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Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?

: Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?

A client who has salicylate intoxication

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?

Abruptio placenta

A nurse is caring for a client who is in labour. Which of the following findings should prompt the nurse to reassess the client?

An urge to have a bowel movement during contractions.

A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?

Assess the newborn's latch while breastfeeding.

A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

At the level of the umbilicus

A nurse is assessing a client who is at 12 weeks of gestation. The nurse should report which of the following findings to the provider as an indication of an imminent spontaneous abortion?

Cervical dilation.

A nurse is assessing a full-term newborn. Which of the following findings should the nurse report to the provider?

Blood pressure 80/50 mm Hg.

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?

Blurred vision

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

Cleanse the site with povidone-iodine.

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?

Expect two to four wet diapers every 24 hr.

A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

Increased muscle weakness.

A nurse in the labour and delivery unit is planning care for a client who has human immunodeficiency virus (HIV). Which of the following is an appropriate action for the nurse to take following the birth of the newborn?

Initiate contact precautions for the newborn.

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption? Which of the following laboratory tests should the nurse expect the provider to prescribe?

Kleihauer-Betke test

A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?

Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress

A nurse is providing teaching about increasing dietary fibre to an antepartum client who reports constipation. Which of the following food selections has the highest fibre content per cup?

Lentils.

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Perform fundal massage

A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect?

Sharp pelvic pain.

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Subconjunctival hemorrhage.

A nurse is caring for a newborn. Which of the following assessment findings should indicate to the nurse that suctioning of the nasopharynx is needed?

The newborn's respiratory rate is irregular.

A nurse is teaching a newly licensed nurse about the uses of ultrasonography in the first trimester of pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Ultrasound is used to determine gestational age in the first trimester.".

A nurse is teaching a prenatal client about listeriosis and dietary modifications during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I can eat grilled chicken on a bun at lunchtime.".

A nurse is providing teaching to a postpartum client who has type 1 diabetes mellitus and is breastfeeding her newborn. Which of the following instructions should the nurse give the client?

"Maintain scheduled mealtimes for yourself.".

A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?

Facial petechiae

A nurse is preparing to palpate the uterine fundus of a client who is at 22 weeks of gestation to measure fundal height. At which of the following locations should the nurse expect to find the fundus?

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part

A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concern about preparing her 2-year-old child for a new sibling. Which of the following is an appropriate response by the nurse?

Let your toddler see you carrying the baby into the home for the first time.".

Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?

Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white

A nurse is assessing the reflexes of a term newborn. After placing the newborn in the supine position, which of the following methods should the nurse use to elicit the Moro reflex?

Make a loud noise above the newborn.

A nurse is caring for a client who is experiencing uterine atony immediately following delivery. The client fails to respond to oxytocin administration. The nurse should anticipate the use of which of the following medications?

Methylergonovine.

A nurse is performing a nonstress test on a client who is at 35 weeks of gestation and has diabetes mellitus. The test reveals no accelerations of fetal heart rate for 20 min. Which of the following actions should the nurse take?

Perform vibroacoustic stimulation.

A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching?

Place newborn bassinets at least 3 feet apart.

A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?

Position the client in a knee-chest position

A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

Uterine tenderness.