuria, because this can indicate a urinary tract infection. e) The nurse should report cracked nipples, because this is caused by breastfeeding difficulties and can lead to mastitis.

A nurse is collecting data from a pt who is at 36 weeks of gestation during a prenatal examination. Which of the following findings should the nurse report to the provider? a) Blurred vision b) Nonpitting ankle edema c) 10 fetal movements in 2 hrs d) Leg cramps

a) The nurse should report blurred vision to the provider as it is an indication that the client might have preeclampsia. b) The nurse should identify that nonpitting ankle edema is an expected finding at 36 weeks of gestation. c) The nurse should identify that 10 fetal movements in a 2-hr period is an expected finding at 36 weeks of gestation. d) The nurse should identify that leg cramps are an expected finding at 36 weeks of gestation due to compression of nerves.

A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions should the nurse take? a) Reposition the newborn every 4 hrs. b) Feed the newborn 30 mL (1 oz) of glucose water 4 times/day. c) Apply a thin layer of lotion to the newborn's skin. d) Place an opaque mask over the newborn's eyes.

a) The nurse should reposition the newborn every 2 to 3 hr during phototherapy to expose all body surfaces to the light. b) The nurse should ensure the newborn is adequately hydrated through frequent breast or formula feeding. Supplementation with plain or glucose water can delay excretion of bilirubin. c) The nurse should not apply lotion to the newborn's skin as it can absorb heat and cause burns. d) The nurse should place an opaque mask over the newborn's eyes during phototherapy to prevent damage to the retinas. The nurse should remove the mask for feedings.

A nurse is reinforcing teaching w/ a pt who has preeclampsia & is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching? a) "We will monitor your BP every 2 hrs." b) "Your fluid intake will be limited to no more than 125 ml/hr." c) "You might notice that you will begin breathing faster than normal." d) "We will monitor your baby's HR once per hr."

a) The nurse should take the client's blood pressure every 15 to 30 min while the client is receiving magnesium sulfate. Hypotension is an adverse effect of this medication. b) The nurse should restrict the client's fluid intake to no more than 125 mL per hr to prevent fluid overload. c) The nurse should identify that magnesium sulfate causes respiratory depression. The nurse should monitor the client's respiratory rate every 15 min. d) The nurse should inform the client that the fetal heart rate will be continually monitored while the client is receiving magnesium sulfate to assess for changes that might indicate fetal distress.

A nurse is contributing to the POC for a pt who has eclampsia. Which of the following interventions should the nurse plan to include as the priority immediately following a seizure? a) Initiate an IV line w/ an 18-gauge needle. b) Insert an indwelling urinary catheter. c) Administer oxygen via facemask at 10 L/min. d) Monitor the pt during magnesium sulfate therapy.

a) The nurse should use an 18-gauge catheter to administer magnesium sulfate to the client; however, there is another action the nurse should take first. b) The nurse should insert an indwelling urinary catheter to monitor the pt's output; however, there is another action the nurse should take first. c) The first action the nurse should take when using the ABC approach to pt care is to administer oxygen via facemask at 10 L/min to increase oxygenation. d) The nurse should monitor the pt during magnesium sulfate therapy, which is used to prevent further seizure activity; however, there is another action the nurse should take first.

A nurse is reinforcing teaching w/ a pt who is at 8 weeks of gestation. Which of the following responses by the pt indicates an understanding of the teaching? a) "I should feel fetal movements by 12 weeks of pregnancy." b) "I should expect my pregnancy to start showing after the 20th week." c) "I should report occasional nausea & vomiting to the doctor immediately." d) "I should expect to have white vaginal discharge during pregnancy."

a) The pt should feel fetal movement, aka quickening, at 16-20 weeks of gestation. b) The pt should expect abdominal enlargement by the 14th week of pregnancy. c) Nausea & vomiting are common during pregnancy & do not require reporting to the HCP d) The pt might experience leukorrhea, a white or gray vaginal discharge that occurs in response to increased estrogen and progesterone, throughout the entire pregnancy.

A nurse is reinforcing teaching about newborn home safety precautions w/ a group of guardians. Which of the following instructions should the nurse include? a) "You should be able to place 3 fingers b/t the mattress & the sides of the crib." b) "You should ensure that the crib slats are no more than 2.25 in apart." c) "You should attach a pacifier to your baby's clothing." d) "You should set your water heater at 130°F."

a) The space b/t the mattress & the sides of the crib should be < 2 finger widths, or < 2 cm (0.8 in), to prevent entrapment, which can lead to extremity fractures & suffocation. b) The nurse should reinforce that crib slats should be > 5.71 cm (2.25 in) apart to prevent entrapment, which can lead to extremity fractures & suffocation. c) Attaching a pacifier to the newborn's clothing can increase the risk of suffocation. d) Guardians should set water heaters at 49°C (120.2°F) or less.

A nurse is reinforcing teaching about formula preparation w/ the parent of a newborn. Which of the following information should the nurse include? a) Warmed formula can increase spitting up. b) Over-diluted formula can result in inadequate growth. c) The water used to prepare the formula must be sterile. d) Formula left in the bottle can be given at the next feeding.

a) There is no clinical evidence that warmed formula can increase spitting up. Spitting up after feeding can be an expected finding for some newborns; for others, it could indicate overfeeding or GERD. b) Over-diluted formulas can result in inadequate growth. Overly concentrated formula can stress the newborn's renal system. c) When preparing formula, the client can use tap water that is clean and free of contamination after it runs from the faucet for 1 min. The client should then boil it for 1 min and cool it for no longer than 30 min. Sterile bottled water is also safe for mixing with formula. d) The client should discard any formula that remains in the bottle after a feeding because of the potential for bacterial contamination.

A nurse is in postpartum unit is caring for a pt who has endometritis & is 48 hr postpartum following a cesarean birth. Which of the following findings should the nurse anticipate? a) WBC 8,000/mm³ b) Erythrocyte sedimentation rate 15 mm/hr c) Respiratory rate 18/min d) Heart rate 110/min

a) This finding is within the expected reference range of 12,000 to 25,000/mm3 during the first week postpartum. For a client who has endometritis, this value would be elevated. b) This finding is within the expected reference range of a value up to 20 mm/hr for women. For a client who has endometritis, this value would be elevated. c) This finding is within the expected reference range. For a client who has endometritis, the respiratory rate would be elevated. d) An elevated heart rate is an expected finding for a client who has endometritis. Other manifestations are chills, fever, nausea, anorexia, fatigue, pelvic pain, and lochia that has a foul odor.

A nurse is caring for a 12-hr old male newborn who was delivered from a breech position. Which of the following findings should the nurse report to the charge nurse? a) Scrotum appears edematous. b) Skin appears jaundiced. c) Voiding has not occurred. d) The umbilical cord contains 2 arteries & 1 vein.

a) This is an expected finding for a 12-hr old newborn. The swelling typically subsides within a few days. b) The nurse should report jaundice within the first 24 hrs of life to the charge nurse. Pathologic jaundice can lead to severe neurologic disorders. c) This is an expected finding for a 12-hr old newborn. Newborns should urinate within the first 24 hrs. d) This is an expected finding for a newborn. If there is only one artery, the newborn night have a renal anomaly.

A nurse is caring for a pt during the postpartum period. Which of the following findings should the nurse expect during the first 24 hrs following birth? (SATA) a) Diuresis b) Soft, boggy uterus upon palpation c) Discharge of clear, yellow fluid from the breasts d) Lochia serosa e) Lower abdominal cramping

a) This is an expected finding that results from the loss of excess fluid that is retained during pregnancy. b) This is not an expected finding in the postpartum period and can cause excessive bleeding. c) This fluid, called colostrum, is an expected finding in the postpartum period. Colostrum is present for 3 to 5 days until the mother's milk appears and can leak from the breasts beginning in the third trimester of pregnancy. d) Lochia serosa is vaginal discharge that is pink or brown, which occurs 3 to 4 days after birth. e) This is an expected finding and results from the contraction of the uterus as it decreases in size.

A nurse is caring for a pt who is in preterm labor & is receiving betamethasone. Which of the following actions should the nurse take? a) Check the pt's BP every 15 mins for 1 hr after administration. b) Monitor the pt's magnesium level. c) Inject the medication into the pt's vastus lateralis muscle. d) Inform the pt that the medication can cause dizziness.

a) This medication does not adversely affect the pt's BP. Therefore, the nurse should continue to monitor the pt's BP per protocol for a pt who is in preterm labor. b) The nurse should monitor the pt's magnesium level when administering magnesium sulfate, rather than betamethasone. c) The nurse should administer the medication IM into the vastus lateralis muscle & administer a 2nd dose 24 hrs later. d) Terbutaline, rather than betamethasone, causes dizziness.

A nurse is reinforcing teaching w/ a pt who has a new Rx for medroxyprogesterone acetate injection for contraception. Which of the following statements by the pt indicates understanding of the teaching? a) "I should not receive this medication while I am breastfeeding." b) "I will need monthly injections of this medication." c) "I am likely to gain weight while taking this medication." d) "I should limit my calcium intake while taking this medication."

a) This medication is safe with established lactation. However, clients should be advised to wait 6 weeks after birth to start this medication if breastfeeding. b) The client will receive a medroxyprogesterone acetate injection every 11 to 13 weeks as a form of contraception. c) A common adverse effect of this medication is weight gain. d) An adverse effect of medroxyprogesterone acetate is a decrease in bone mineral density. Therefore, the nurse should instruct the client to take a calcium supplement.

A nurse is collecting data from a pt who is 1 day postpartum. Which of the following findings should the nurse identify as an indication of infection? a) BUN 15 mg/dL b) WBC 35,000/mm³ c) Urine specific gravity 1.025 d) Hgb 10 g/dL

a) This value is within the expected reference range. b) After delivery, the client's WBC count can increase up to 30,000/mm3 and still be within the expected reference range, due to leukocytosis. A value greater than 30,000/mm3 could indicate infection. c) This value is within the expected reference range. d) During the postpartum period, the client's Hgb level can decline moderately for 3 to 4 days, because of blood lost during delivery. It takes about 6 weeks to return to the client's usual level. Therefore, an Hgb slightly below the expected reference range is not necessarily a cause for concern.

A nurse is collecting data from a pt who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider? a) Tinnitus b) Proteinuria 3+ c) Increased urine output d) Respiratory rate 10/min

a) Tinnitus is not an indication of magnesium toxicity and not a finding associated with preeclampsia. b) Proteinuria 3+ is an indication of preeclampsia rather than magnesium toxicity. c) Magnesium sulfate is normally excreted in the urine. Decreased urine output can lead to inadequate elimination of the medication, which can result in magnesium toxicity. d) Respiratory depression is an indication of magnesium toxicity. The nurse should report this finding to the provider.

A nurse in a prenatal clinic is caring for a group of pts. Which of the following pts should the nurse recommend the provider see first? a) A pt who is at 37 weeks of gestation & reports a persistent headache. b) A pt who is at 38 weeks of gestation & reports irregular uterine contractions c) A pt who is at 12 weeks of gestation & reports abdominal cramping d) A pt who is at 26 weeks of gestation & reports periodic numbness in the fingers

a) When using the urgent vs. non-urgent approach to care, the nurse should determine that the priority finding is a client who is at 37 weeks gestation and reports a persistent headache. The nurse should identify that a persistent headache is a manifestation of preeclampsia and recommend that the provider see this client first. b) The nurse should identify that a client who is at 38 weeks of gestation and is having irregular uterine contractions might be in the latent phase of labor. However, the nurse should recommend that the provider see another client first. c) The nurse should identify that a client who is at 12 weeks of gestation and reports abdominal cramping might be experiencing a miscarriage. However, the nurse should recommend that the provider see another client first. d) The nurse should identify that a client who is at 26 weeks of gestation and reports periodic numbness in the fingers might be experiencing brachial plexus traction syndrome from drooping of the shoulders. However, the nurse should recommend that the provider see another client first.