Synthesis Exam 4 Final

Ans: A, B, C, F, H. Rationales: The initial assessment for the pregnant client includes urine, cervical, and blood samples to evaluate the mother's health, as well as to promote early identification of infectious or metabolic conditions that might negatively affect the fetus and pregnancy. Laboratory tests include blood type, baseline hemoglobin and hematocrit, platelets, rubella status, renal function, urinalysis, cultures for Neisseria gonorrhea, chlamydia, and syphilis, and HIV status (Choices B, C, F, H). Nutrition and weight gain are addressed at every visit, but in the first trimester the focus is on minimizing the effects of pregnancy-related nausea and vomiting and determining the optimal weight gain for the pregnant woman (Choice A).

. A 36-year-old female client has her initial prenatal primary health care provider visit at 9 weeks' gestation. Which prenatal care activities would the nurse likely include in today's visit? Select all that apply. A. Provide nutrition education. B. Obtain a midstream urinalysis. C. Send a blood sample for a complete blood count. D. Send a blood sample for alpha-fetoprotein (AFP) testing. E. Advise the client to have DNA testing. F. Assist the primary health care provider in collecting specimens for vaginal culture. G. Complete an obstetric ultrasound. H. Enter a prescription to obtain the client's blood typing.

Ans: The first stage of labor lasts from the time 1) dilation begins to the time when the 2) cervix is fully dilated. The second stage of labor lasts from the time of full cervical 3) dilation to the birth of the 4) infant. The third stage of labor lasts from the 5) infant's birth to the expulsion of the 6) placenta. The fourth stage of labor begins with the delivery of the 7) placenta and includes at least the first 8) 2 hours after birth.

18C1. The nurse is caring for a 34-year-old laboring woman and provides health teaching about the stages of labor. Complete the statements below. The first stage of labor lasts from the time _________1___________ begins to the time when the _______2_______ is fully dilated. The second stage of labor lasts from the time of full cervical ___________1____________ to the birth of the __________3__________. The third stage of labor lasts from the _________3________'s birth to the expulsion of the ________4__________. The fourth stage of labor begins with the delivery of the _____4______ and includes at least the first ___5___ hours after birth.

Indicated: 1. Contractions every 5 minutes for at least an hour with a pattern of increasing regularity, frequency, duration, and intensity 2. Any gush or trickle of fluid from the vagina 3. Vaginal bleeding 4. Decreased fetal movement 5. Any feeling that something is wrong. Non-Essential: 1. Awakening less than twice per night with the need to urinate 2. "Nesting" or feeling the need to clean 3. Feeling the baby move more than usual R: Awakening once nightly to urinate, nesting, and feeling the baby move often are all normal occurrences in late pregnancy. The other changes indicate that the client is likely going into labor or having a complication, such as placenta previa or fetal distress. Therefore the client needs to return to the hospital to keep both herself and the fetus healthy.

18C2. A 19-year-old nulliparous client is being sent home from the hospital after being monitored for 2 hours with no cervical change. She is at 36 5/7 weeks' gestation and has had occasional prenatal care. She states that she is "terrified of going into labor in public." Indicate what health teaching by the nurse is Indicated or Non-Essential before discharge that would alert the client about the need to return to the hospital.

Ans: C, D, G. Rationales: Contractions are measured with 1 minute being represented by the dark bold line. The contraction pattern is represented in minutes. A contraction pattern that is every minute would display a contraction starting at each and every dark bold line (or comparable) (Choice C). The fetus's oxygenation has very little, if anything, to do with variability. Moderate variability is displayed, and that is considered good (as opposed to absent or marked) (Choice D). There are no decelerations on the strip displayed. Strength of contractions, when using an external monitor, cannot be visualized on the fetal monitor strip. When using an external monitor, only the health care professional's touch can assess strength. An average fetal heart rate is 110 to 160, and this monitor strip shows a baseline of 120 (Choice G).

18C3. The nurse is caring for a client who is having her first child. The client asks about what the fetal monitor tracing is showing the health care team. An external monitor is being used for contractions and fetal heart rate. The monitor strip shows the following. Which of the following statements are appropriate for the nurse when interpreting the fetal monitoring strip results? Select all that apply. A. "We are concerned about your fetus's oxygenation because of absent variability." B. "We can see that you are having contractions every minute." C. "Your contraction pattern is every 4 to 5 minutes." D. "The beat-to-beat difference in your baby's heartbeat shows that there is variability." E. "The decelerations have been reported to your primary health care provider." F. "The contractions are not strong enough to cause cervical change." G. "An average fetal heart rate is 110 to 160, and your baby has a baseline of 120."

Ans: B, C, F, H. Rationales: An average fetal heart rate is 110 to 160 beats/min, and this strip shows a baseline within that range at 145 (Choice H). Accelerations are defined as an increase in fetal heart rate of 15 beats for 15 seconds, and this strip displays data that meet that definition. Accelerations are a positive fetal sign (Choices B and C). There are no decelerations on the strip displayed (Choice F). The variability of this fetus is not marked, and variability does not change based on the stage of labor. Different types of decelerations indicate different things. Not all decelerations prove fetal compromise. For example, some decelerations show head compression, and others show decreased oxygenation.

18C4. The nurse evaluates the following external fetal monitor strip of the client at 40 weeks' gestation who is contracting and in active labor. Which statements correctly describe the fetal heart rate in this strip and would be documented by the nurse? Select all that apply. A. "The fetal heart rate is tachycardic and needs to be evaluated." B. "The fetal heart rate shows accelerations." C. "The type of accelerations are a positive indicator of fetal well-being." D. "The decelerations are common with contractions." E. "The marked variability of this fetus is abnormal for this stage of labor." F. "No fetal decelerations in the heart rate are present." G. "The normal fetal heart rate is any rate above 120 beats per minute." H. "The baseline fetal heart rate is 145 beats per minute." I. "All decelerations indicate fetal compromise."

Ans: B, E, F. R: When using an external monitor, only the health care professional's touch can assess strength. Contractions are measured with 1 minute being represented by the dark bold line. Contraction paern is represented in minutes (2 to 3 minutes) (Choice B). Duration of contractions is measured from the start of a contraction to the end of that same contraction. Duration is represented in seconds, with each small box representing 10 seconds (50 to 70 seconds) (Choice F). Resting tone is the time between each contraction. Adequate resting tone is at least 1 minute between each contraction (Choice E). False labor can be diagnosed only with a vaginal exam that reveals no cervical change. False versus true labor is not assessed using a fetal monitor strip. Marked contraction pattern is not a definition for a contraction pattern. With pushing efforts, a strip may show a "spikey" top to the contractions, but coughing or sneezing can create the same effect.

18C5. The nurse evaluates the following fetal monitoring strip for a laboring client at 40 3⁄7 weeks' gestation. Which statements correctly describe the contraction pattern in this strip and would be provided by the nurse in a report to the primary health care provider? Select all that apply. A. "Contractions are strong in intensity." B. "Contraction frequency is every 2 to 3 minutes." C. "The duration of contractions is 3 to 4 minutes." D. "Cervical change is occurring with this contraction pattern." E. "There is adequate resting tone at this time." F. "The duration of contractions is 50 to 70 seconds." G. "This contraction pattern shows false labor." H. "Contraction frequency is every 60 seconds." I. "This marked contraction pattern shows pushing efforts."

Ans: First, the nurse will ask the client to empty her 1) bladder to prevent 2) uterus displacement. Next, the nurse will assist the client to a 3) supine position with her knees flexed. Then, the nurse will apply clean gloves and lower the perineal pads to observe lochia as the 4) fundus is palpated. To 5) support and anchor the lower uterine segment, the nurse's nondominant hand is placed above the woman's symphysis pubis. Finally, palpation begins at the 6) umbilicus, and the nurse gently palpates until the 7) fundus is located. Rationales This is the evidence-based procedure for doing a postpartum fundal assessment.

18E1. The nurse performs a fundal assessment on a postpartum client. Complete the statements below. First, the nurse asks to the client to empty her _____1______ to prevent __________2___________ displacement. Next, the nurse assists the client to a __________3__________ position with her knees flexed. Then, the nurse applies clean gloves and lower the perineal pads to observe lochia as the __________4__________ is palpated. To ____________5______________ and anchor the lower uterine segment, the nurse's nondominant hand is placed above the woman's symphysis pubis. Finally, palpation begins at the ___________6__________ and the nurse gently palpates until the _________7_________ is located.

Ans: A, C, E.Rationales: Grand multiparity is defined as five or more births (Choice A). Overdistention of the uterus is caused by a large infant (Choice C). These factors and an operative delivery (Choice E) place the client at a higher risk of hemorrhage.

18E2. A postpartum client delivered her sixth infant via cesarean section 5 hours ago. She delivered her last four children via cesarean section, including the current infant, and all infants weighed over 9 lb (4082 g). When assessing this client, which of the following factors place her at an increased risk for hemorrhage? Select all that apply. A. Grand multiparity B. Prolonged labor C. Overdistention of the uterus D. Retained placental fragments E. Operative cesarean delivery F. Preeclampsia G. History of postpartum hemorrhage

Requires follow-up: 1. Blood type is A negative 2. Had a total of four prenatal visits 3. Rubella status is nonimmune 4. Uses ibuprofen and oxycodone regularly for pain 5. No colostrum noted with hand expression 6. No running water available at her home Expected: 1. Temperature = 98.6°F (37°C) 2. Hepatitis B status is negative 3. Blood pressure = 132/78 mm Hg 4. Had one previous term delivery R: A negative blood type needs follow-up to determine if RhoGAM is needed for Rh incompatibility. Inadequate prenatal care requires follow-up to determine if follow-up care is available for this client and why prenatal care is so important. Rubella status needs follow- up to make sure that the client receives a rubella booster immunization. Oxycodone is an opioid and follow-up is needed to educate on general opioid use and also with breast-feeding. The client has no colostrum by this time and a breast-feeding consultation is needed. Client should have running water for cleanliness, and a resources follow-up is needed.

18E3. A client delivered her newborn 30 hours ago vaginally and experienced a second-degree laceration that was repaired. She has chosen to breast-feed her infant and is preparing for hospital discharge soon. The nurse assesses her discharge teaching and intervention follow-up needs. Which health assessment finding requires Nursing Follow-Up (could be harmful to client) or is Expected (no follow-up is required) for the client at this time.

Ans: a. Continues to rate her pain at 5/10 (on a 0 to 10 pain scale) with medication administration b. Having trouble sleeping c. Has first baby in family d. Babysat once for a neighbor's 6-year-old e. Father of the baby not involved f. Infant boy has many characteristics of father of the baby g. Cesarean birth Non-concerning: a. Has large support system b. Has read "what to expect the first year" c. Has a positive attitude d. Term infant with no issues Rationales: The nurse is concerned about the client's poor pain control and insomnia while caring for a newborn. In addition, the client has no infant-caring experience. Her baby looks like the father, but he is not involved, which may increase the mother's resentment of the baby and affect bonding. A surgical birth can inhibit adaptation because of the lengthier recovery.

18E4. A client delivered her first baby 36 hours ago at 2:21 a.m. (0221) via cesarean delivery for failure to progress. Although she was able to dilate to 8 cm, she was not able to progress past the second stage of labor. Her birth plan included wanting a safe vaginal delivery. Which assessment findings that require follow-up by the nurse?

Ans: A, B, E, G. Rationales: Notifying the primary health care provider of an increased blood pressure, especially when the client is on medication to decrease blood pressure, is crucial (Choice A). Therefore administering an antihypertensive medication is a priority (Choice B). A magnesium level will guide the magnesium infusion rate. It is always essential to stay with a client in an emergency situation (Choices E and G). Positioning with the client's head elevated will not affect eclampsia.

18F1. The nurse is caring for a client after a spontaneous vaginal delivery of a term fetus. The client's pregnancy blood pressure at that time was 150/85 mm Hg. The client has been on magnesium sulfate therapy for preeclampsia for the past 8 hours per protocol. Current assessment data are as follows: Temp 98°F (36.7°C) Heart rate 100 beats/min Respirations 22 breaths/min Blood pressure 198/104 mm Hg Oxygen saturation 100% (on room air) Pain level 8/10 (on 0 to 10 pain scale) (headache) Based on the client's current assessment findings, which of the following actions would the nurse take? Select all that apply. A. Notify the primary health care provider of change in vital signs. B. Administer antihypertensive medication per protocol. C. Administer acetaminophen. D. Encourage the client to empty her bladder. E. Draw a magnesium level as ordered. F. Position client in a high-Fowler position to decrease blood pressure. G. Remain with client until new prescriptions are received.

Ans: A, D, E. Rationales: The correct choices are all symptoms of postpartum affective mood disorders (Choices A, D, and E). The remaining choices are all expected postpartum reactions and symptoms.

18F4. When discharging a 2-day postpartum client, the nurse would teach her to notify the primary health care provider if which signs and symptoms of postpartum affective mood disorder occur? Select all that apply. A. Feelings of sadness and crying B. Feelings of extra energy and cleaning the house C. Inability to sleep through the night D. Easily distracted, difficulty concentrating E. Dreams of harming self or infant F. Feelings of wanting to protect infant from outside disturbances G. Supplementing feedings at night to encourage maternal rest H. Nightmares about the pregnancy or delivery

Ans: A, B, D, E, G. Rationales: Assessing the newborn for any respiratory or cardiac complications is the priority for the nurse; this includes assessing for hypoxia (Choices B and D). However, giving routine oxygen is no longer recommended, so the newborn must be cyanotic or in respiratory distress to receive oxygen. Protecting the newborn from various infections is part of the initial treatment of a newborn; this includes giving hepatitis B vaccine (Choice A). Vitamin K is given shortly after birth to protect the newborn from hemorrhage because the gut is sterile and the newborn is not able to synthesize vitamin K for cloing purposes at birth (Choice E). Maintaining a stable body temperature of the newborn, promoting bonding time with the mother, and breast-feeding success can be accomplished by placing the newborn in skin-to-skin contact with the mother (Choice G). This is often referred to as kangaroo care. Completing a hearing test and an oximetry test to identify congenital cardiac heart defects are also recommended procedures in the newborn time period, but these can wait until after the transitional period.

18G1. The nurse is caring for a newborn born at 39 weeks' gestation 1 hour ago. What evidence-based care will the nurse provide to the newborn during the transitional period? Select all that apply. A. Administer hepatitis B vaccine per protocol. B. Assess for hypoxia. C. Administer oxygen therapy per protocol. D. Perform a gestational assessment. E. Administer intramuscular vitamin K per protocol. F. Complete an otoacoustic test. G. Encourage skin-to-skin contact with the baby's mother. H. Complete congenital cardiac heart defect screening. I. Place identification and security safety bands on the newborn.

Ans: To accurately assess the newborn, the nurse will count heart rate and respirations for 1) 60 seconds, measure the weight of the baby 2) without clothes or diaper at the same time of day daily, and monitor the feeding patterns of the newborn daily. These feeding paerns are then compared with 3) expected intake to identify 4) potential growth difficulties. Rationales: To accurately assess the newborn, the nurse will count heart rate and respirations for 60 seconds because of the natural fluctuations in a newborn's heart rate and breathing. The best way to obtain accurate weights of the baby is without clothes or diapers, and at the same time of day every day with the same scale. Daily weights are critical for the evaluation of whether or not feeding in the newborn is adequate and demonstrates that the newborn is growing appropriately.

18G3. Nursing care for an infant during the first 24 to 48 hours after birth includes frequent assessments. Complete the statements below. To accurately assess the newborn, the nurse will count heart rate and respirations for ____1____ seconds, measure the weight of the baby _____2_____ clothes or diaper at the same time of day daily, and monitor the feeding patterns of the newborn daily. These feeding patterns are then compared with ______3______ intake to identify ____4_____ growth difficulties.

Ans: day of fall - 3 days after fall a. Glasgow Coma Scale score : 15 - 13 b. PERRLA: present c. Level of consciousness: alert - lethargic d. Orientation: 3/3 - 2/3 (oriented to person & place) Rationales: The client needs follow-up for the Glasgow Coma Scale (GCS) score, PERRLA (because of decreasing GCS score), level of consciousness (LOC), and orientation. According to the client information provided, the GCS score is 13 (Eye opening, 3; Motor response, 6; Verbal response, 4) and the LOC is lethargic (drowsy but easily awakened). These are all signs of neurologic impairment, and follow-up is needed to determine the cause.

21.1. A 79-year-old male client with a recent hip open reduction and internal fixation (ORIF) is discharged to a skilled nursing facility for postsurgical rehabilitative therapy. While at the facility, the client has a witnessed fall and sustains a head injury. The nurse performs a head-to-toe assessment and notes no neurologic changes. Three days later, the client is difficult to keep awake, asks to miss school that day because he doesn't feel well, and equally squeezes the nurse's hands when asked. The nurse compares assessment findings from today with those from 3 days ago. Which assessment findings that require follow-up by the nurse.

Ans: A, B, D, F, H. Rationales: The client may have a subdural hematoma, as indicated by the changes in orientation, level of consciousness, and vital signs. These changes indicate possible Cushing triad: bradycardia, widened pulse pressure, and hypertension. A head CT scan can help diagnose cranial perfusion health problems (Choice A). The nurse gives a 500- mL bolus of saline to increase circulating volume, helping the diastolic blood pressure (Choice B). A CBC is not indicated because the anoxia to the brain causes increased hemoglobin and hematocrit (Choice C). The National Institutes of Health Stroke Scale assesses motor, sensory, language, and muscular function to help find the area of the brain that is injured (Choice D). There is not enough information to administer alteplase (rtPA); if the client is experiencing a hemorrhagic stroke, alteplase will worsen the bleeding (Choice E). The client should have a blood glucose test because hypoglycemia can mimic cerebral anoxia (Choice F). At this time, there is no indication for intubation (Choice G). Pupillary size and responses can indicate increased intracranial pressure. Dilated, unequal, and ovoid pupils are all signs of brain hern

21.3. A 79-year-old male client has been transferred to the emergency department from a skilled nursing facility because of changes in orientation and level of consciousness due to a fall. In addition to starting oxygen therapy, which of the following nursing actions are needed for the client at this time? Select all that apply. A. Obtain a CT scan of the head. B. Administer 500-mL IV bolus of normal saline. C. Draw blood for a complete blood cell count (CBC). D. Determine the National Institutes of Health Stroke Scale score. E. Administer alteplase (rtPA). F. Check the client's blood glucose level. G. Prepare to intubate the client. H. Check pupil size and responsiveness.

a. Increased CO2: Apply continuous capnography b. Hypothermia: Apply warm blankets. c. Increased ICP and decreased gas exchange: Elevate HOB to > 30 degrees. d. Increased brain swelling and damage: Perform mental status checks every hour. e. VTE: Apply and maintain sequential or pneumatic compression stockings or devices. R: Applying continuous capnography allows the nurse to monitor the amount of carbon dioxide (CO2) being exhaled. Too much CO2 in the brain's blood supply causes cerebral dilation and increased ICP. Too lile CO2 in the blood supply causes cerebral vasoconstriction and ischemia. Applying warm blankets gently increases the client's temperature and allows for oxygenation of the peripheral tissues through circulation. Elevating the head of the bed decreases intracranial pressure through gravitational pull on cerebrospinal fluid, increases oxygenation by decreasing the work of the lungs, and increases comfort by decreasing abdominal pressure and work of breathing. Hourly mental status checks allow the nurse to monitor increased swelling and damage. Because the client is intubated and unable to move freely, venous thromboembolism prevention needs to be initiated and maintained

21.4. A 24-year-old man is found on the floor at his home by his girlfriend, who calls 911. He has a known history of heroin use and no one is aware of when he lost consciousness. The police find that the client has a "low" pulse and shallow respirations and feels cool to the touch. One of the officers administers naloxone per protocol. The paramedics arrive and insert an endotracheal tube and transport the client to the hospital. After assessment in the emergency department, the client is admied to the critical care unit for further monitoring. Which nursing action is appropriate for the potential complication.

Ans: A, B, C, D, E, F, G, H. Rationales: Most clients with moderate-to-severe brain injuries have long-term physical, cognitive, and emotional deficits. Because of their brain injury, they often have emotional lability, temper outbursts, and memory problems as they adjust to what they are able to accomplish (Choices A and C). Clients with this level of brain injury will need constant supervision to ensure their safety, and may never be able to care for themselves independently (Choice B). Because of these needs, primary caregivers may experience significant role strain and need respite care to keep themselves healthy. The family of the client may feel anger toward the client for all of the changes that need to be made. Local support groups can help families adjust to their new responsibilities and be a worthwhile resource for the family (Choices D, E, and F). Any client who has suffered a brain injury is at an increased risk for seizures. Therefore the nurse needs to teach caregivers what to do in case of a seizure (Choice G). Clients who have a structured environment usually have less emotional and behavioral problems (Choice H).

21.5. A 24-year-old male client who sustained a severe traumatic brain injury was hospitalized for opiate overdose. After the client is transferred from the critical care unit to the general medical unit, the client becomes easily agitated, does not follow commands, is nonverbal, and is unable to perform ADLs. The care coordination team is determining the best plan for the client's discharge and rehabilitation. What health teaching will the nurse provide for the family about the expected rehabilitation process for the client? Select all that apply. A. "The client may be depressed and lonely." B. "The client may need constant supervision." C. "The client may fatigue and be irritated easily." D. "The client's primary caregiver may need respite care at times." E. "The client's family may feel anger toward the client." F. "The client's family should join a local support group." G. "The client is at an increased risk for seizure." H. "The client will benefit from a structured environment."

Indicated: ALL a. Screened for medical conditions b. Comatose as determined by a primary health care provider, diagnostic testing, and history c. Normal or near normal core body temperature d. Normal systolic blood pressure (>100 mm Hg) e. Neurologic examination by a neurologist or intensivist f. Donation coordinated by a local organ-procurement organization Non-Essential: 0 R: All of these considerations are required for a client to be a successful organ donor. Being comatose, as determined through more than one source of information, and neurologic testing are required to ensure brain death. The medical condition screening, temperature, and blood pressure requirements are necessary to ensure that the procured tissues from the donor will be viable in the recipient. Organ donation is coordinated by local organ-procurement organizations.

21.6. A 33-year-old man was involved in a motor vehicle crash and sustained a severe head wound. When the paramedics arrived, they found that the client was comatose. The paramedics inserted an endotracheal tube on the scene. The client has not regained consciousness and has no reflexes. When inventorying the client's belongings, the nurse finds the man's driver's license, which indicates the client wished to be an organ donor. The client's family has questions about organ donation. The nurse understands there are required criteria for a client to be considered as a donor. Indicate whether the criteria below are Indicated (appropriate or necessary) or Non-Essential (make no difference or are not necessary) when considering the client as an organ donor?

The client's gravida is 1) 4 and her parity is 2) 3. The number of term deliveries is 3) 1, the number of preterm deliveries is 4) 2, the number of aborted deliveries is 5) 0, and the number of living children is 6) 3. The client's estimated date of delivery is 7) September 19, 2020. Rationales: An obstetric history is often abbreviated as GTPAL. Gravida (G) is the number of times that a woman has been pregnant, regardless of the duration of the pregnancy or the number of fetuses. The client was pregnant in 2012, 2013, and 2014 and is currently pregnant, for four total pregnancies. To calculate parity (P), the pregnancy must reach 20 weeks' gestation, and this client delivered after 20 weeks for her previous three pregnancies. Preterm pregnancy is a pregnancy that extends from 20 to 366⁄7 weeks' gestation at delivery. Term (T) pregnancies are divided into early term, full term, and late term, but the time period generally extends from 37 to 416⁄7 weeks' gestation at delivery. Pregnancies that end prior to 20 weeks' gestation, either spontaneously or electively, are referred to as abortions (A). The (L) in the obstetric history stands for "living children" and is based on the current num

A 36-year-old female client arrives at her primary health care provider's office for her initial prenatal visit at 9 weeks' gestation. Obstetric history LMP: 12/12/2019

Require follow-up: a. Blood pressure = 132/ 78 mm Hg b. Previous preterm delivery(s) c. Daily sertraline d. Naproxen sodium as needed for pain Expected: a. Temperature = 98.6°F (37°C) b. Respiratory rate = 14 breaths/min c. Heart rate = 76 beats/min d. Timing of initial visit (9 weeks) e. Previous term delivery(s) f. Estimated date of delivery (EDD) g. Height: 66 in (167.64 cm) h. Acetaminophen as needed for pain R: Results for temperature, heart rate, respiratory rate, obstetric history, and current medications are all appropriate and expected. The blood pressure is borderline high; this should be followed up on to see if it is chronic or acute and should be treated accordingly. All NSAID medications are contraindicated throughout the pregnancy owing to interference with neural tube development and risk of bleeding. Sertraline is contraindicated in the third trimester, so the client needs to be transitioned to a replacement medication, or an alternative therapy should be discussed. Understanding the impetus and outcome of the preterm delivery is always important in order to identify any potential implications for the current pregnancy. History of a preterm delivery is one of the bigge

A 36-year-old female client has her initial prenatal primary health care provider visit at 9 weeks' gestation. The nurse completes the initial assessment of the client and reviews the client's health and obstetric history. Which findings require follow-up?

Ans: 1 R: Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Note that options 2, 3, and 4 are comparable or alike in that they indicate an abnormal test result finding.

S196. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a cesarean section

Ans: 2 R: Accurate use of Näegele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2020; subtract 3 months, July 19, 2020; add 7 days, July 26, 2020; add 1 year, July 26, 2021. Test-Taking Strategy: Focus on the subject and use knowledge regarding Näegele's rule to Ans this question. This rule requires addition and subtraction, so read all options carefully, noting the dates and years in the options, before selecting an Ans.

S202. A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2020. Using Näegele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2021 2. July 26, 2021 3. August 12, 2021 4. August 26, 2021

Ans: 2 R: Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to beat variability of the fetal heart rate. Test-Taking Strategy: Note the strategic word, next. Use the ABCs—airway, breathing, and circulation. Fetal heart rate reflects the ABCs.

S233. The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

Ans: 1 R: Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy. Test-Taking Strategy: Note the strategic words, further teaching is needed. These words indicate a negative event query and the need to select an incorrect client statement. Eliminate options 2, 3, and 4 because they are comparable or alike and are accurate statements. Remember that insulin needs decrease in the first trimester of pregnancy.

S211. The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2. "My insulin dose will likely need to be increased during the second and third trimesters." 3. "Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4. "My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

Ans: 1. R: A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that indicates positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process. Test-Taking Strategy: Read all options carefully before selecting an Ans and focus on the subject, the normal grieving process. Note that options 2, 3, and 4 are comparable or alike in that they relate to childbearing.

S215. The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately."

Ans: 3 R: Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the obstetrician's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure. Test-Taking Strategy: Focus on the subject, nursing implications related to amniocentesis. Recalling that this procedure is invasive will direct you to the correct option.

S194. The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure. 2. Hospitalization is necessary for 24 hours after the procedure. 3. An informed consent needs to be signed before the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen.

Ans: 2 R: Leukorrhea begins during the first trimester. Many clients notice a thin, colorless, or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently. Test-Taking Strategy: Eliminate options 1 and 3 first because they are comparable or alike, indicating that the client requires medical attention. From the remaining options, recalling that this manifestation is a normal physiological occurrence or that tampons should be avoided will assist in directing you to the correct option.

S195. A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2. "The vaginal discharge may be bothersome, but is a normal occurrence." 3. "Report to the emergency department at the maternity center immediately." 4. "Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."

Ans: 2, 3, 4, 5. R: Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization or as specified by the obstetrician because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze. Test-Taking Strategy: Focus on the subject, client instructions regarding the rubella vaccine. Rec

S197. A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

Ans: 2. R: The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the primary health care provider (PHCP) if she feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the PHCP. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. If you are unfamiliar with this procedure, recalling that the risk of vena cava (supine hypotensive) syndrome exists when the client lies on her back will direct you to the correct option.

S198. The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? 1. "I will record the number of movements or kicks." 2. "I need to lie flat on my back to perform the procedure." 3. "If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." 4. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

Ans: 3 R: During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks' gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process. Test-Taking Strategy: Focus on the subject, the location of fundal height. Remember that during the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm.

S199. The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? 1. The client is measuring large for gestational age. 2. The client is measuring small for gestational age. 3. The client is measuring normal for gestational age. 4. More evidence is needed to determine size for gestational age.

Ans: 1, 2, 3, 4 R: The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography. Test-Taking Strategy: Focusing on the subject, probable signs of pregnancy, will assist in Ansing this question. Remember that detection of the fetal heart rate and an outline of the fetus via radiography or ultrasonography are positive signs of pregnancy.

S200. The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

Ans: 3 R: Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, there is no reason to notify the primary health care provider. This client is not in preterm labor and, therefore, does not need to be placed on bed rest or be admitted to the hospital to be monitored. Test-Taking Strategy: Options 1 and 4 are comparable or alike and can be eliminated first. From the remaining options, knowing that Braxton Hicks contractions are common and normal and can occur throughout pregnancy will assist in directing you to the correct option.

S201. A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? 1. Contact the primary health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Inform the client that these contractions are common and may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.

Ans: 2 R: Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks of gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks of gestation; included in parity [number of births] if past 20 weeks of gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1. Test-Taking Strategy: Focus on the subject of the question. Recalling the meaning of the acronym GTPAL and focusing on the information in the question will direct you to the correct option.

S203. The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

Ans: 1. R: When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their primary health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious/spiritual practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings. Test-Taking Strategy: Use knowledge of therapeutic communication techniques to Ans the question. The correct option is the only option that reflects use of therapeutic communication techniques.

S206. A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

Ans: 3. R: Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or obstetrician's office. Signs of infection need to be reported to the obstetrician.. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select an incorrect client statement. Also, noting the closed-ended word "avoid" in the correct option will assist in Ansing the question.

S207. The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I should stay on the diabetic diet." 2. "I should perform glucose monitoring at home." 3. "I should avoid exercise because of the negative effects on insulin production." 4. "I should be aware of any infections and report signs of infection immediately to my obstetrician."

Ans: 4. R: Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the primary health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy. Test-Taking Strategy: Note the strategic word, most. Focus on the subject, a complication of preeclampsia. Eliminate options 1, 2, and 3 because they are comparable or alike and are normal occurrences in the last trimester of pregnancy.

S208. The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2. Complaints of feeling hot when the room is cool 3. Periods of fetal movement followed by quiet periods 4. Evidence of bleeding, such as in the gums, petechiae, and purpura

Ans: 1, 3, 5. R: In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Predisposing conditions include abruptio placentae, amniotic fluid embolism, gestational hypertension, HELLP syndrome, intrauterine fetal death, liver disease, sepsis, severe postpartum hemorrhage, and blood loss. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage. Test-Taking Strategy: Note the strategic word, most. Focus on the subject, the client at most risk for DIC. Think about the pathophysiology associated with DIC and select the options that identify abnormal conditions. This will direct you to the correct options.

S209. The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1. A primigravida with abruptio placenta 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida 2 who has just been diagnosed with dead fetus syndrome 4. A gravida 4 who delivered 8 hours ago and has lost 500 mL of blood 5. A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension

Ans: 1 R: A sign of preeclampsia is persistent hypertension. A low-grade fever or increased pulse rate is not associated with preeclampsia. Generalized edema may occur but is not a specific sign of preeclampsia because it can occur in many conditions. Test-Taking Strategy: Focus on the subject, a sign of preeclampsia. Thinking about the pathophysiology associated with preeclampsia will direct you to the correct option. Remember that hypertension is associated with preeclampsia.

S210. The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia? 1. Hypertension 2. Low-grade fever 3. Generalized edema 4. Increased pulse rate

Ans: 4. R: Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The R for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission since hepatitis B does not spread through airborne transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B. Test-Taking Strategy: Note the strategic word, best. Focus on the subject, disease transmission to the newborn. This focus will direct you to the correct option.

S216. The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding. 2. The mother holds the newborn properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

Ans: 2. R: Strict bed rest throughout the remainder of the pregnancy is not required for a threatened abortion. The client should watch for the evidence of the passage of tissue. The client is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The client is advised to curtail sexual activities until bleeding has ceased and for 2 weeks after the last evidence of bleeding or as recommended by the health care provider. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and the need to select an incorrect client statement. Noting the word strict in the correct option will assist in directing you to this option.

S217. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? 1. "I will watch to see if I pass any tissue." 2. "I will maintain strict bed rest throughout the remainder of the pregnancy." 3. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." 4. "I will avoid sexual intercourse until the bleeding has stopped and for 2 weeks following the last episode of bleeding."

Ans: 2, 3, 5. R: The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots. Test-Taking Strategy: Note the subject, planning care for the pregnant client who is obese. If you can recall the general complications associated with obesity, this will help you choose the correct options. Recall that preventive m

S218. The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1. Bed rest as a necessary preventive measure may be prescribed. 2. Administration of subcutaneous heparin postdelivery as prescribed. 3. An overbed lift may be necessary if the client requires a cesarean section. 4. Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

Ans: 2. R: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa. Test-Taking Strategy: Focus on the subject, assessment findings in abruptio placentae. Remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with abruptio placentae, as opposed to painless bleeding with placenta previa.

S219. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

Ans: 2 R: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia. Test-Taking Strategy: Focus on the subject, nursing care of the client with placenta previa. Use knowledge of the pathophysiology associated with placenta previa. Note the words question which prescription in the event query. Also, note that the correct option is the only procedure that is invasive to the pregnancy and endangers the physiological safety of the client and the fetus.

S220. The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.

Ans: 1 R: Abruptio placentae is the premature separation of the placenta from the uterine wall after the 20th week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae. Test-Taking Strategy: Focus on the subject, management of abruptio placentae. Use knowledge regarding the pathophysiology and management of abruptio placentae to Ans the question. Note the words term gestation and moderate vaginal bleeding. Knowing that the goal is to deliver the fetus will direct you easily to the correct option.

S221. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

Ans: 2. R: In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa. Test-Taking Strategy: Focus on the subject, the risks associated with placenta previa. Thinking about the pathophysiology associated with this disorder and recalling that bleeding is a primary concern in this client will direct you easily to the correct option.

S222. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

Ans: 4, 5, 6. R: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and board-like on palpation, as the blood penetrates the myometrium and causes uterine irritability. Test-Taking Strategy: First, eliminate options 1 and 2 because they are comparable or alike. Next, remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with abruptio placentae, as opposed to painless bright red bleeding with placenta previa.

S223. The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational Age

Ans: 3, 5. R: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1. Test-Taking Strategy: Eliminate options 2 and 4 first because they are comparable or alike. From the remaining options, recalling that regular contractions occur before the second stage of labor will direct you to the correct option.

S224. The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2. The membranes have ruptureds. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The Ferguson reflex is initiated from perineal pressure.

Ans: 1. R: Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment. Test-Taking Strategy: Note the strategic words, most appropriate. Use the ABCs— airway, breathing, and circulation—and knowledge related to the significance of a late deceleration to Ans this question.

S225. The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

Ans: 2. R: A normal fetal heart rate is 110 to 160 beats per minute. A fetal heart rate of 180 beats per minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of, 11,000-15,000/mm3 (11-15 × 109/L) up to 18,000/mm3 (18 × 109/L) During the immediate postpartum period, the white blood cell count may be 25,000-30,000/mm3 (25-30 × 109/L) because of increased leukocytosis that occurs during delivery. Test-Taking Strategy: Focus on the subject, normal assessment and laboratory findings and those that indicate the need to contact the PHCP. Knowledge regarding the normal and abnormal findings in a pregnant client and fetus will direct you to the correct option.

S226. The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? 1. Hemoglobin of 11 g/dL (110 mmol/L) 2. Fetal heart rate of 180 beats per minute 3. Maternal pulse rate of 85 beats per minute 4. White blood cell count of 12.000/mm3 (12 × 109/L)

Ans: 3 R: Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is measured in centimeters and noted as a negative number above the line and as a positive number below the line. At the negative 1 (−1) station, the fetal presenting part is 1 cm above the ischial spine. Option 1 is at the negative 5 (−5) station and the fetal presenting part is 5 cm above the ischial spine. Option 2 is at the negative 2 (−2) station, and the fetal presenting part is 2 cm above the ischial spine. Option 5 is at the positive 3 (+ 3), and the fetal presenting part is 2 cm below the ischial spine. Test-Taking Strategy: Recalling that station is measured in centimeters and uses the ischial spine as a reference point will assist in Ansing this question. Focus on the data in the question and note the location of the ischial spine and that the stations range from −5 cm to + 5 cm above or below this reference point.

S227. The nurse is reviewing the record of a client in the labor room and notes that the primary health care provider has documented that the fetal presenting part is at the −1 station. This documented finding indicates that the fetal presenting part is located at which area? Refer to figure. 1. 1 2. 2 3. 3 4. 4

Ans: 3, 5 R: Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary after this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part. Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, an amniotomy. Recalling that amniotomy is performed to augment labor if the progress begins to slow will direct you to the correct option.

S228. A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a −2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

Ans: 4 R: Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction. Test-Taking Strategy: Focus on the subject, umbilical cord compression. Recalling that variable decelerations occur if the umbilical cord becomes compressed will direct you to the correct option.

S229. The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

Ans: 1 R: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone or semi-Fowler's position is not practical for this type of abdominal surgery. Test-Taking Strategy: Focus on the subject, positioning the pregnant woman. Visualizing each of the positions identified in the options and considering the effect that the position may have on the mother and the fetus will direct you to the correct option.

S230. A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

Ans: 1 R: A normal fetal heart rate is 110 to 160 beats per minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the data in the question. Knowledge that the normal fetal heart rate is 110 to 160 beats per minute will assist you to recognize that fetal bradycardia is present.

S231. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate? 1. Notify the primary health care provider (PHCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

Ans: 4 R: Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary. Test-Taking Strategy: Note the strategic words, most appropriate. Options 1, 2, and 3 are comparable or alike in that they indicate the need for further intervention. Also, knowing that accelerations indicate fetal well-being will direct you to the correct option.

S232. The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the primary health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

Ans: 4 R: True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor. Test-Taking Strategy: Focus on the subject, the signs of true labor. Noting the word true in the question and its relationship to the words increase in duration and intensity in the correct option will direct you to this option.

S234. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

Ans: 3 R: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy. Test-Taking Strategy: Note the strategic word, first. Because of the risk of a prolapsed cord after an amniotomy, the first action is to check the fetal heart rate for signs of nonreassuring fetal heart rate patterns.

S235. Which assessment finding after an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

Ans: 2 R: The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips should be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time. Test-Taking Strategy: Note the strategic word, primary. Also, noting the words pushing effectively will assist in directing you to the correct option.

S236. The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

Ans: 2 R: The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation, but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time. Test-Taking Strategy: Focus on the strategic word, priority. Focus on the data in the question and note the relationship of the words undergoing induction and the correct option. Also recall that physiological needs are prioritized over psychosocial needs.

S237. The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats per minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin. 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present.

Ans: 2 R: Preterm labor occurs after the 20th week but before the 37th week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years. Test-Taking Strategy: Options 1, 3, and 4 are comparable or alike and are average and normal findings. Also note that the correct option is the only option that identifies an abnormal condition.

S238. The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida. 2. The client has a history of cardiac disease. 3. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4. The client is a 20-year-old primigravida of average weight and height.

Ans: 1, 2, 3 R: Risk factors that increase a woman's risk for dysfunctional labor include the following: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 54 years is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with fertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal, and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs. Test-Taking Strategy: Focus on the subject, risk factors for labor dystocia. Additionally, focus on the data in the question, look at each option, and determine whether these are normal assessment findings.

S239. The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1. Age 54 years 2. Body mass index of 28 3. Previous difficulty with fertility 4. Administration of oxytocin for induction 5. Potassium level of 3.6 mEq/L (3.6 mmol/L)

Ans: 4 R: Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor. Test-Taking Strategy: Focus on the subject, signs of fetal or maternal compromise. Eliminate options 1, 2, and 3 because they are comparable or alike and are normal expectations during labor.

S240. The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate

Ans: 1 R: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest. Test-Taking Strategy: Focus on the strategic word, priority. Also note that options 2, 3, and 4 are comparable or alike and are therapeutic measures for hypotonic dysfunction.

S241. The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin infusion closely.

Ans: 3 R: Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic. Test-Taking Strategy: Note the word question. This word indicates the activity that the nurse should not implement without clarification. Options 1, 2, and 4 are comparable or alike and are expected activities for the nurse to perform for a client with premature rupture of the membranes. Performing a vaginal examination every shift should not be done on a client with premature rupture of the membranes because of the risk of infection, so the nurse would question this prescription.

S242. The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer an antibiotic per prescription and per agency protocol.

Ans: 2 R: Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority. Test-Taking Strategy: Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory and the ABCs—airway, breathing, and circulation—to assist in Ans.ing the question. These strategies will direct you to the correct option.

S243. The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

Ans: 4 R: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect, because the intravenous infusion should be increased (per primary health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect, because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Test-Taking Strategy: Note the strategic words, most important. Use the ABCs— airway, breathing, and circulation. Oxygen is the only option that would improve cardiac output and improve perfusion to the fetus. The other options would not improve perfusion to the fetus.

S244. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the intravenous flow rate. 2. Continue the oxytocin drip if infusing. 3. Place the client in a high Fowler's position. 4. Administer oxygen, 8 to 10 L/minute, via face mask.

Ans: 2 R: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the primary health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation. Test-Taking Strategy: Note the strategic word, first, and that the umbilical cord is protruding from the vagina. Options 3 and 4 can be eliminated first because these actions delay necessary and immediate treatment. Recalling that the goal is to relieve cord compression and to increase fetal oxygenation will direct you to the correct option. Also remember that the cord should not be pushed back into the vagina.

S245. The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the primary health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

Ans: 4. R: The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the obstetrician is not necessary. Test-Taking Strategy: Note the strategic word, priority, and use knowledge regarding the physiological findings in the immediate postpartum period to Ans this question. Recalling that a temperature elevation often is related to the dehydrating effects of labor will direct you to the correct option. Also, increasing hydration relates to a physiological client need.

S246. The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Notify the obstetrician. 3. Retake the temperature in 15 minutes. 4. Increase hydration by encouraging oral fluids.

Ans: 3. R: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a prescription. Option 4 is unnecessary. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the subject, client safety. Option 4 is unnecessary and should be eliminated first. Elevating the client's head is not a helpful intervention. To select from the remaining options, recall that safety is a primary issue.

S247. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.

Ans: 1. R: After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Focus on the subject and use general principles related to postpartum care. Eliminate options 2 and 4 first because of the length of time stated in these options. From the remaining options, eliminate option 3, because it would seem unreasonable that bowel function would return that quickly in the postpartum woman.

S248. The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum

Ans: 1. R: The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume. Test-Taking Strategy: Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory to eliminate option 3, because this is a psychosocial, not a physiological, need. To select from the remaining options, focus on the data in the question.

S249. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

Ans: 1, 2, 3, 6. R: The postpartum client should wear a bra that is well fitted and supportive. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or medications. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Test-Taking Strategy: Focus on the subject and note the words understood the instructions. Think about the physiology associated with milk production and the complications of breast-feeding to Ans correctly.

S250. The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged, I will limit my breastfeeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

Ans: 1. R: The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed. Test-Taking Strategy: Note the subject, teaching for the breast-feeding client. Remember that fluids and calories should be increased when the client is breastfeeding.

S251. The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

Ans: 2. R: If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Test-Taking Strategy: Focus on the subject, a soft and boggy uterus. Visualize the situation and recall the therapeutic management for uterine atony. Remember that a full bladder displaces the uterus.

S252. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.

Ans: 4. R: Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client. Test-Taking Strategy: Note the strategic words, need for follow-up. These words indicate a negative event query and the need to select the abnormal assessment finding. Note the words foul-smelling in the correct option.

S253. The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats per minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

Ans: 2. R: Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the OB. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the words larger than 1 cm. Think about the significance of lochial clots in the postpartum period to Ans correctly.

S254. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Notify the obstetrician (OB). 3. Reassess the client in 2 hours. 4. Encourage increased oral intake of fluids.

Ans: 4. R: Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light = less than 10 cm (< 4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the OB in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized. Test-Taking Strategy: Note the strategic word, initially. Focus on the data in the question, a saturated perineal pad in 15 minutes. Next, determine if an abnormality exists. The data and the use of guidelines determine the amount of lochial flow will help you determine that this is abnormal and warrants notification o

S255. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? 1. Document the finding. 2. Encourage the client to ambulate. 3. Encourage the client to increase fluid intake. 4. Contact the obstetrician (OB) and inform him or her of this finding.

Ans: 1. R: A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Keeping in mind that the client had a cesarean delivery and noting the word immediately in the correct option will assist in directing you to this option.

S256. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify my obstetrician if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

Ans: 2. R: Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings. Test-Taking Strategy: Use therapeutic communication techniques. The correct option is the only option that acknowledges the client's feelings. Advising the client to massage the fundus and call the physician if excessive bleeding occurs is the priority because such bleeding can lead to hemorrhage, causing loss of fluid balance and fainting. Although recommending that a new mother sleep when her neonate sleeps can help the mother avoid exhaustion, this teaching point isn't the top priority. Sleeping with the neonate is a potential hazard; rolling over can suffocate the infant. Telling the client not to worry doesn't provide proper instruction and doesn't address concerns the client may have.

S257. After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record.

Ans: 2. R: During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal. Test-Taking Strategy: Note the strategic word, early. Think about the physiological occurrences of hemorrhage and shock and the expected findings in the postpartum period. This should assist in directing you to the correct option.

S258. The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4° F (38° C) 2. An increase in the pulse rate from 88 to 102 beats per minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths per minute

Ans: 1, 2, 3, 4. R: Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess. Test-Taking Strategy: Focus on the subject, treatment measures for mastitis. Think about the pathophysiology associated with mastitis to Ans correctly. Recalling that supportive measures include rest, moist heat or ice packs, antibiotics, analgesics, increased fluid intake, breast support, and decompression of the breasts will assist in Ans.ing the question.

S259. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

Ans: 4. R: Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and the need to select the option that identifies the incorrect client statement. Recalling that the use of soap is drying to the skin and could cause cracking and provide an entry point for organisms will direct you easily to the correct option.

S260. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast- feeding." 4. "I should wash my nipples daily with soap and water."

Ans: 3. R: Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding. Test-Taking Strategy: Eliminate option 4 first because this is a normal and expected finding. Next, eliminate options 1 and 2 because they are comparable or alike.

S261. The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

Ans: 4. R: If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen. Test-Taking Strategy: Note the strategic word, initial. Use the ABCs—airway, breathing, and circulation—to assist in directing you to the correct option.

S262. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate 4. Administer oxygen, 8 to 10 L/minute, by face mask.

Ans: 3. R: If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the OB. Test-Taking Strategy: Note the strategic word, initial. Focus on the data in the question, noting the clinical manifestations identified in the question. Eliminate option 2 first because, if the uterus is firm, it would not be necessary to perform fundal massage. Knowing that Trendelenburg's position interferes with cardiac and respiratory function will assist in eliminating option 4. From the remaining options, noting the words bleeding is excessive will assist in directing you to the correct option.

S263. The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the obstetrician (OB). 4. Place the client in Trendelenburg's position.

Ans: 3. R: The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage. Test-Taking Strategy: Note the strategic word, most. Focus on the subject, the client at most risk for hemorrhage. Read the client description in each option. Noting the words large and oxytocin in the correct option will direct you to this option.

S264. The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia

Ans: 2. R: Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage. Test-Taking Strategy: Focus on the subject, measures to treat cystitis, and note the strategic word, priority. Remember that increased fluids are a priority intervention.

S265. A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

Ans: 1. R: Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues. Test-Taking Strategy: Note the strategic word, best. Also note that the client received epidural anesthesia. With this in mind, eliminate options 3 and 4. From the remaining options, use the ABCs—airway, breathing, and circulation—to direct you to the correct option.

S266. The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

Ans: 4. R: A hematoma is a localized collection of blood in the tissues of the reproductive tissues after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma. Ambulation hourly increases the risk for bleeding. Client assessment every 4 hours is too infrequent. Test-Taking Strategy: Focus on the subject, a small vulvar hematoma. Think about the effect of each action in the options; this focus will assist in directing you to the correct option.

S267. The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage ambulation hourly. 2. Assess vital signs every 4 hours. 3. Measure fundal height every 4 hours. 4. Prepare an ice pack for application to the area.

Ans: 3. R: If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Test-Taking Strategy: Note the strategic word, initial, in the question. Focus on the subject, that the uterus is soft and boggy. Recalling the therapeutic management for uterine atony will assist in directing you to the correct option.

S268. On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Document the findings 2. Elevate the client's legs. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.

Ans: 3. R: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact). Test-Taking Strategy: Note the strategic words, most effective. Recalling that evaporation of moisture from a wet body dissipates heat along with the moisture will assist in directing you to the correct option.

S269. The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

Ans: 1. R: Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client should be instructed to notify the primary health care provider (PHCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are not the most appropriate nursing interventions for an umbilical cord infection as described in the question. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the clinical manifestations provided in the question to assist in Ansing. Noting the word discharge in the question will assist in directing you to the option that indicates that the newborn needs to be seen by the PHCP.

S270. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence and no further action is needed. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

Ans: 2. R: The highest priority on admission to the nursery for a newborn with a low Apgar score is the airway, which would involve preparing respiratory resuscitation equipment and oxygen. The remaining options are also important, although they are of lower priority. The newborn would be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer would provide an external heat source, which is necessary to prevent further respiratory distress. Test-Taking Strategy: Note the strategic words, highest priority. This question asks you to prioritize care on the basis of information about a newborn's condition. Use the ABCs—airway, breathing, and circulation. A method of planning for airway support is to have the resuscitation bag connected to an oxygen source.

S271. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5° C (97.6° F).

Ans: 3. R: The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the PHCP. Because the findings identified in the question are normal, the nurse would document the assessment findings. Test-Taking Strategy: Note the strategic words, most appropriate, and focus on the assessment findings in the question. This should assist in directing you to the correct option, because this is a normal occurrence after circumcision.

S272. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the primary health care provider (PHCP).

Ans: 1, 2, 4, 5. R: A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Hypotension and a barrel chest are not clinical manifestations associated with respiratory distress syndrome.Test-Taking Strategy: Focus on the subject, signs of respiratory distress syndrome. Eliminate hypotension, as this is not a finding associated with respiratory distress syndrome. Also, respiratory distress syndrome is an acute occurrence, and a barrel chest develops with a chronic condition. In addition, note the relationship between the diagnosis and the signs noted in the correct options.

S273. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Presence of a barrel chest

Ans: 2. R: Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary. Test-Taking Strategy: Eliminate options 3 and 4 because they are comparable or alike. These options discourage the continuation of breast-feeding and should be eliminated. From the remaining options, recalling the pathophysiology associated with hyperbilirubinemia will assist you in eliminating option 1.

S274. The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.

Ans: 3, 4, 5. R: A newborn of a woman who uses drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held. This infant is not lethargic or sleepy. Test-Taking Strategy: Lethargy and sleepiness are comparable or alike in that they indicate hypoactivity of the newborn, and therefore can be eliminated. From the remaining options, recalling the pathophysiology associated with an infant born to a drug-addicted mother and that the newborn is irritable will assist you in eliminating that this infant will be easily comforted and cuddle when held.

S275. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held

Diagnostic Test - Indication - Nursing Implication 1. Fetal nonstress test - to evaluate the viability of the fetus and the placenta's ability to perfuse the fetus - Place client on external fetal monitor and instruct her to push the buon every time the fetus moves. 2. Alpha-fetoprotein - Screening marker used to identify increased risk for birth defects - Perform test after 10 weeks' gestation and include gestation with serum sample. 3. Fetal biophysical profile - to identify if a fetus is in distress and assesses fetal heart rate reactivity, breathing and body movements, muscle tone, and amniotic fluid volume - The overall score will dictate if and when the test has to be repeated. 4. Chorionic villus sampling - Genetic testing that can be done at 8-12 wk for pregnancies associated with high risk for genetic defects - Potential complications include spontaneous or accidental abortion. 5. Amniocentesis - to measure fetal maturity, fetal distress, and risk for respiratory distress syndrome - Test is contraindicated in clients with abruptio placentae and may cause amniotic fluid emboli. 6. Glucose tolerance test - to evaluate clients with hypoglycemia - Instruct the client to fast for 12

The nurse is preparing a 41-year-old female client and her husband for various testing that will be done throughout the pregnancy to monitor for maternal and fetal well-being. The client is a gravida 3 para 2 (G3P2) with a history of cephalopelvic disproportion and previous cesarean section. She is currently at 156⁄7 weeks' gestation.

During the client's first trimester, routine primary health care provider visits will be every 1) 4 weeks. The primary health care provider will order an ultrasound to check for fetal 2) anatomy that could indicate fetal anomalies. The client can expect to hear the heartbeat during the second trimester and feel fetal 3) movements after 16 weeks. A noninvasive way to monitor the 3) growth of the fetus is by measuring the 5) fundal height and is done at every visit after 6) 20 weeks' gestation but may have a 7) 2-week margin of error. R: Although routine prenatal visits can be individualized based on the client's health and needs, they generally are not more frequent than every 4 weeks in the first trimester and increase in frequency as the pregnancy develops. Ultrasound during pregnancy is used to assess for multiple fetuses, fetal measurements, weeks of gestation, and biparietal diameter (BPD) to evaluate potential complications. It also gives the mother a more accurate expected date of delivery (EDD). Fundal heights are generally consistent with gestation from 18 to 30 weeks and are thus used as a noninvasive means of evaluating fetal development.

The nurse provides health teaching for a 36-year-old female client during her initial prenatal primary health care provider visit at 9 weeks' gestation. Choose the most likely answers for the information missing from the statements below. During the client's first trimester, routine prenatal visits will be every ________1________ week(s). The primary health care provider will prescribe an ultrasound to check for fetal ________2________ that could indicate fetal anomalies. The client can expect to hear the heartbeat during the second trimester and feel fetal _________3___________ after 16 weeks. A noninvasive way to monitor the ___________4____________ of the fetus is by measuring the ________5________ height and is done at every visit after ________6________ weeks' gestation but may have a ________7________ -week margin of error.