ATI Capstone Maternal, Newborn, and Women's Health

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. The finding indicates the newborn is experiencing a complication related to which of the following? Maternal/newborn blood group incompatibility Absence of vitamin K Physiologic jaundice Maternal cocaine abuse

Maternal/newborn blood group incompatibility; Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life.

A nurse is assessing a client who is 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of hypoglycemia? Blurred vision Oliguria Polydipsia Irritability

Polydipsia; The nurse should identify that polydipsia, polyphagia, flushed, dry skin, thirst, and fruity breath are manifestations of hyperglycemia.

A nurse is caring for a client who is in active labor and notes late deceleration in the FHR. Which of the following actions should the nurse take first? Elevate the client's legs. Position the client on her side. Administer oxygen via face mask. Increase the infusion rate of the IV fluid.

Position the client on her side; Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.

A nurse is teaching a client about the proper use of a diaphragm. Which of the following statement to the nurse make? "Have your diaphragm refit if you have a weight fluctuation of 20 percent or more." "You should replace your diaphragm once every 3 years." "You should leave your diaphragm in place for 3 hours after intercourse." "Your bladder should be full before inserting the diaphragm in your vagina."

"Have your diaphragm refit if you have a weight fluctuation of 20 percent or more."; The nurse should instruct the client to have the diaphragm refit for a 20% fluctuation in weight. Also, an annual gynecologic examination is necessary to ensure the proper fit of the diaphragm.

A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by nurse? "Fertilization takes place in the outer third of the fallopian tube." "Implantation occurs between 2 and 3 weeks after conception." "Sperm remain viable in the woman's reproductive tract for 2 to 3 days." "Bleeding or spotting can accompany implantation."

"Implantation occurs between 2 and 3 weeks after conception."; This statement requires clarification because implantation occurs between 6 to 10 days following conception.

A nurse in a provider's office is caring for a client who is 36 weeks gestation and scheduled for an amniocentesis. The client ask why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? "This will determine if there is more than one fetus." "It is useful for estimating fetal age." "It assists in identifying the location of the placenta and fetus." "This is a screening tool for spina bifida."

"It assists in identifying the location of the placenta and fetus."; Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.

A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching? "Refrain from exercises that include stretching." "Moderate exercise improves circulation." "It is recommended to increase your weight-bearing exercises." "It is recommended to rest for 30 minutes before each new exercise."

"Moderate exercise improves circulation."; Improving circulation is just one of the many benefits of moderate exercise during pregnancy. It enhances well-being, promotes rest and relaxation, and improves muscle tone.

A nurse is providing teaching to a client who is 2 days postpartum about breastfeeding their newborn. Which of the following instructions should the nurse include? "Supplement with formula after each breastfeeding session until your milk comes in." "Wash your nipples with soap and water prior to breastfeeding." "Awaken your newborn to breastfeed once every 4 hours during the day." "Observe your newborn for hand-to-mouth motions that indicate hunger."

"Observe your newborn for hand-to-mouth motions that indicate hunger."; Mothers should initiate breastfeeding when the newborn demonstrates early feeding readiness cues, such as rooting and sucking on their fists. Crying is a late feeding cue.

A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching? "The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." "The sex of the baby is determined by week 8 of pregnancy." "Very fine hairs, called lanugo, cover your baby's entire body by week 36 of pregnancy." "You will first feel your baby move in week 24 of pregnancy."

"The baby's heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy."; The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of gestation.

A nurse is providing teaching to the guardian of a newborn about vitamin K administration. Which of the following statements should the nurse make? "This medication will improve your newborn's immune system." "This medication is given to assist your newborn with blood clotting." "This medication will prevent your newborn from developing jaundice." "This medication is an antibiotic used to prevent newborn infections."

"This medication is given to assist your newborn with blood clotting."; Vitamin K is given to prevent hemorrhagic disease in the newborn. It is given because the newborn does not have the intestinal flora to produce vitamin K in the first week following birth.

The nurse is providing teaching about breastfeeding with the client. Identify if the following information is anticipated or contraindicated. Allow the newborn to sleep up to 6 hr between feedings Monitor breasts for redness, tenderness, and pain. Breastfeed newborn at least 8 to 12 times in a 24-hr period. Wash hands prior to breastfeeding. Supplement the newborn twice per day with 2 oz of formula

Anticipated: - Monitor breasts for redness, tenderness, and pain. - Breastfeed newborn at least 8 to 12 times in a 24-hr period. -Wash hands prior to breastfeeding. Contraindicated: - Allow the newborn to sleep up to 6 hr between feedings - Supplement the newborn twice per day with 2 oz of formula

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? Encourage the client to perform Kegel exercises. Encourage the client to move to the left lateral position. Ask the client to rate her pain. Assist the client to the bathroom to void.

Assist the client to the bathroom to void; A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.

A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect? Absent plantar reflexes Lengthened thigh on the affected side Inwardly turned foot on the affected side Asymmetric thigh folds

Asymmetric thigh folds; Gluteal and thigh skin folds that are not equal and symmetric is a sign of DDH.

A nurse providing teaching about potential complications of pregnancy to a client who is at 20 weeks of gestation. The nurse should instruct the client to report which of the following findings to the provider? Abundant amounts of white discharge Varicose veins Periodic numbness of the fingers Blurred vision

Blurred vision; Blurred vision indicates a potential complication of hypertensive conditions or preeclampsia. Therefore, the nurse should instruct the client to report this finding to the provider immediately.

A nurse is reviewing the electronic medical record for a postpartum client who is suspected of having deep vein thrombosis. Which of the following findings is a risk factor for this condition? Alcohol use disorder Cesarean birth Primigravida 23 years of age

Cesarean birth; Cesarean birth almost doubles the risk for deep vein thrombosis.

A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin. The nurse should verify which of the following prior to administration? Client is Rh positive and the newborn is Rh positive. Client is Rh negative and the newborn is Rh negative. Client is Rh negative and the newborn is Rh positive. Client is Rh positive and the newborn is Rh negative.

Client is Rh negative and the newborn is Rh positive.; Rho (D) immunoglobulin contains antibodies to Rho (D). Administering it prevents antibody formation in women who are Rh negative following exposure to Rh positive blood, such as from a fetus who is Rh positive.

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first? Expulsion of a blood-tinged mucous plug Continuous contraction lasting 2 min Pressure on the perineum causing the client to bear down Expulsion of clear fluid from the vagina

Continuous contraction lasting 2 min; A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse is assessing a client who is 4 hour postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? Saturated perineal pad in 30 min Deep tendon reflexes 4+ Fundus at level of umbilicus Approximated edges of episiotomy

Deep tendon reflexes 4+; Deep tendon reflexes 4+ are hyperactive and indicate that the client is at greatest risk for preeclampsia and seizures. The nurse should identify this as the priority finding. The nurse should also monitor for headaches, visual disturbances and epigastric pain. The provider will likely prescribe magnesium sulfate IV infusion.

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? Over-riding suture lines Dilated scalp veins Hypertension A backward sloping appearance of the forehead

Dilated scalp veins; Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement.

A nurse is planning care for a client who is 2 hrs postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? Apply warm, moist heat to the client's lower extremities. Massage the client's posterior lower legs. Place pillows under the client's knees when resting in bed. Have the client ambulate.

Have the client ambulate; Venous stasis is a major cause of thrombophlebitis. To prevent clot formation, have the client ambulate as soon as she can after delivery and as often as possible.

A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has a new prescription for terbutaline. Which of the following findings should the nurse report to the provider prior to administering the medication? History of hyperemesis gravidarum Hypothyroidism History of cardiac disease Renal calculi

History of cardiac disease; The nurse should report a history of cardiac disease to the provider before administering terbutaline to the client. Terbutaline is a beta-adrenergic agonist with adverse effects including tachycardia, hypertension, arrhythmias, and myocardial ischemia.

A nurse is caring for a newborn who is 36 hr old. The parent requests circumcision prior to discharge from the hospital. The nurse should identify that which of the following conditions is a contraindication for a circumcision? Jaundice Hypospadias Epithelial pearls Pendulous scrotum

Hypospadias; Hypospadias is an abnormal positioning of the urethra on the ventral surface of the penis. This condition is a contraindication for a circumcision because the prepuce skin can be needed for surgical repair of the penis.

A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta? Increased blood pressure in the arms with decreased blood pressure in the legs Decreased blood pressure in the arms with increased blood pressure in the legs Increased blood pressure in both the arms and the legs Decreased blood pressure in both the arms and the legs

Increased blood pressure in the arms with decreased blood pressure in the legs; There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.

A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care? Initiate a controlled low-protein diet. Educate parents on blood glucose monitoring. Administer thyroid hormone replacement. Obtain a blood sample for blood type.

Initiate a controlled low-protein diet; PKU is managed by eliminating phenylalanine from the diet. It is found in most natural food proteins, such as milk and infant formulas. A special low-protein, amino-acid formula that is low in phenylalanine is initiated and included in the plan of care.

A nurse in an antepartum clinic is caring for a client who is pregnant the patient tells the nurse" my last menstrual period was June 1st". When using Nagele's rule which of the following date should the nurse identify as the patient expected date of delivery? April 15 April 8 March 15 March 8

March 8; The nurse should identify that March 8th is the client's expected date of delivery. According to Nägele's rule, June 1 minus 3 months, plus 7 days and 1 year equals the expected date of delivery.

A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? Assess client's blood pressure. Assess the bladder for distention. Massage the client's fundus. Prepare to administer a prescribed oxytocic preparation.

Massage the client's fundus; The initial management of excessive uterine bleeding is firm massage of the uterine fundus. This action stimulates contraction of the uterine muscles, which constrict the maternal uterine blood vessels.

A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of LR with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include BP 146/95, pulse 80, RR 18. The nurse reviews the prescriptions from the provider. Which of the following prescriptions from the provider. Which of the following prescriptions requires clarification? Methylergonovine 0.2 mg IM now. Insert an indwelling urinary catheter. Administer oxygen by nonrebreather mask at 5 L/min. Obtain laboratory study of prothrombin and partial thromboplastin time.

Methylergonovine 0.2 mg IM now; Methylergonovine is contraindicated in the client with a blood pressure greater than 140/90 mm Hg. This prescription requires clarification.

A nurse is caring for a preterm newborn who has nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following? Overstimulation Necrotizing enterocolitis Need for placement of a gastrostomy tube Intraventricular hemorrhage

Necrotizing enterocolitis; Premature newborns who are formula fed are much more likely to contract this acute inflammatory disease of the gastrointestinal mucosa.

A nurse is assessing a client who is at 27 weeks of gestation. Which of the following findings should the nurse identify as manifestations of placenta previa? Polyuria Abdominal tenderness Painless, bright red vaginal bleeding Firm abdomen on palpation

Painless, bright red vaginal bleeding; Painless, bright red vaginal bleeding is a manifestation of a placenta previa.

A nurse is preparing the client for a forceps-assisted birth. Which of the following actions should the nurse take immediately prior to the procedure? Assess the client's temperature. Palpate the client's bladder for distention. Apply oxygen at 10 L/min via facemask for the client. Administer terbutaline to the client.

Palpate the client's bladder for distention; The bladder should be palpated and emptied via catheterization, if indicated, just prior to a forceps-assisted birth. This action will minimize the risk of injury to the client's bladder.

A nurse is assessing a client for postpartum infection. Which of the following finding should indicate to the nurse that the client requires further evaluation for endometritis? Moderate amount of dark red lochia with a bloody odor A localized area of breast tenderness Pelvic pain Hematuria

Pelvic pain; Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.

A nurse is planning care for a client who is at 16 weeks of gestation and has a positive rapid plasma reagin (RPR). Which of the following medications should the nurse expect to administer? Penicillin G Azithromycin Ceftriaxone Acyclovir

Penicillin G; The nurse should plan to administer penicillin G to the client. A positive RPR indicates that the client has syphilis. Penicillin G is recommended for the treatment of primary, secondary, and early latent stage syphilis.

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients BP is 80/40 mmHg and the fetal HR is 140/min. Which of the following is the priority nursing action? Elevate the client's legs. Monitor vital signs every 5 min. Notify the provider. Place the client in a lateral position

Place the client in a lateral position; Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? Abruptio placentae Placenta previa Precipitous labor Threatened abortion

Placenta previa; Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.

A nurse is reviewing the electronic medical record of a client who is at 37 weeks of gestation and has a new prescription for an oxytocin challenge test. Which of the following conditions should the nurse identify as a contraindication for performing this test? Diabetes mellitus Placenta previa Hypertension Oligohydramnios

Placenta previa; The nurse should identify that placenta previa is a contraindication for performing an oxytocin challenge test. An oxytocin challenge test stimulates uterine contractions, which could cause a client who has placenta previa to bleed and result in an emergency cesarean birth.

A nurse is providing teaching to the mother of a newborn born small for gestational age.Which of the following should the nurse include as a possible cause of this condition? Placental insufficiency Preterm delivery Fetal hyperinsulinemia Perinatal asphyxia

Placental insufficiency; Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.

A nurse on the postpartum unit is caring for a group of clients with an AP. which tasks should the nurse delegate to the AP? Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Observe an area of redness on the breast of a client who is 1 day postpartum. Monitor vital signs during admission of a client who has gestational hypertension. Change the perineal pad of a client who just transferred from labor and delivery.

Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum; Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment.

A nurse is caring for a client who is at 18 weeks gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? Ballottement Lightening Quickening Chloasma

Quickening; Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement.

A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? Remove the hood every hour for 10 min to facilitate bonding. Insert an orogastric tube for decompression of the stomach. Place the newborn in Trendelenburg position. Maintain oxygen saturations between 93% to 95%.

Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%.

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? Diminished deep-tendon reflexes Respiratory rate of 16/min Urine output of 50 mL in 4hr Heart rate of 56/min

Respiratory rate of 16/min; The client's respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes bradypnea. Based on this finding, the nurse may continue the infusion.

A nurse providing discharge teaching to a postpartum client about findings that should be reported to the provider. Which of the following information to the nurse include? Saturation of perineal pads between 3 and 7 days after birth Dark red vaginal drainage between 1 and 3 days after birth Oral temperature between 37.2° and 37.6° C (99° and 99.7° F) Breast swelling between 3 and 5 days after birth

Saturation of perineal pads between 3 and 7 days after birth; The client should notify the provider of saturation of perineal pads with moderate lochia rubra that occurs between 3 and 7 days after birth. During this time, the lochia flow should decrease and change to a light pink color (serosa). The cause of the increased bleeding should be investigated by the provider.

A nurse is caring for a client who is at 28 weeks of gestation and is experiencing preterm labor. The client has a new prescription for betamethasone. Which of the following should the nurse identify as the intended effect of this medication? Stimulating fetal lung maturity Stabilizing fetal blood glucose Inhibiting maternal uterine contractions Increasing maternal amniotic fluid volume

Stimulating fetal lung maturity; Betamethasone is a glucocorticoid given to clients who are experiencing preterm labor. It stimulates fetal lung maturity by promoting the release of enzymes that should induce the production of lung surfactant. It is given between 24 and 34 weeks of gestation to prevent or reduce neonatal respiratory distress syndrome.

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? Suction the nose with a bulb syringe. Suction the mouth with a bulb syringe. Use a suction catheter with low negative pressure. Turn the newborn on his side.

Suction the mouth with a bulb syringe; The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.

A nurse is assessing a postpartum client and notes a boggy fundus that is displaced to the right lateral side. Which of the following conditions should the nurse identify as a risk factor for uterine atony? Urinary retention Sexually transmitted infection Diabetes mellitus Previous stillborn fetus

Urinary retention; Urinary retention can cause uterine atony and hemorrhage. If the nurse palpates a boggy fundus that is displaced to the right lateral side, this indicates the client has a full bladder. The nurse should assist the client to empty the bladder or insert an indwelling urinary catheter. The nurse should also massage the uterine fundus to expel clots and promote firmness.

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 11 lb 6 oz. (5160 g). The nurse should recognize that this client is at risk for which of the following postpartum complications? Puerperal infection Retained placental fragments Thrombophlebitis Uterine atony

Uterine atony; A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes Lidocaine gel to the umbilical stump Haemophilus influenza type b immunization (Hib)

Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes Vitamin K injection is correct. Vitamin K is administered by a single intramuscular injection of 0.5 to 1 mg soon after birth to prevent hemorrhagic disease of the newborn. Vitamin K is not present in the gastrointestinal tract of the newborn, but production will begin at about 7 days of age as bacteria begin to form in the intestines.Hepatitis B immunization is correct. Hepatitis B immunization is recommended at birth, 1 to 2 months, and between 6 to 18 months. It is injected intramuscularly soon after birth. For newborns born to hepatitis-infected mothers, hepatitis B immune globin (HBIG) also should be administered within 12 hr of birth. The vastus lateralis is the preferred site of intramuscular injections in newborns, and no more than 0.5 mL should be administered in one injection. Parental consent must first be obtained prior to the administration of this immunization.Antibiotic ointment to both eyes is correct. Due to the risk of eye infections to newborns born to women who have vaginal infections (e.g., chlamydia, gonorrhea), the instillation of prophylactic antibiotics is mandatory in the United States. The medication used is dependent upon facility protocols but is usually erythromycin or tetracycline ophthalmic ointment. It is administered into both eyes within 1 to 2 hr after birth. It should be applied from inner canthus to outer canthus, being careful not to touch the eye. After 1 min, the excess ointment can be wiped off.Lidocaine gel to the umbilical stump is incorrect. A clamp is applied to the umbilical cord immediately following birth and removed in about 24 hr, or when the cord has dried sufficiently that bleeding is no longer an issue. The cord is not painful. There is no indication for lidocaine gel.Haemophilus influenz