test tuesday1

A 24-year-old client who has had type 1 diabetes for 6 years is concerned about how her pregnancy will affect her diet and insulin needs. How should the nurse respond?

"Insulin dosage and dietary needs will be adjusted in accordance with the results of blood glucose monitoring." Insulin requirements may decrease in early pregnancy because of increased fetal needs for nutrients and the possibility of maternal nausea and vomiting. Insulin requirements increase in the second and third trimesters as resistance to insulin develops. The blood glucose level is monitored to prevent ketoacidosis and harm to both the mother and fetus. Telling the client that protein needs will increase and adjustments to the insulin dosage will be necessary conveys information that is true only during early pregnancy. Even the nondiabetic woman makes dietary adjustments necessary to keep pace with the increased nutritional demands of pregnancy; in addition, insulin requirements increase in the second and third trimesters. Most nutrient requirements, not just protein, increase during pregnancy.

A client who has type O Rh-positive blood gives birth. The neonate has type B Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the infant's skin appears yellow. What is the most likely cause?

ABO incompatibility There is an apparent ABO incompatibility because the mother is O and the infant is B; incompatibility can cause jaundice within the first 24 hours. The information provided does not indicate neonatal sepsis. Rh incompatibility is not a factor because the mother is Rh positive. Jaundice in the first 24 hours is not physiologic; it is pathologic.

A primigravida is admitted with a ruptured fallopian tube (resulting from an ectopic pregnancy), and surgery is performed to remove the fallopian tube. Which intervention should be included in the postoperative nursing care plan?

C) Explaining that the client may still be capable of becoming pregnant Removing a fallopian tube does not impair the ovaries' ability to release an egg, which may be fertilized in the remaining tube if it is undamaged. There is no known way to prevent future tubal pregnancies. There is no information to indicate that the client is Rh negative, requiring the administration of Rho (D) immune globulin. Liquid from a douche does not reach the fallopian tube or dislodge a fertilized egg; in addition, douching is no longer recommended at any time.

The nurse is caring for a couple who have just received amniocentesis results indicating that their fetus has trisomy 18. Why is it important for a nurse to support the parents' decision to abort a fetus with a birth defect even if the nurse is morally opposed to abortion?

It is important for maintenance of the family equilibrium (Although support may help minimize guilt and feelings of pressure, it will not eliminate it; however, support will sustain family cohesion and unity)

Which action of a breastfeeding mother indicates the need for further instruction?

Leans forward to bring breast toward the baby. Correct

Which instructions should the nurse include when teaching a mother about the storage of breast milk?

Milk thawed in the refrigerator can be stored for 24 hours. Correct Wash hands before expressing breast milk. Correct

A postpartum patient is worried that she cannot feed her child effectively. What are the most suitable nursing interventions for decreasing the patient's anxiety?

Providing education about breastfeeding Providing information for lactation support Monitoring the neonate's weight, intake, and output

The nurse is caring for a postpartum patient who reports severe pain after a cesarean delivery. Which position should the nurse advise the patient to assume during breastfeeding?

The clutch hold position is suitable for a patient who gave birth by cesarean section. This position prevents pressure on the abdomen and reduces strain on the abdominal sutures. If the patient complains of severe pain after vaginal delivery, she is instructed to breastfeed in the side-lying position. This position enables the patient to rest while feeding. The cradle hold and across-the-lap hold are suitable for the infant who is accustomed to feeding and has effective latching. The modified cradle hold is suitable for neonates and during early feedings.

When the fetal head begins to crown during an emergency precipitous birth, how should the nurse respond?

The nurse should respond BY APPLYING GENTLE PERINEAL PRESSURE. Application of gentle perineal pressure will prevent the excessive rapid expulsion of the foetus head which can cause perineal laceration in the mother. Read more on Brainly.com - https://brainly.com/question/6620645#readmore

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. What should the nurse consider before responding?

These accelerations are a sign of fetal well-being.

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb (3175 g) at birth. Which finding should be reported immediately to the healthcare provider?

Weight of 6 lb 4 oz (2835 g) (A loss of 12 oz (340 g) since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%. Hemoglobin of 16.2 g/dL (162 mmol/L), total serum bilirubin of 10 mg/dL (171 µmol/L), and three wet diapers over the last 12 hours are all normal and expected findings.)

While changing a newborn girl's diaper a nurse observes a brick-red stain on the diaper. How does the nurse interpret this clinical finding?

an uncommon benign ocurance The brick-red color in the urine is caused by albumin and urates that are found in the first week of life. Iron is eliminated by way of the gastrointestinal tract. The finding is unrelated to the sex of the infant; it is not hormonally based. No medication administered during labor will cause this discoloration

A nurse is caring for a group of postpartum clients. Which client is at the highest risk for disseminated intravascular coagulation (DIC)?

gravida 1 fetal uterines death Intrauterine fetal death is one of the risk factors for DIC; other risk factors include abruptio placentae, amniotic fluid embolism, sepsis, and liver disease. Multiple pregnancy, endometriosis, and increased birthweight are not risk factors for DIC.

A nurse is assessing a newborn whose mother had a precipitate birth at home. For which complication should the nurse assess the newborn?

intracranial hemmorrhage A rapid birth does not give the fetal head adequate time for molding, so pressure against the head is increased, which may result in intracranial hemorrhage. Facial palsy (paralysis) is caused by pressure on the facial nerve during birth. This is the result of a prolonged second stage of labor or a forceps birth; it does not occur during a precipitous birth. A dislocated hip is more likely to occur in a footling breech birth. A fractured clavicle may occur if pulling on the shoulders during the birth is required.

The nurse plans to weigh a newborn. What is the most appropriate way to obtain the newborn's weight most accurately?

placing the newborn ona scale

A client is admitted with a diagnosis of preeclampsia. Which significant clinical finding does the nurse expect when reviewing the client's history?

proteeinuria A characteristic of preeclampsia is vasospasms that cause renal injury, resulting in loss of protein in the urine. The maternal heart rate is not affected by preeclampsia. An increased serum glucose level is associated with uncontrolled diabetes, not preeclampsia. There are no data to indicate that the client had or is having a seizure. The admitting diagnosis is preeclampsia, not eclampsia.

While the infant is sleeping the nurse finds that the infant's heart rate is 80 beats per minute. What should the nurse do in this situation?

reasses hr in 30 minutes

The nurse notes the infant's body temperature to be 38.5° C (101.3° F). Upon further assessment, the nurse finds that the infant has extension posture, dilated blood vessels of the skin, warm hands and feet, and an appearance of flushed skin. What does the nurse conclude from these findings

swaddled in too many blankets

The parent of a newborn reports to the nurse, "My baby has small, red papules on the face and hands." What response should the nurse give to the parent?

the reaction is normal The newborn has small, red papules on her face and hands that indicate transient rashes due to erythema toxicum. This condition is not clinically significant and does not require any treatment. Cyanosis is the appearance of a bluish tint on the skin, but it is not accompanied by small, red papules on the body. Adequate oxygen supply does not lead to small, red-colored papules on the skin. Exposure to direct sunlight does not lead to the formation of papule-like lesions on the skin.

The nurse is teaching a new mother about breastfeeding. What infant assessment should the nurse ask the mother to perform to find out whether the infant's milk intake is adequate?

urine output

A nurse is teaching a class regarding childbearing and contraceptive options. The nurse explains that fertilization of the ovum by the sperm occurs during a very specific time frame. Which statement best describes when fertilization occurs?

when sperm onwe leaves Fertilization occurs when one sperm penetrates one ovum, producing a viable zygote. Fertilization occurs in the fallopian tube, not when the ovum is expelled from the ovary or in the uterus. After the sperm penetrates the ovum in a fallopian tube, the impregnated ovum travels down the tube to the uterus.

During labor a client states that she does not want eyedrops or ointment placed in her baby's eyes immediately after birth. How should the nurse respond?

3 "Let's talk about why you don't want the medicine to be put into your baby's eyes." Talking about why the client doesn't want the medicine to be put into her baby's eyes provides the mother with an opportunity to express her concerns regarding prophylactic eye medication. Saying that the medicine protects the baby and that's why it's used cuts off communication and does not reflect back the mother's statement. It is the nurse's responsibility to discuss this issue with the mother. Stating that the medicine is required by law and should be administered right after the baby is born blocks communication; instillation may be delayed for an hour.

The nurse concludes that a couple with a newborn with Erb palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion?

3 months recovery

What is the optimal nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs (Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.)

The nurse is taking the health history of a client who has been admitted for repair of a cystocele and rectocele. Which signs or symptoms would the nurse expect the client to report?

As the uterus drops, the vaginal wall relaxes. When the bladder herniates into the vagina (cystocele) and the rectal wall herniates into the vagina (rectocele), the individual feels pressure or pain in the lower back and/or pelvis. When there is an increase in intraabdominal pressure in the presence of a cystocele, incontinence results. A white vaginal discharge (leukorrhea) and vaginal itching (pruritus) do not indicate cystocele and rectocele; they are common with a vaginal infection. Sporadic bleeding is not expected with cystocele and rectocele. Increased temperature and intractable diarrhea are not expected with cystocele and rectocele; a fever would indicate an infection; constipation, not diarrhea, is more likely to occur.

A client has been taking methadone 40 mg/day for treatment of an opioid addiction. During a methadone clinic visit she tells the counselor that she is 3 months pregnant and receiving prenatal care. The counselor notifies the nurse in the prenatal clinic about the client's addiction history. What should the nurse in the prenatal clinic recommend that the client do?

Continue the prescribed methadone to prevent withdrawal symptoms. Withdraw the methadone slowly over the next several weeks. Continue the prescribed methadone to prevent withdrawal symptoms. Temporarily discontinue the methadone to improve maternal and neonatal outcome. Leave the methadone maintenance program during the pregnancy and reenter it after the birth

A 36-year-old primagravida is receiving treatment for preeclampsia at 29 weeks' gestation. In light of the latest information on the client's record, what does the nurse identify as the priority of care?

Epigastric pain, blurred vision, and headache are prodromal symptoms of eclampsia in a client with preeclampsia. Minimal urine output in 8 hours would be 240, or 30 mL/hr. The risk for a tonic-clonic seizure increases dramatically, and death is possible. Because the client is receiving a central nervous system depressant, it is more likely that the fetal heart rate will be decreased. The client is usually on nothing-by-mouth status during magnesium sulfate administration, particularly with unstable clinical findings, because of the possible need for an emergency cesarean birth. Although it is important to monitor the client's respirations and to ensure that calcium gluconate (magnesium sulfate antagonist) is available, neither is the priority in a life-threatening situation.

A nurse in the clinic is conducting a routine assessment of a primigravida client. The nurse notes bruises on the client's upper arms. When questioned, the client responds that her boyfriend was upset and hit her. What is the priority nursing action?

Rationale By developing a plan with the client, the nurse makes her aware of options that are available and how she can seek safety. Calling the nurse manager is unnecessary, because the client has stated the source of the bruises. The nurse should record the finding and probably discuss it with the nurse manager. Informing the client that her pregnancy is in danger is not a therapeutic response, because it may increase the client's anxiety. Notifying social services may further aggravate the home situation, and the client may choose to be uncooperative.

What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation?

Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. The temperature of the preterm infant is expected to decrease due to immature thermoregulation.

At 1 minute after birth the nurse determines that an infant is crying, has a heart rate of 140 beats/min, has blue hands and feet, resists the suction catheter, and keeps the legs flexed and the arms extended. What Apgar score should the nurse assign?

The Apgar score is 8; 1 point is deducted for diminished muscle tone (the baby's arms do not flex) and 1 point for acrocyanosis, which manifests as bluish hands and feet. Scores of 6 and 7 are too low and a score of 9 is too high.

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a third-degree laceration. The client tells the nurse that her perineal area is very painful. What is the physiological finding that is the cause of this pain?

anal sphincter A third-degree laceration extends through the perineal muscles and continues through the anal sphincter muscle. Cutting of the perineal muscles constitutes a second-degree laceration. Trauma to the rectum constitutes a fourth-degree laceration. Damage to superficial muscles is a first-degree laceration.

An infant in the newborn nursery has cyanosis of the hands and feet and circumoral pallor when crying. In light of these assessment findings, which actions should the nurse consider taking next?

circumal palor Cardiac pathology can be detected at an early age, and circumoral pallor may be a sign. Circumoral pallor is not expected in a healthy newborn, or in a person of any age. Cyanosis does not indicate increased intracranial pressure.

A nurse is preparing a premenopausal client for a hysterectomy. What should the preoperative teaching include?

cystic ostillation A hysterectomy is the removal of the uterus but not of other female organs. Consequently menstruation ceases, but the hypophyseal and ovarian hormone cycles continue. Removal of the uterus does not affect the secretion of ovarian hormones. Usually, menopause begins gradually; after an oophorectomy, it begins immediately. However, an oophorectomy is not planned. Because an oophorectomy is not planned, ovarian hormones will continue to be secreted.

The nurse is caring for an infant born with two teeth. The mother of the infant is upset, as the primary health care provider (PHP) suggested that the teeth of the infant be extracted. What is the best action adopted by the nurse in this situation?

extract teeth

A mother reports that her baby's skin always appears flushed. What does the nurse suspect to be the reason for this condition in the infant?

loss of heat Loss of heat from the infant's body dilates the skin vessels, therefore causing the skin to appear flushed. Loss of water and fluids from the body occurs to prevent overheating complications, such as cerebral damage from dehydration or even heat stroke and death. Increased production of acids results in increased bilirubin levels, which leads to jaundice. If the infant has increased heat production in the body because of sepsis, vessels in the skin are constricted and the skin appears pale.

A newborn's total body response to noise or movement is often distressing to the parents. How would the nurse best explain this response to the parents?

reflex is expected This is the Moro reflex, which indicates an intact nervous system. The Moro reflex continues as long as the third to sixth month of life; if it persists there may be a neurologic disturbance. This reflex has no relationship to hunger; it is an involuntary response to environmental stimuli

A nurse is preparing a client with a ruptured tubal pregnancy for immediate surgery. What type of surgery should the informed consent include?

salpoingectomy The ruptured fallopian tube may be removed rather than repaired; repair of the tube may result in scarring, predisposing the client to another tubal pregnancy. Myomectomy is a procedure for removing leiomyomas (fibroids) from the uterus. The uterus is uninvolved in a tubal pregnancy and does not need to be removed. The ovaries should not be removed, especially if another pregnancy is desired.

A client at 36 weeks' gestation is admitted to the high-risk unit with heavy bleeding because of complete placenta previa. Why does the nurse place the client in a lateral Trendelenburg position?

to prevent shock The Trendelenburg position shunts blood to the upper body and vital organs. The Trendelenburg position will not help control the bleeding. Pressure on the cervix is thought to have no bearing on bleeding episodes. In late pregnancy the placenta does not change its location in the uterus. Also, the Trendelenburg position cannot move the placenta from the cervix.

The nurse is caring for a pregnant client with type 1 diabetes. Which complication is the result of type 1 diabetes?

A) Increased risk of hypertensive states The likelihood of gestational hypertension increases fourfold in the client with diabetes mellitus, probably because of a preexisting vascular disorder. Abnormal implantation occurs because of scarring or uterine abnormalities, not because of diabetes. Most pregnant women have an increased appetite; excessive weight gain may be caused by a macrosomic fetus and hydramnios. More than 2000 mL of amniotic fluid (hydramnios, polyhydramnios) is associated with diabetes; its exact cause is unknown. It also occurs with major congenital fetal anomalies, Rh sensitization, and infections (e.g., syphilis, toxoplasmosis, cytomegalovirus, herpes, and rubella).

A client undergoes anterior and posterior surgical repair of a cystocele and rectocele and returns from the postanesthesia care unit with an indwelling catheter in place. What should the nurse tell the client about the primary reasons for the catheter? Select all that apply

Discomfort is minimized. Retention of urine is prevented. Pressure on the suture line is relieved Distention causes discomfort; this is avoided because the catheter prevents retention. The effects of anesthesia and the inflammatory process may impede voiding, leading to urine retention; an indwelling catheter empties the bladder. Distention places pressure on the suture line; this is avoided because the indwelling catheter prevents retention. Because the bladder is continually empty when an indwelling catheter is in place, it loses tone; this is an expected side effect. Hourly urine output can be easily measured, but this is not necessary; hourly urine output is a reflection of kidney function.

The nurse reports to the primary health care provider that a newborn has hypoglycemia and passes meconium stools until the fifth day. Which intervention does the nurse expect may benefit the newborn?

expressed breastmilk

Which information should the nurse include in the discharge teaching of a postpartum client?

prenatal kegel Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.