ATI Maternity Practice
APGAR score
Physiological assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the new born arrives in the nursery.
A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for med administration? "This meed will stop your labor" "This med stimulates fetal lung maturity" "This med will decrease your risk for uterine infections" "This med will increase your baby's weight"
"This med stimulates fetal lung maturity" The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? A client who has gestational diabetes and a fasting blood glucose of 120 mg/dL A client who is at 34 weeks of gestation and reports epigastric pain A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
A client who is at 34 weeks of gestation and reports epigastric pain -When using the urgent vs non urgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.
Position for NST
Semi-Fowler's or sitting position and tilted to the right or left to prevent supine hypotension and promote uterine perfusion
A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? Acrocyanosis of the extremities Murmur at the left sternal border Substernal chest retractions Positive Babinski reflex
Substernal chest retractions while sleeping -Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment. and interventions by the nurse. The other options are expected findings.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? O2 saturation Temp BP Urinary output
Temp -The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.
A nurse is providing dietary teaching to a client who has hyperemsis gravidarum. Which of the following statements by the client indicates understanding of the teaching? "I will eat foods that taste good instead of balancing my meals." "I will avoid having a snack before I go to bed each night." "I will have a cup of hot tea with each meal." "I will eliminate products that contain dairy from my diet."
"I will eat foods that taste good instead of balancing my meals." -Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. -Avoid going to bed on an empty stomach. Eat a healthy snack before bed. -Alternate liquids and solids every 2 to 3 hours to avoid an empty stomach and overfilling at each meal. -Encourage consumption of dairy products because they are less likely to cause nausea than other foods.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? Decreased platelet count Increased erythrocyte sedimentation rate (ESR) Decreased megakaryocytes Increased WBC
Decreased platelet count -A client who has ITP has an autoimmune response that results in a decreased platelet count. Increased ESR would indicate chronic renal failure. A patient with ITP would have megakaryocytes within the expected reference range. Increased WBC indicates infection.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? SOB when climbing stairs Swelling of feet and ankles at the end of the day Headache that is unrelieved by analgesia Braxton Hicks contractions
Headache that is unrelieved by analgesia -A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.
A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients? Calcium Vitamin E Iron Vitamin D
Iron -The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? Just above the umbilicus Just above the symphysis pubis The right lower quadrant The left lower quadrant
Just above the symphysis pubis -At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? Place a client in a supine position for 30 min following the first dose of anesthetic solution Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution
Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution -The nurse should plan to obtain a baseline BP to the initiation of anesthetic solution. The nurse should then continue to monitor the client's BP every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.
A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the med. For which of the following findings should the nurse instruct the client to notify the provider? SOB Breakthrough bleeding Vomiting Breast tenderness
SOB -The nurse should instruct the client to notify the provider immediately of any SOB. SOB and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches blurred vision and severe leg pain.
A nurse is calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? September 3 September 20 August 3 August 20
September 3 -When using Nagele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3.
A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? Insert the syringe tip before compressing the bulb. Suction each of the nares before suctioning the mouth. Insert the tip of the syringe into the center of the newborn's mouth. Stop suctioning when the newborn's cry sounds clear.
Stop suctioning when the newborn's cry sounds clear. -The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (SATA) Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder
Cholecystitis, hypertension, migraine headaches -A history of gallbladder disease, migraine headaches and hypertension are all contraindications for the use of oral contraceptives.
A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? "You can miss your period for several other reasons. Describe your typical menstrual cycle" "If you have been sexually active and haven't used protection, it is likely that you are pregnant" "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" "Because you have missed your period, you should try taking a home pregnancy test before you start worrying"
"You can miss your period for several other reasons. Describe your typical menstrual cycle" -Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.
A nurse caring for a newborn who was transferred to the nursey 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? Confirm the newborn's APGAR score. Verify the newborn's identification. Administer vitamin K to the newborn. Determine obstetrical risk factors.
Verify the newborn's identification. -When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.
Descent phase of labor
Characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.
Active phase of labor
Characterized by cervical dilation of 4-7 cm and contractions every 3-5min, each lasting 40-70 seconds.
A nurse is reviewing the lab report of a newborn who is at 24 hours old. Which of the following results should the nurse report to the provider? Hgb 20g/dL Total bilirubin 5mg/dL Blood glucose 30mg/dL
Blood glucose 30 mg/dL
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Decreased heart rate Chin quivering Pinpoint pupils Slowed respirations
Chin quivering -Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. Other indications of pain include increase in heart rate, dilation of the pupil's, and rapid/shallow respirations.
A nurse in the antepartum clinic is assessing a client's adaption to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following? Emotional lability Focusing phase Cognitive restructuring Couvade syndrome
Emotional lability -The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of this med? SATA Flaccid uterus Cervical laceration Excess vaginal bleeding Increased afterbirth cramping Increased maternal temperature
Flaccid uterus, excess vaginal bleeding -Because oxytocin increases uterine contractility
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? Restrict hourly fluid intake to 150 mL/hr. Have calcium gluconate readily available. Assess deep tendon reflexes every 6 hours. Monitor intake and output every 4 hours.
Have calcium gluconate readily available. -To prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. Restrict hourly fluid intake to no more than 125 mL/hr. Urine output should be 30mL/hr or greater. Assess deep tendon reflexes every 1 to 4 hours during continuous infusion of mag sulfate. Monitor intake and output hourly
A nurse is reviewing the lab results for a client who is at 10 weeks of gestation. Which of the following lab findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 15,000/mm RBC count 5.8 million/mm Hematocrit 34%
Hemoglobin 10 g/dL -A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this lab finding to the provider.
A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? Jitteriness Hypertonia Abdominal distention Mottling
Jitteriness -Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? Oligohydramnios Hyperemesis gravidarum Leukorrhea Periodic tingling of the fingers
Oligohydramnios -The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, IUGR, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.
A nurse is including discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include? Place the shoulder harness in the slots above the newborn's shoulders. Place the retainer clip at the level of the newborn's armpits. Place the newborn at a 60 degree angle in the car seat. Place the newborn in a blanket before securing them in the car seat.
Place the retainer clip at the level of the newborn's armpits. -The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpit's.
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following lab results should the nurse report to the provider? Hct 39% Serum albumin 4.5 g/dL WBC 9,000/mm3 Platelets 50,000/mm3
Platelets 50,000/mm3 -This platelet count is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor? Active Transition Latent Descent
Transition -The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.
A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? "You will need to drink the glucose solution 2 hours prior to the test." "Limit your carb intake for 3 days prior to the test." "A blood glucose of 130 to 140 is considered a positive screening result." "You will need to fast for 12 hours prior to the test."
"A blood glucose of 130 to 140 is considered a positive screening result." -The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.
A nurse is teaching a client who has pregestational type 1 DM about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should have a goal of maintaining my fasting blood glucose between 100 and 120" "I should engage in moderate exercise for 30 mins if my blood glucose is 250 or greater" "I will continue taking my insulin if I experience nausea and vomiting" "I will ensure that my bedtime snack is high in refined sugar"
"I will continue taking my insulin if I experience nausea and vomiting" -The nurse should teach the client to continue to take her insulin. as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? "I will get injections of the med once daily until my labor stops" "My blood sugar may be low while I'm on this med" "I will have blood tests because my potassium might decrease" "My blood pressure may increase while on this med"
"I will have blood tests because my potassium might decrease" -An adverse effect of terbutaline is hypokalemia Other adverse effects include hyperglycemia and hypotension and it is administered subq every 4 hours for no longer than 24 hr
A nurse is teaching a client who is Rh-negative about Rh(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? "I will receive this medication if my baby is Rh-negative" "I will receive this medication when I am in labor" "I will need a second dose of this med when my baby is 6 weeks old" "I will need this med if I have an amniocentesis"
"I will need this med if I have an amniocentesis." -Rh(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBC's entering the maternal circulation. (Administer at 28 weeks to clients who are Rh-negative or following the birth of a newborn who is Rh-positive)
A nurse is teaching a postpartum client about the steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? "The nurse will carry your newborn to the nursery for procedures." "We will document the relationship of visitors in your medical record." "Your baby will stay in the nursery while you are asleep." "Staff members who take care of your baby will be wearing a photo ID badge."
"Staff members who take care of your baby will be wearing a photo ID badge." -Nurse should instruct the client that all staff members that care for newborns are required to wear a photo ID badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.
A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? "I think that is something you should discuss with your doctor." "This procedure should have no effect on your sexual performance or adequacy." "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." "If this concerns you, perhaps you should reconsider and use another form of contraception."
"This procedure should have no effect on your sexual performance or adequacy." -The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function.
A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? "You can share your room with your baby for the next few weeks." "Cover your baby with a light blanket while sleeping." "Check the temperature of your baby's bath water with your hand." "Your baby can nap in the car seat during the daytime."
"You can share your room with your baby for the next few weeks." -The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct thee parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? "You should replace the diaphragm every 5 years." "You should leave the diaphragm in place for at least 6 hours after intercourse." "You should use an oil-based product as a lubricant when inserting the diaphragm." "You should insert the diaphragm when your bladder is full."
"You should leave the diaphragm in place for at least 6 hours after intercourse." -The client should keep the diaphragm in place for at least 6 hours after intercourse to provide protection against pregnancy.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? "You should take the med within 72 hours following unprotected sex" "You should avoid taking this med if you are on an oral contraceptive" "If you don't start your period within 5 days of taking this med, you will need a pregnancy test" "One dose of this med will prevent you from becoming pregnant for 14 days after taking it"
"You should take the med within 72 hours following unprotected sex" -Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this med as soon as possible within 72 hr after unprotected sex.
A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? "You will receive IV fluids prior to the test." "The procedure will take approximately 10 to 15 mins." "You will be offered orange juice to drink during the test." "You will need to sign an informed consent form each time you have this test."
"You will be offered orange juice to drink during the test." -A NST is performed to measure fetal activity. Having the client drink oj or another bev high in glucose will stimulate fetal movement during the procedure, helping to obtain results. IV fluids are initiated for an oxytocin-stimulated contraction test, not a NST. The procedure takes 20-40 mins. It is a noninvasive procedure.
A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hours. Which of the following statements should the nurse make? "Let me help you into a comfortable pushing position so you can begin bearing down." "I am going to call the doctor to get a prescription for medication to open your cervix." "I will give you some IV pain medicine to strengthen your contractions." "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."
"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." -Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor. The client should not start bearing down until the second stage of labor. Cervical ripening agents are not used during the active stage of labor. Administering IV pain meds can decrease the intensity of uterine contractions.
Diaphragm
-Client should be properly fitted by a provider. -Replace every 2 years. -Avoid oil-based products because they can weaken the rubber in the diaphragm. -The client should have an empty bladder prior to inserting the diaphragm. -Prior to sex the diaphragm is inserted vaginally over the cervix with spermicidal jelly or cream that is applied to the cervical side of the dome and around the rim. -Spermicide must be reapplied every time they **** -Diaphragm should be washed with mild soap and warm water after each use.
Vitamin K administration for infant
-The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. -Injection can be delayed until after initial bonding time and first breastfeeding if necessary. -Vitamin K is not produced in the GI tract of the newborn until around day 7. -Vitamin K is produced in the colon by bacteria that forms once formula or breast milk is introduced into the gut of the newborn. -Administer 0.5 to 1 mg IM into the vastus lateralis (where muscle development is adequate) within 1 hr after birth. -Do NOT give vit K and hep B injections in the same thigh. Alternate sites.
A nurse is reviewing lab results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? Bilirubin 9 mg/dL Hemoglobin 18 g/dL Platelets 175,0000/mm Hematocrit 45%
Bilirubin 9 mg/dL -A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old if 2 to 5 mg/dL. The nurse should report this finding to the provider.
A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? Review below Diagnostic results: Lecithin/sphinogomyelin (L/S) ratio 1.4:1 ; Phosphatidylglycerol (PG) absent; ABO-Rh B-negative Med Administration record: Terbutaline 0.25 mg SQ every hr PRN contractions; Rho(D) immune globulin 300 mcg IM once; Nalbuphine 10 mg IV every 3 hr PRN pain Progress Report: 1655 Amniocentesis completed, trocotransducer and external fetal monitor applied 1700 FHR 130/min moderate variability, uterine contractions q 5 to 8 min lasting 30-60 sec duration, uterine contractions palpated at 1+ intensity, client reports uterine contraction pain 2 on scale of 1-10 -Administer terbutaline -Discuss possible genetic anomalies with the client -Administer nalbuphine -Discontinue external fetal monitoring
Administer terbutaline -The nurse should administer terbutaline to stop contractions because the lab results indicate that the fetus's lungs are not mature enough for birth.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacologic interventions should the nurse include in the plan of care for lactation suppression? Place warm, moist packs on the breasts. Apply cabbage leaves to thee breasts. Wear a loose-fitting bra. Put green tea bags on the breasts.
Apply cabbage leaves to the breasts. -Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. Cold compresses can decrease breast discomfort during lactation suppression. A tight-fitting bra will support the breasts during engorgement, decreasing pain. Tea bags are used to relieve nipple soreness.
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? Place a rolled towel beneath one of the client's hips Apply internal upward pressure to the presenting part using two gloved fingers Administer oxygen to the client via a nonrebreather mask at 10 L/min Increase the IV infusion rate
Apply internal upward pressure to the presenting part using two gloved fingers -Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? Reassess the client in 2 hr. Administer simethicone. Assist the client to empty her bladder. Instruct the client to lie on her right side.
Assist the client to empty her bladder. -The nurse should assist the client to empty her bladder because the assessment findings indicate that the clients bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.
A nurse is caring for a client who is at 41 weeks of gestation and has has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? Percutaneous umbilical blood sampling Amnionfusion Biophysical profile (BPP) Chorionic villus sampling (CVS)
BPP -The nurse should prepare the client for a. BPP to further assess fetal well-being. A positive contraction stress test indicates there is a potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and psychological characteristics of the fetus and observe for fetal biophysical responses to stimuli.
Latent phase of labor
Characterized by cervical dilation of 0-3 cm and contractions every 5 to 30 min, each lasting 30-45 seconds.
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Cover the newborn's eyes while under the phototherapy light Keep the newborn in a shirt while under the phototherapy light Apply a light moisturizing lotion to the newborn's skin Turn and reposition the newborn every 4 hr while undergoing phototherapy
Cover the newborn's eyes while under the phototherapy light -Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and her partner. Repeat information to ensure client understanding. Listen to the client and her partner as they reflect upon the birth experience. Demonstrate to the client how to perform a newborn bath.
Demonstrate to the client how to perform a newborn bath. -Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? Determine respiratory function. Increase the IV fluid rate. Access emergency medications from cart. Collect a maternal blood sample for coagulopathy studies.
Determine respiratory function. -The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. The nurse should increase the IV fluid rate to maintain circulation, butt it is not the priority. The nurse should access emergency meds for resuscitative efforts. The nurse should collect a blood sample in prep for a blood transfusion, but not the priority action.
A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation of her forehead. Which of the following actions should the nurse take? Tell the client to follow up with a dermatologist. Explain to the client this is an expected occurrence. Instruct the client to increase her intake of vitamin D. Inform the client she might have an allergy to her skin care products.
Explain to the client this is an expected occurrence. -Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. Seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, nurses should reassure the client that this is an expected occurrence which usually fades after delivery.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? Large for gestational age Hyperglycemia Bradypnea Vomiting
Vomiting -Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
Betamethasone
Given to enhance fetal lung maturity for clients who are experiencing preterm labor between 24 and 34 weeks of gestation
A nurse is caring for a client who is at 35 weeks gestation and has placenta previa. Which of the following actions should the nurse take? Perform a vaginal exam to determine cervical dilation every 2 hr. Instruct the client to ambulate in the hallway once every 4 hr. Administer betamethasone to the client via IM injection. Initiate continuous external fetal monitoring.
Initiate external fetal monitoring. -The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor lab values. Also, the nurse should implement interventions to prepare for an emergency bath.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? Maintain the client NPO throughout the procedure. Place the client in a supine position. Instruct the client to massage the abdomen to stimulate fetal movement. Instruct the client to press the provided button each time fetal movement is detected.
Instruct the client to press the provided button each time fetal movement is detected. -Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? Increased fetal movement Leakage of fluid from the vagina Upper abdominal discomfort Urinary frequency
Leakage of fluid from the vagina -Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. Decreased fetal movement is a potential complication to be reported to the provider. Upper abdominal discomfort and urinary frequency are not potential complications associated with an amniocentesis
A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? LUQ RUQ LLQ RLQ
Left lower quadrant -The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. (Positions:) LSA= LUQ RSA= RUQ ROA= RLQ
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which or the following actions should the nurse take next? Massage the client's fundus Insert an indwelling urinary catheter Administer oxygen at 10 L/min Elevate the client's right hip
Massage the client's fundus -The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.
Sequence of steps to perform Leopold maneuvers
Palpate the fundus to identify the fetal part. Determine the location of the fetal back. Palpate for the fetal part presenting at the inlet. Identify the attitude of the head.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? Swelling of the face Varicose veins in the calves Nonpitting 1+ ankle edema Hyperpigmentation of the cheeks
Swelling of the face -Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. (Varicose veins would be an expected finding in the 2nd trimester, nonpitting edema of lower extremities and hyperpigmentation are expected findings of the 3rd trimester)
A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? Persistent abdominal striae Temp 37.8 C (100 F) Unilateral breast pain Brownish-red discharge day 5
Unilateral breast pain -Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider. (Persistent abdominal striae is an expected postpartum finding, temp above 38 C could be indicative of infection, and brownish red discharge is expected days 3-10 postpartum)
