Evolve Exam 2
A 37 year old G3P2001 client with hypertension and type 1 diabetes with good glycemic control is seen in the antepartum testing unit for NST at 36 weeks. Her OB history includes an intrauterine fetal death at 38 weeks. What risk factors in the client's history indicate the need for an NST?
- Age older than 35 years - The risk for placental insufficiency - A history of stillbirth from her last pregnancy - Hypertension - Type 1 Diabetes
A client at 37 weeks gestation is in the ER after a motor vehicle accident. Vital signs upon admission are BP 110/72, HR 98. The client begins complaining of sudden, sharp abdominal pain, and repeated vital signs are BP 90/60 and HR 108. Which is the initial nursing intervention at this time?
- Apply an electronic fetal monitor
A primigravida at 42 weeks gestation has fluid leaking from her vagina and is complaining of back pain. Which conclusion is supported by the assessment data recorded below?
- Cesarean birth is anticipated
A client who is in labor is admitted 30 hours after her membranes ruptured. Which condition is this client at increased risk for?
- Chorioamnionitis
When performing a client's postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?
- Decreased blood pressure
Which finding would the nurse report to the health care provider after assessing a 12-hour-old newborn?
- Jaundice
Which statement contains information that would be included when answering a client's questions about episiotomy versus laceration?
- Lacerations are easier to repair than an episiotomy
Which finding would lead the nurse to postpone a newborn's discharge from the hospital after delivery?
- Lack of infant car seat
Which assessment and interventions are necessary once an epidural catheter has been inserted?
- Maintain intravenous fluid administration - Have oxygen available in case of hypotension - Check the bladder for distension every 2 hours - Monitor fetal hr and labor progress per hospital protocol
Which area is optimal for the nurse to assess adequate tissue oxygenation in a Black neonate?
- Mucous membranes of the mouth
Which assessment finding in a newborn of 33 weeks' gestation alerts the nurse to notify the health care provider?
- Nasal Flaring
The nurse is assessing the Apgar scores of 4 different newborns in a pediatric ward. Which newborn would the nurse anticipate is experiencing severe distress?
- Newborn A
Which statement about the transition from intrauterine to extrauterine life is accurate?
- Newborns are susceptible to heat loss and cold stress
Which sign would the nurse expect in a client with placenta previa?
- Painless vaginal bleeding in the third trimester
The nurse is reevaluating a newborn who had an axillary temperature of 97 F and was placed skin to skin with the mother. The newborns axillary temperature is still 97 F after 1 hour of skin-to-skin contact. Which intervention would the nurse implement next?
- Placing the newborn under a radiant warmer and attaching a skin probe
Immediately following rupture of membranes, the fetal hr monitor shows variable deceleration of more than 90 seconds followed by bradycardia. Which condition does the nurse suspect?
- Prolapsed cord
Which action involving client needs would the nurse delegate to an unlicensed health care worker?
- Providing ice chips to a primigravida in early labor per the primary health care providers prescription
A client who is 38 weeks pregnant has a nonstress test. The resulting fetal monitor strip is shown. Which interpretation would the nurse assign to this findings?
- Reassuring; fetal heart accelerates with movement
An infant born at 36 weeks gestation weighs 4 lb 3 oz (1899 g) and has Apgar scores of 7 and 9. Which nursing action(s) will be performed upon the infant's admission to the nursery?
- Recording the neonate's vital signs - Evaluation of the neonate's health status - Keeping the neonate's body warm
Which information would tell the nurse if a woman at 40 weeks gestation having contractions is in true labor?
- The cervix dilates and becomes effaced in true labor
A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. Which statement would be the correct interpretation of these findings?
- The fetus may be compromised in utero
Which nursing interventions help to prevent heat loss in newborns?
- The nurse keeps the newborn covered in warm blankets - The nurse keeps the newborn under the radiant warmer - The nurse places the newborn on the mother's abdomen
An intravenous infusion of oxytocin is started to induce labor in a client. When the client's contractions begin, they are 1.5 to 2 minutes in duration. While the nurse is in the room, one contraction lasts 3 minutes. Which action would the nurse take first?
- Turn off the oxytocin infusion
Which result after 20 minutes of a nonstress test is suggestive of fetal reactivity?
- Two acceleration of 15 beats/min lasting 15 seconds
The nurse is caring for a client in the first stage of labor, and an external fetal heart monitor is in place. Which do the tracings indicate?
- Variable decelerations
While assessing a newborn, the nurse notes that the infant's skin is mottled. Which would the nurse primary intervention be?
- Warm the environment
Although the newborn was just cleaned and examined, the mother notes a red rash consisting of small papules on the face, chest, and back of the newborn. Which condition would the nurse recognize?
- Erythema toxicum
A client in active labor is 100% effaced, dilated 3 cm, and at +1 station. which stage of labor has this client reached?
- First
Which action will the nurse anticipate needing to take when a client develops hypotension immediately after receiving spinal anesthesia?
- Increase intravenous flow rate
Which intervention would the nurse suggest to ease back discomfort during labor?
- having support persons use back massage techniques
In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however, the baby soon goes back to sleep. which is the most appropriate nursing action in response to this behavior?
- Documenting an intact reflex
A client's membranes ruptured 20 hours before admission. She gave birth 18 hours after admission. For which postpartum complication is the client at risk?
- Infection
Which is the priority nursing action when caring for a client who has just had an amniotomy and the fetal heart rate immediately decreases from 140 to 80 beats/ min?
- Inspecting the vagina
While caring for a client during labor, which would the nurse remember about the second stage of labor?
- It ends at the time of birth
Which is the purpose of vitamin K injection in a newborn?
- It provides protection from hemorrhage
The nurse notes irregular, deep-blue pigmentation on the gluteal regions while assessing an infant. How would the nurse interpret the examination findings?
- The observations are consistent with slate gray nevi (Mongolian spots)
A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. Which is the best response by the nurse?
- This antibiotic helps keep babies from contracting eye infections
A 42-year-old client at 39 weeks gestation has a reactive nonstress test. Which interpretation pertains to this result?
- This is the desired response at this stage of gestation
The nurse is teaching a nursing student about tocolytics. Which statement by the student indicates teaching was effective?
- Tocolytics inhibit labor and maintain a pregnancy
For which reason would the nurse encourage a client to void during the first stage of labor?
- A full bladder may inhibit the progress of labor
Which condition contraindicates oxytocin induction?
- Active genital herpes infection
Which nursing action promotes psychosocial development for a newborn?
- Placing the newborn in the parent's arms during the first hour of life
The nurse is performing an assessment of a 1-hour-old newborn, which reveals that the newborn's hands and feet are cyanotic, and there is circumoral pallor when then infant cries of feeds. Which action would the nurse preform based on these findings?
- Notify the practitioner, because circumoral pallor may indicate cardiac problems
A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data include blood pressure of 110/70 mm Hg, pulse of 90 beats/min, respiratory rate of 22 breaths/min, and fetal heart rate of 132 beats/min. The uterus is nontender, the client is reporting no contractions, and the membranes are intact. In light of this information, which problem would the nurse suspect?
- Placenta previa
The nurse prepares to administer vitamin K to a newborn. Which rationale explains why newborns are deficient in this vitamin?
- A newborn's intestinal tract does not synthesize it for several days after birth
A primigravida at term has dark red vaginal bleeding and complains of pain continuing between contraction. The nurse palpates the abdomen, which is firm and shows no sign of relaxation. Which complication does the nurse suspect?
- Abruptio placentae
A client in early active labor at 40 week's gestation reports that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart range between 169 and 174 beats/min. Which is the priority nursing action?
- Assessing maternal vital signs
A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education would be provided as soon as mom and baby are settled into their room?
- Wash your hands before touching the newborn - All client identification bands should remain in place until discharge - Check the identification of staff, and if there is a question of validity, call the nursing station
The nurse, providing discharge instructions to the parents of a newly circumcised male newborn, asks them to repeat the findings that would prompt them to call the primary health care provider. Which findings is reassuring and would not require notification of the provider?
- a yellowish exudate around the incision
An amniotomy is performed in a laboring client at 42 weeks gestation. place the nursing care actions in their priority order.
- checking the fetal heart tracings - inspecting the perineum for umbilical cord prolapse - assessing the characteristics of the amniotic fluid - monitoring the client for signs of an infection