ATI PN Maternal Newborn Online Practice 2020 A with NGN

A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and reports having constipation. Which of the following information should the nurse include? a. Consume 28 g of fiber per day. b. Decrease daily protein intake. c. Use laxatives daily. d. Drink 1 L of fluid per day.

a. Consume 28 g of fiber per day

A nurse is reviewing the prenatal record of a client who is 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome. a. Negative rubella titer b. Reactive nonstress test c. 1-hr glucose tolerance screening test result of 150 mg/dL d. Hemoglobin 9.5 g/dL

b. Reactive nonstress test The nurse should identify that a reactive nonstress test indicates fetal well-being and is a desirable outcome.

A nurse is assisting in the care of a newborn who is 24 hr old. Complete the following sentence by using the list of options

The newborn is at greatest risk for developing hypoglycemia as evidenced by the newborn's temperature The newborn has the greatest risk of developing hypoglycemia due to heat loss. The newborn will attempt to warm themselves by increasing their basal metabolic rate, which can result in depletion of glucose stores. The newborn's temperature is below the expected range of 36.5° to 37.5° C (97.7° to 99.5° F). In response to a low body temperature, a sequence of metabolic and physiological changes occur as the body diverts oxygen and energy from the brain and heart. Dehydration is incorrect. The newborn is breastfeeding within the expected guidelines of 8 to 12 times per day. The newborn has voided within the expected reference range of at least two wet diapers per day for the first 2 days of life. While the newborn could potentially develop dehydration, they are at a greater risk for developing another condition. Sepsis is incorrect. The newborn has no identified risk factors for developing sepsis. Risk factors for neonatal sepsis include prematurity, prolonged rupture of membranes, resuscitation after birth, and maternal GBS colonization. While the newborn could potentially develop sepsis, they are at a greater risk for developing another condition.. Neonatal abstinence syndrome (NAS) is incorrect. The urine toxicity screen was negative at 37 weeks of gestation. While the newborn could still potentially develop NAS if the birthing parent used opioids, they are at a greater risk for developing another condition. Peripheral perfusion is incorrect. Mottling of the extremities and acrocyanosis is a physiological response by the newborn to conserve internal heat by constricting peripheral blood vessels. Uric acid crystals are incorrect. Uric acid crystals are an expected finding during the first week of life. Reflexes are incorrect. The presence of a Moro reflex is an expected finding at birth. This reflex is usually elicited in response to the newborn being startled or experiencing a sensation of falling.

The nurse reinforced the discharge teaching with the adolescent. For each of the statements made by the adolescent, click to specify whether the statement indicates an understanding or requires reinforcement of education.

Understanding: A. "I should continue taking all my medications even if I don't show any symptoms." The nurse instructed the adolescent to complete all of their medications, even if they begin to feel better. B. "If I continue to get this type of infection, it can affect my ability to have kids in the future." The nurse instructed the adolescent that repeated instances of PID can cause infertility. E. "I'm more likely to get a sunburn while taking these medications." The nurse informed the adolescent that they might experience increased sensitivity to sunlight while using doxycycline and that they should use sunscreen and wear protective clothing while taking the medication. Reinforcement of Education Needed: C. "I should go to the emergency department if my urine turns dark."The nurse informed the adolescent that while taking metronidazole their urine might turn dark, they should not be alarmed because dark urine is an adverse effect of taking this medication. D. "As long as I keep my IUD, I don't need to use condoms." The nurse informed the adolescent that they should use a condom to decrease the risk of contracting an STI; IUDs effectively prevent pregnancy, not STIs.

A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first? a. A client who is at 37 weeks of gestation and reports a persistent headache. b. A client who is at 38 weeks of gestation and reports irregular uterine contractions. c. A client who is at 12 weeks of gestation and reports abdominal cramping. d. A client who is at 26 weeks of gestation and reports periodic numbness in the fingers.

a. A client who is at 37 weeks of gestation and reports a persistent headache. When using the urgent vs. non-urgent approach to care, the nurse should determine that the priority finding is a client who is at 37 weeks gestation and reports a persistent headache. The nurse should identify that a persistent headache is a manifestation of preeclampsia and recommend that the provider see this client first.

A nurse in a clinic is caring for a 16-year-old adolescent Which of the following findings should the nurse report to the provider? Adolescent is sexually active with two current partners.IUD in place. Reports not using condoms during sexual activity. History of type 1 diabetes Select all that apply. a. Abdominal assessment b. Vaginal discharge c. Heart Rate d. Temperature e. Dyspareunia

a. Abdominal assessment Correct. Abdominal tenderness with palpation is not an expected finding with an abdominal assessment. Therefore, this finding should be reported to the provider. b. Vaginal discharge Correct. Greenish vaginal discharge indicates that the adolescent has an infection, which is not an expected finding. Therefore, this finding should be reported to the provider c. Heart rate Incorrect. The client's heart rate of 100/min is within the expected reference range. Therefore, this finding does not need to be reported to the provider. d. Temperature Correct. The client's temperature of 38.3° C (101° F) is above the expected reference range. An elevated temperature could signal infection or inflammation. Therefore, this finding should be reported to the provider. e. Dyspareunia Correct. Dyspareunia is painful intercourse, which can be associated with STIs. Therefore, this finding should be reported to the provider.

A nurse is caring for a client during the postpartum period. Which of the following findings should the nurse expect during the first 24 HR following birth? a. Diuresis b. Soft, boggy uterus upon palpation c. Discharge of clear, yellow fluid from the breasts d. Lochia serosa e. Lower abdominal cramping

a. Diuresis This is an expected finding that results from the loss of excess fluid that is retained during pregnancy. c. Discharge of clear, yellow fluid from the breasts; This fluid, called colostrum, is an expected finding in the postpartum period. Colostrum is present for 3 to 5 days until the mother's milk appears and can leak from the breasts beginning in the third trimester of pregnancy. e. Lower abdominal cramping This is an expected finding and results from the contraction of the uterus as it decreases in size.

A nurse is caring for a newborn. For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn. Physical Examination: 1830: Absent Moro reflex noted in right arm.Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated with wrist and fingers flexed.Positive palmar grasp reflex bilaterally.Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis. Which of the following actions should the nurse plan to implement? a. Remind the parents to begin range-of-motion (ROM) exercises on the affected arm after 1 week. b. Check grasp reflex. c. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. d. Reinforce to parents to limit physical handling for 2 weeks.

a. Remind the parents to begin range-of-motion (ROM) exercises on the affected arm after 1 week. Indicated Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. b. Check grasp reflex. Indicated With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should check for a palmar grasp reflex. c. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. Indicated Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning their sleeve to their shirt. d. Reinforce to parents to limit physical handling for 2 weeks. Contraindicated. Parents need to participate in the physical care of their newborn to increase parental-infant attachment. Reinforcing teaching and providing practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.

A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the following findings should the nurse report to the provider? a. Uterine contraction b. Fetal Heart Rate c. Gestation age d. Vaginal examination e. Client's Blood Pressure

a. Uterine contractions is correct. The client is experiencing regular uterine contractions and cervical change, which are indicators of preterm labor. Therefore, the nurse should notify the provider about this finding. b. Fetal heart rate is incorrect. The fetal heart rate is within the expected reference range. Therefore, the nurse should not report this finding to the provider. c. Gestational age is correct. The client is at 32 weeks of gestation and is experiencing regular uterine contractions and cervical dilation, which indicates that the client is in preterm labor. Therefore, the nurse should notify the provider about this finding. d. Vaginal examination is correct. The client's cervix is dilated to 2 cm and is 50% effaced, which indicates the client is in preterm labor. Therefore, the nurse should notify the provider about this finding. e. Client's blood pressure is incorrect. The client's blood pressure is within the expected reference range. Therefore, the nurse should not report this finding to the provider.

A nurse is reinforcing family planning options with a client who is requesting information about contraceptives. Which of the following client statements indicates an understanding of the teaching? a. "The diaphragm should be removed 2 hours after having intercourse." b. "I can use water-soluble lubricant when my partner wears a latex condom." c. "It is okay for me to remove the birth control sponge within 2 hours after having intercourse." d. "When I use the birth control patch, it must be changed once a month."

b. "I can use a water-soluble lubricant when my partner wears a latex condom." Water-soluble lubricants should be used with male latex condoms, because the use of any other lubricant can compromise the integrity of the condom.

A nurse is reinforcing teaching about car seat safety with the parent of a newborn. Which of the following client statements indicates an understanding of the teaching. a. "My baby should be in a rear-facing car seat until he is 6 months old and 15 pounds." b. "If my baby rides in a car with no back seat, the passenger air bag must be turned off." c. "It is dangerous to secure the car seat using the vehicle's seat belts." d. "I will place my baby's car seat at a 90-degree angle in the back seat."

b. "If my baby rides in a car with no back seat, the passenger air bag must be turned off." The nurse should reinforce to the parent that in the event that a newborn cannot ride in the rear seat, the parent must disable the front passenger air bag to prevent potential injuries caused by air bag deployment.

A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the newborn to his daughter's room. Which of the following responses should the nurse make? a. "I'll first need to see your photo ID before I can release the baby to you." b. "Let me wash my hands and then I'll take the baby to his mother." c. "Please wash your hands first, then I'll allow you to carry the baby to your daughter's room." d. "Have your daughter call the nursery so that the staff can release the baby to you."

b. "Let me wash my hands and then I'll take the baby to his mother." Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal-newborn unit should transport newborns.

A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching? a. "We will monitor your blood pressure every 2 hours." b. "Your fluid intake will be limited to no more than 125 milliliters per hour." c. "You might notice that you will begin breathing faster than normal." d. "We will monitor your baby's heart rate once per hour."

b. "Your fluid intake will be limited to no more than 125 milliliters per hour." The nurse should restrict the client's fluid intake to no more than 125 mL per hr to prevent fluid overload

A nurse is assisting with the care of a client who is postpartum and is receiving magnesium sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should the nurse identify as manifestations of magnesium toxicity? a. Hyperreflexia b. Decreased respiratory rate c. Polyuria d. Decreased level of consciousness e. Double vision

b. Decreased respiratory rate Respiratory depression is a manifestation of magnesium sulfate toxicity. d. Decreased level of consciousness is a manifestation of magnesium sulfate toxicity. e. Double vision is a manifestation of magnesium sulfate toxicity.

A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for routine prenatal visist. Which of the following findings in the data from the client's medical records should the nurse report to the provider. a. Weight b. Fundal Height c. Fetal Heart Rate d. Blood Pressure

b. Fundal Height The height of the fundus in centimeters at 20 weeks of gestation is approximately the same as the number of weeks of gestation plus or minus 2 cm. Therefore, a fundal height of 25 cm is greater than the expected finding for 20 weeks of gestation.

A nurse is caring for a client who has received methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication. a. Hyperglycemia b. Hypertension c. Urinary retention d. Hyporeflexia

b. Hypertension Methylergonovine is an oxytocic agent that stimulates uterine contractions and is used for postpartum hemorrhage. It can cause nausea, vomiting, cramping, headache, and dizziness. The nurse should report changes in blood pressure to the provider because methylergonovine can cause both hypertension and hypotension.

A nurse is reviewing the laboratory results of 4 HR-old newborn. Which of the following findings should the nurse report to the provider? a. Hemoglobin 20 g/dL b. Platelet count 120,000/mm3 c. Glucose 50 mg/dL d. WBC count 20,000/mm3

b. Platelet count 120,000/mm3 The nurse should identify that a platelet count of 120,000/mm3 is below the expected reference range of 150,000 to 300,000/mm3 for a newborn. Therefore, the nurse should report this finding to the provider.

A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include? a. Begin giving approximately 240 mL (8 oz) per feeding after the first week. b. Position the bottle at a 45° angle during feedings. c. Ensure that the newborn empties the bottle. d. Wait to burp the newborn until the end of the feeding.

b. Position the bottle at a 45° angle during feedings. The nurse should reinforce with the parents to position the bottle at a 45° angle during feedings to allow the newborn to have more control during feedings and prevent the swallowing of air.

A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following? a. Facilitate the storage of iron in the fetus' liver b. Prevent certain kinds of birth defects c. Inhibit premature labor d. Aid in the absorption of other important nutrients

b. Prevent certain kinds of birth defects. The nurse should inform the client that adequate folic acid intake prior to and early during pregnancy is necessary to help prevent neural tube defects.

A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching? a. "Some assistive personnel might not have name badges." b. "A nurse will carry my baby back to the nursery in their arms for routine care when it is needed." c. "I will ask the nurse to take my baby back to the nursery if I need to leave my room." d. "I can remove my baby's security band before giving her a bath."

c. ."I will ask the nurse to take my baby back to the nursery if I need to leave my room." The nurse should instruct the parent not to leave the newborn unattended. If the parent needs to leave the room, the parent should call the nurse to transport the newborn back to the nursery.

A nurse is reinforcing teaching about food sources that are high in folate with a group of clients who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate. a. 1 cup dried prunes b. 1/2 cup boiled potatoes c. 1/2 cup dried peas d. 1 cup grapes

c. 1/2 cup dried peas Clients who are pregnant should consume 400 mcg of folate per day. One-half cup of dried green split peas provides 127 mcg of folate and is the best of these sources of folate for the nurse to recommend.

A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse report to the provider? a. Calcium 9.2 mg/dL b. Heart Rate 160 BPM c. Blood Glucose 28 mg/dL d. Axillary temperature 36.5° C (97.7° F)

c. Blood glucose 28 mg/dL The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 40 to 45 mg/dL for a newborn. Therefore, the nurse should report this finding to the provider

A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication? a. Fetal lung maturity b. Maternal blood glucose control c. Cessation of uterine contractions d. Resolution of maternal nausea

c. Cessation of uterine contractions Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the smooth muscle of the uterus.

A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting. Which of the following instructions should the nurse include? a. Eat foods that are served hot. b. Drink 360 mL (12 oz) of fluids during mealtimes. c. Consume small meals frequently each day. d. Eat a high-protein snack before getting out of bed.

c. Consume small meals frequently each day. The nurse should instruct the client to eat five to six small meals throughout the day. The client should avoid an empty stomach, as this increases nausea.

A nurse in a prenatal clinic is caring for a client who Is at 16 weeks of gestation and has a positive hepatitis B result. Which of the following actions should the nurse take? a. Instruct the client to avoid crowds until a repeat hepatitis B test is negative. b. Tell the client that they will need to start the hepatitis B vaccine series after birth. c. Explain to the client that they will receive the hepatitis B immune globulin immediately. d. Inform the client that hepatitis B cannot be transmitted to the fetus.

c. Explain to the client that they will receive the hepatitis B immune globulin immediately. The nurse should explain to the client the need to receive the hepatitis immune globulin to decrease the risk of transmission to the fetus. The nurse should also instruct the client that all sexual partners and members of the client's household should see their providers to begin prophylactic treatment.

A nurse is assisting with planning care for client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include. a. Instruct the client to discontinue feeding from the affected breast. b. Tell the client to wear an underwire bra. c. Instruct the client to apply warm compresses to the affected breast. d. Administer an antiviral medication.

c. Instruct the client to apply warm compresses to the affected breast. The nurse should instruct the client to apply warm compresses to the breast, which will decrease inflammation and edema. This will enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth.

A nurse is observing a client bathe her 1-day-old newborn. Which of the following actions should the nurse identify as an indication that the clinet understands how to bathe her newborn? a. The client shakes powder from the container onto the newborn's skin. b. The client uses a cotton-tipped swab to clean the newborn's ears. c. The client washes the newborn's hair before unwrapping them. d. The client rinses the newborn under warm, running water.

c. The client washes the newborn's hair before unwrapping them. Keeping the newborn wrapped while washing their hair helps prevent heat loss.

A nurse is assisting with monitoring a newborn who is 3 days old and has received phototherapy. Which of the following laboratory results should the nurse recognize as an indication that the therapy has been effective a. Glucose 45 mg/dL b. WBC count 10,000/mm3 c. Total bilirubin 5 mg/dL d. Hgb 16 g/dL

c. Total bilirubin 5 mg/dL The nurse should identify that phototherapy is used to treat newborns who have hyperbilirubinemia. Therefore, the nurse should monitor the newborn's bilirubin level before, during, and after phototherapy. A total bilirubin of 5 mg/dL is within the expected reference range of 1 to 12 mg/dL, which indicates the phototherapy has been effective.

A nurse in a clinic is caring for a 16-year-old adolescent. The nurse is reviewing the assessment findings. For each finding, click to specify if the findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.

Abdominal Pain: Gonorrhea Abdominal pain is consistent with gonorrhea. Gonorrhea can present with reports of acute or chronic lower abdominal pain. Greenish Discharge: Trichomoniasis, Gonorrhea Greenish discharge is consistent with trichomoniasis and gonorrhea. Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white, lumpy discharge. Diabetes: Candidiasis. Diabetes is a predisposing factor for yeast infections because high glucose levels provide an environment with enough glucose to allow the growth of yeast. Pain on Urination: Trichomoniasis, Gonorrhea, Candidiasis Pain on urination is consistent with trichomoniasis, gonorrhea, and candidiasis. Dysuria is a manifestation of trichomonas, gonorrhea, and candidiasis and may be the result of urine flowing over the irritated, inflamed, and sore vulva and surrounding skin. Absence of Condom Use: Trichomoniasis, Gonorrhea Absence of condom use is consistent with trichomoniasis and gonorrhea. Sexual activity without the use of a condom can result in the transmission of STIs. Candidiasis is a vaginal infection that is not sexually transmitted.

For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one disease process.

Decreased temperature: hypoglycemia and sepsis. In response to a decreased body temperature, the newborn will attempt to warm themselves by increasing their basal metabolic rate. This can result in depletion of glucose stores and hypoglycemia. Temperature instability, either below or above the expected reference range, is a manifestation of sepsis or infection. Yellow sclera and oral mucosa: hyperbilirubinemia and sepsis. The newborn's liver has a reduced ability to metabolize and excrete bilirubin, which is a byproduct of the breakdown of red blood cells. The excess circulating bilirubin can accumulate in the skin, sclera, and mucus membranes, leading to yellow discoloration. A change in the color of the newborn can also be a manifestation of sepsis. This includes jaundice, cyanosis, or pallor. Poor feeding: hypoglycemia, hyperbilirubinemia and sepsis. Decreased oral intake can be both a cause and a manifestation of hypoglycemia due to inadequate intake of nutrients and resulting behavioral changes. Adequate oral intake is necessary for the newborn to pass the conjugated bilirubin through their stools. Poor feeding decreases stooling, which causes the conjugated bilirubin to be reabsorbed from the intestines into the circulating bloodstream. Sepsis can lead to neurological changes, which decrease the newborn's interest and ability to feed. Ecchymotic caput succedaneum: hyperbilirubinemia. The presence of bruising from birth trauma increases the number of red blood cells being broken down as the extravasated blood is reabsorbed Respiratory distress: hypoglycemia and sepsis. A newborn who has a low body temperature will attempt to warm themselves by increasing their metabolic rate. This change increases the demands for glucose and oxygen, which can result in hypoglycemia and respiratory distress. In neonatal sepsis, the systemic inflammatory response to the bacterial infection leads to the development of tachypnea and increased effort of breathing. Lethargy: hypoglycemia and sepsis.Hypoglycemia can result in behavioral changes that can present as either jitteriness or lethargy. Sepsis can cause neurological changes, which present as either irritability or lethargy.

The nurse is reviewing the provider's prescription in the adolescent's medical chart. Complete the following sentence by using the list of options. The nurse should first implement

Reinforcing education on medications is correct. The nurse should first reinforce the teaching with the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy. Administering ceftriaxone is correct. Ceftriaxone is designated as a stat prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after reinforcing teaching with the adolescent about the purpose and potential adverse reactions of the medication. Scheduling follow-up appointments and administering doxycycline are incorrect. The nurse should schedule the adolescent for a follow-up appointment. However, there is another action that the nurse should take first. The nurse should not administer doxycycline because it is a prescription for the adolescent to begin once discharged, and the prescription will be provided to the adolescent upon discharge. Therefore, there is another action that the nurse should take. Administering metronidazole and reinforcing education on condom use are incorrect. The nurse should not administer metronidazole because it is a prescription for the adolescent to begin once discharged, and the prescription will be provided to the adolescent upon discharge. Therefore, there is another action that the nurse should take. The nurse should reinforce education with the adolescent regarding condom use. However, there is another action that the nurse should take first.

The nurse is reviewing laboratory results in the adolescent's medical record. Adolescent is sexually active with two current partners. IUD in place. Reports not using condoms during sexual activity. History of type 1 diabetes The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options.

The adolescent is most likely developing a pelvic inflammatory disease as evidenced by C-reactive protein. Pelvic inflammatory disease is correct. Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result of untreated vaginal infections. Manifestations include fever, increased C-reactive protein, nausea, and vomiting. The nurse should suspect the adolescent is developing PID. C-reactive protein is correct. The adolescent's C-reactive protein is elevated. PID is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result of untreated vaginal infections. Manifestations include fever, increased C-reactive protein, nausea, and vomiting. The nurse should suspect the adolescent is developing PID.

A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in newborns with a group of clients who are pregnant. Which of the following risk factors should the nurse include. a. Cord compression b. Chronic hypertension c. Alcohol use during pregnancy d. Prematurity

d. Prematurity A newborn who is premature has inadequate surfactant production, which can lead to RDS

A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? a. Maternal temperature of 37.5° C (99.5° F) b. Contractions every 3 min c. Presence of bloody show d. Prolonged deceleration of FHR

d. Prolonged deceleration of FHR The nurse should report a prolonged deceleration of the FHR to the charge nurse because it can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord prolapse. The charge nurse should notify the provider about this change in FHR pattern.

A nurse is collecting data from a client who is 32 HR postpartum. Which of the following findings should the nurse expect. a. Saturation of one perineal pad every 15 min b. Fundus 2 cm above the umbilicus c. Temperature of 39° C (102.2° F) d. Urine output of 3,000 mL in 24 hr

d. Urine output of 3,000 mL in 24 hr The nurse should expect postpartum diuresis to begin approximately 12 hr after birth. Therefore, a urine output of 3,000 mL in 24 hr is an expected finding for this client.

A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions. a. "I will massage my breasts while I take a shower." b. "I should wear an underwire bra during the day." c. "I should use a breast pump several times a day to relieve discomfort." d. "I will apply cold cabbage leaves to my breasts throughout the day."

d. "I will apply cold cabbage leaves to my breasts throughout the day." Frequent application of cold cabbage leaves to the breasts can prevent engorgement during lactation suppression for a client who is bottle-feeding her newborn. The client should also apply ice packs or cold compresses to her breasts, take mild analgesics, and wear a well-fitting and supportive bra.

A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider? a. Vernix in the skin folds b. Positive Moro reflex c. Apneic episode of 10 seconds d. Apical heart rate of 90/min while crying

d. Apical heart rate of 90/min while crying The nurse should identify that an apical heart rate of 90/min while crying is below the expected reference range of 110 to 160/min for a newborn. A heart rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn.

A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? a. Leg cramps b. Tingling of fingers c. Varicose veins d. Epigastric pain

d. Epigastric pain The nurse should identify epigastric pain as a potential complication of pregnancy. Epigastric pain is a manifestation of preeclampsia.

A nurse is caring for a client 6 HR after a vaginal birth who is going to be breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0 -10. The nurse also notes mild perineal edema and ecchymosis with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority? a. Administer analgesics. b. Apply an ice pack to the perineum. c. Assist the client with breastfeeding. d. Help the client ambulate to the toilet.

d. Help the client ambulate to the toilet. The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the priority intervention by the nurse is to assist the client to urinate and completely empty the bladder, which will allow the uterus to contract.

A nurse is preparing to administer clindamycin 450 mg PO to client who has endometritis. The amount available is clindamycin 150 mg/cap. How many capsules should the nurse administer?

3 capsules (150 mg x 3 = 450 mg)

The nurse is contributing to the plan of care for the adolescent. The nurse should anticipate a provider's prescription for

Ceftriaxone and Doxycycline Ceftriaxone is an anti-infective used to treat a variety of infections, including gonorrheal infection. Ceftriaxone is administered as a one-time IM injection for the treatment of gonorrhea. The adolescent is exhibiting manifestations of a gonorrheal infection. Doxycycline is an anti-infective used to treat a variety of infections, including gonorrhea. Doxycycline is administered along with ceftriaxone to treat mild to moderate PID. The adolescent is exhibiting manifestations of a gonorrheal infection and PID. Acyclovir, fluconazole, and imiquimod are incorrect. Acyclovir is an antiviral used to treat herpes infections by interfering with the virus' DNA synthesis. The adolescent has no manifestations of genital herpes. Fluconazole is an antifungal used to treat various fungal infections, including candidiasis. The adolescent has no manifestations of candidiasis or any fungal infection. Imiquimod is a topical antitumor medication used to treat keratoses, tumors of the skin, and genital warts. The adolescent does not have manifestations of genital warts.

A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? a. BUN 14 mg/dL b. Platelet count 200,000/mm^3 c. Hematocrit 30% d. Creatinine 1.0 mg/dL

Hematocrit 30% The nurse should identify that a hematocrit of 30% is below the expected reference range of greater than 33% for a client who is pregnant. A low Hct is an indication of anemia. Therefore, the nurse should report this finding to the provider.

A nurse is reinforcing home care safety with the guardian of a newborn prior to discharge. Which of the following statements by the guardian indicates an understanding of the teaching? a. "I can place a pillow in my baby's crib." b. "I can allow my toddler to sleep in the bed with my baby." c. "I should place my baby's crib away from windows." d. "I should keep my baby's bath water at 97 degrees Fahrenheit."

I should place my baby's crib away from windows. The guardian should place the newborn's crib away from windows to prevent drafts or entanglement in blinds or drapery.

A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has repiratory distress. Which of the following findings should the nurse report to the provider? a. Acrocyanosis b. Tachypnea c. Nasal flaring d. Retractions e. Expiratory grunting

Tachypnea is correct. Tachypnea is a respiratory rate greater than 60/min and is a finding associated with respiratory distress in the newborn. Nasal flaring is correct. Nasal flaring is a finding associated with respiratory distress in the newborn. Retractions is correct. Retractions are a finding associated with respiratory distress in the newborn. Expiratory grunting is correct. Expiratory grunting is a finding associated with respiratory distress in the newborn.. Acrocyanosis is incorrect. Acrocyanosis is a bluish discoloration of the hands and feet of the newborn and is an expected finding during the first 48 hr after birth.

A nurse is reinforcing teaching with a client who has asked about continuing routine exercise during pregnancy. Which of the following responses should the nurse make? a. "Drink plenty of water after exercising." b. "Lie on your back for 5 minutes after exercising." c. "You should limit exercise to once per week" d. "Increase your exercise intensity as your pregnancy progresses."

a. "Drink plenty of water after exercising." The client should drink plenty of water during and after exercising to decrease the risk of dehydration from diaphoresis.

A client request information about the use of a diaphragm for birth control. Which of the following statements should the nurse make. a. "You will need to replace your diaphragm every 2 years." b. "You can use an oil-based lubricant with your diaphragm." c. "You should have a full bladder when you insert the diaphragm." d. "You should remove your diaphragm 1 hour after intercourse to clean it."

a. "You will need to replace your diaphragm every 2 years."

A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider? a. 2+ urinary protein b. Leukorrhea c. Spider nevi d. 30 cm fundal height

a. 2+ urinary protein The nurse should identify that 2+ proteinuria is a manifestation of preeclampsia. Therefore, the nurse should report this finding to the provider.

A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? a. Intramuscular b. Intradermal c. Subcutaneous d. Topical

c. Subcutaneous Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication should be administered subcutaneously every 4 hr.

A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect to complete? a. Apgar score b. Newborn Hearing Screen c. Critical Congenital Heart Disease screen (CCHD) d. Neonatal Abstinence Scoring System

d. Neonatal Abstinence Scoring System This newborn is exhibiting manifestations of opioid withdrawal and should be screened using the Neonatal Abstinence Scoring System. Some additional manifestations of withdrawal include restlessness, tremors, increased muscle tone, and an exaggerated Moro reflex.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? a. Reposition the newborn every four hours. b. Feed the newborn 30 mL (1 oz) of glucose water four times per day. c. Apply a thin layer of lotion to the newborn's skin. d. Place an opaque mask over the newborn's eyes.

d. Place an opaque mask over the newborn's eyes. The nurse should place an opaque mask over the newborn's eyes during phototherapy to prevent damage to the retinas. The nurse should remove the mask for feedings.