exit k

In a noisy room a sleeping newborn initially startles and exhibits rapid movements but soon goes back to sleep. What is the most appropriate nursing action in response to this behavior?

Documenting an intact reflex

The nurse is caring for a pregnant client who is undergoing an ultrasound examination during the first trimester. The nurse explains that an ultrasound during the first trimester is used to:

Estimate fetal age

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor?

Greenish-tinged amniotic fluid

A nurse is caring for the newborn of a mother with diabetes. For which signs of hypoglycemia should the nurse assess the newborn? Select all that apply.

Irritability Hypotonia Ineffective sucking

After the birth of a neonate, a parent asks, "What is that white substance over the baby's body?" The nurse initially responds:

It's expected, and it's called vernix caseosa

A nurse helps a client to the bathroom to void several times during the first stage of labor. This is done because a full bladder:

May inhibit the progress of labor

A nurse is caring for a client in the transition phase of labor. What breathing pattern should the nurse instruct the client to use when there is an urge to push at 9 cm of dilation?

Panting-blowing pattern

A laboring client experiences a spontaneous rupture of membranes. The nurse's priority is:

Assessing the fetal heart rate

An infant has surgery for repair of a myelomeningocele. For which early sign of impending hydrocephalus should the nurse monitor the infant?

Bulging fontanels

List the mechanisms of labor in the correct sequence.

Engagement Descent Flexion Internal rotation Extension Restitution External rotation Expulsion

During a prenatal visit, a client at 37 weeks' gestation tells a nurse that she has painful, irregular contractions. What should the nurse recommend?

Walking around until they subside

Shortly after birth the nurse instills erythromycin ophthalmic ointment in the newborn's eyes. The father asks why an antibiotic is needed because the mother does not have an infection. The nurse explains that it protects the newborn from:

Chlamydia and gonorrhea

During labor a client who is receiving epidural anesthesia has an episode of severe nausea, and her skin becomes pale and clammy. What is the immediate nursing action?

Elevating the legs

A nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment?

Empty her bladder.

Which of the following variables are scored on a biophysical profile? Select all that apply.

Fetal tone Fetal movement Amniotic fluid index Fetal breathing movements

A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn's blood type is B positive. What should the plan of care include?

`Obtaining a prescription to administer RhoGAM to the mother

What type of lochia should the nurse expect to observe on a client's pad on the fourth day after a vaginal delivery?

moderate serosa

A vaginal examination reveals that a client in labor is dilated 8 cm. Soon afterward she becomes nauseated and has the hiccups, and bloody show increases. What phase of labor does the nurse determine the client is entering?

transition

A new mother's laboratory results indicate the presence of cocaine and alcohol. Which craniofacial characteristic indicates to the nurse that the newborn has fetal alcohol syndrome (FAS)? Select all that apply.

- Thin upper lip - Small upturned nose - Smooth vertical ridge in the upper lip..

A client in labor is admitted to the birthing room. The nurse's assessment reveals that the fetus is at −1 station. Where is the presenting part?

1 cm above the ischial spines

A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine life?

2:1

A Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of:

7.5

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents?

A reflex that is expected in the healthy newborn

A newborn's total body response to noise or movement is often distressing to the parents. What should the nurse tell the parents this response represents?

A reflex that is expected in the healthy newborn.

A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient?

Audible fetal heartbeat

A client's membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?

Auscultating the fetal heart rate

A nurse is assessing a newborn in the birthing room. What finding indicates that a newborn has failed to make the appropriate adaptation to extrauterine life?

Central cyanosis

How does the nurse know that a client at 40 weeks' gestation is experiencing true labor?

Cervical dilation

The parents of a newborn decide not to have their son circumcised. What should the nurse's discharge teaching for the care of an uncircumcised neonate include?

Clean the penis with warm water without moving the foreskin.

A nurse assesses the process of involution by measuring the location of the client's fundus during the postpartum period. Click the location the fundus is expected to be 1 day after birth in a client whose bladder is not distended.

Created with Raphaël 2.1.2 Pegadito al ombligo

A nurse determines that a newborn is in respiratory distress. Which signs confirm this assessment? Select all that apply.

Cyanosis Tachypnea Retractions

A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus:

Even with the umbilicus

What findings occur with supine hypotensive syndrome? Select all that apply.

Feeling of faintness Increased venous pressure Decreased systolic pressure

A client asks the nurse what advantage breastfeeding holds over formula feeding. What major group of substances in human milk are of special importance to the newborn and cannot be reproduced in a bottle formula?

Gamma-globulins

How should a nurse direct care for a client in the transition phase of the first stage of labor?

Helping the client maintain control

A nurse is caring for a 3-week-old infant who was admitted with untreated phenylketonuria (PKU). How should the nurse document the odor of the infant's urine?

Mousy or musty,,

A newborn's Apgar score at 5 minutes is 5. With what condition that requires intensive monitoring of this neonate does a low Apgar score 5 minutes after birth correlate?

Neonatal morbidity.

A client is admitted to the birthing suite in early active labor. Which nursing action takes priority during the admission process?

Auscultating the fetal heart`

During labor a client begins to experience dizziness and tingling of her hands. What should the nurse instruct the client to do?

Breathe into her cupped hands.

A nurse is caring for a primigravida during labor. At 7 cm of dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?

Butorphanol (Stadol)

A client's membranes rupture while her labor is being augmented with an oxytocin (Pitocin) infusion. The nurse observes variable decelerations in the fetal heart rate on the fetal monitor strip. What action should the nurse take next?

Changing the client's position

A nurse is assessing a newborn with congenital toxoplasmosis. What clinical finding does the nurse expect to identify on assessment?

Chest circumference larger than head circumference

A pregnant client is asking the nurse when she will gain the most weight. At which time during prenatal development should the nurse tell the client to expect the greatest fetal and maternal weight gain?

Third trimester

A client arrives in the birthing room with the fetal head crowning. Birth is imminent. What should the nurse tell the client to do?

Use the pant-breathing pattern.

At 38 weeks' gestation a client is admitted to the birthing unit in active labor, and an external fetal monitor is applied. Late fetal heart rate decelerations begin to appear when her cervix is dilated 6 cm and her contractions are occurring every 4 minutes and lasting 45 seconds. What does the nurse conclude is the cause of these late decelerations?

Uteroplacental insufficiency

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb at birth. Which finding should be reported immediately to the health care provider?

Weight of 6 lb 4 oz

A client in the 18th week of pregnancy is scheduled for ultrasonography. What instruction should the nurse give the client?

Don't urinate for at least 3 hours before the test."

A primigravida asks when she will be able to hear the fetal heartbeat for the first time. The nurse should explain that the heartbeat can be heard with:

Doppler ultrasound at 10 to 12 weeks

After a newborn has skin-to-skin contact with the mother, a nurse places the newborn under a radiant warmer. What complication is the nurse attempting to prevent?

Metabolic acidosis

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by:

Metabolism of brown fat

A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by:

Metabolism of brown fat,

Five minutes after being born, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings?

Opioid drug withdrawal.

Early in the ninth month of pregnancy a client experiences painless vaginal bleeding and is admitted to the hospital. What should the client's plan of care include?

Placing the client in the semi-Fowler position to increase cervical pressure

What is the priority nursing intervention for a laboring client with a sudden prolapse of the umbilical cord protruding from the vagina?

Preparing the client for surgery

A client is admitted to the birthing unit in active labor. Amniotomy is performed by the health care provider. What physiologic change does the nurse expect to occur after the procedure?

Progressive dilation and effacement

What nursing action is the priority for a client in the second stage of labor?

Promote effective pushing by the client.

The nurse administers the prescribed vitamin K intramuscularly to a newborn immediately after birth to:

Promote the synthesis of prothrombin

After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. What is the priority nursing care for this newborn?

Protecting the sac with moist sterile gauze

A nurse is assessing a newborn with trisomy 21 (Down syndrome). What clinical findings does the nurse expect? Select all that apply.

Protruding tongue Hypotonic muscle tone Broad nose with a depressed bridge

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. The nurse should immediately:

Reposition the client from supine to left lateral.

A nurse is caring for a pregnant client during a contraction stress test (CST). In what position should the nurse place the client?

Semi-Fowler position to avoid hypotension

A nurse on the birth unit is assessing a primigravida who states that labor has begun. How does the nurse know that this client is in true labor?

The cervix is dilated.

Which assessment leads a nurse to suspect that a newborn with a spinal cord lesion has increased intracranial pressure (ICP)? Select all that apply.

- Irritability - High-pitched cry - Ineffective feeding behavior

A client at 38 weeks' gestation is admitted with the diagnosis of placenta previa. What is the priority nursing care at this time?

Assessing for hemorrhage

A mother is breastfeeding her newborn. She asks when she may switch the baby to a cup. The nurse concludes that the mother understands the teaching about feeding when she says she will start to introduce a cup after the baby reaches:

6 months

A nurse is reviewing the laboratory report of a newborn whose hematocrit level is 45%. What value denotes a healthy infant?

Between 45% and 65%

A nurse is preparing a pregnant client for an amniocentesis. What should nursing care include?

Encouraging her to void before the test

Shortly after birth a newborn is found to have Erb's palsy. What condition does the nurse suspect caused this problem?

Injury to brachial plexus during birth

A client arrives at the hospital at 38 weeks' gestation with profuse painless bright-red vaginal bleeding. She states that it came on suddenly, without any contractions. Which condition does the nurse report to the health care provider?

Placenta previa

During labor a client who has been receiving epidural anesthesia has a sudden episode of severe nausea, and her skin becomes pale and clammy. What is the nurse's immediate reaction?

Turning the client on her side

The nurse is interpreting the results of a non-stress test (NST) on a client at 41 weeks' gestation. Which result after 20 minutes is suggestive of fetal reactivity?

Two accelerations of 15 beats/min lasting 15 seconds

A client in her 10th week of pregnancy exhibits presumptive signs of pregnancy that the nurse may detect, including which of the following? Select all that apply.

Amenorrhea Breast changes Urinary frequency

Which criterion should a nurse use when assessing the gestational age of a preterm infant?

Breast bud size

A nurse in the birthing unit assesses a primigravida who is at 42 weeks' gestation. Fluid is leaking from her vagina, and she is complaining of back pain. Which conclusion is supported by the data collected?

Cesarean birth is anticipated

A preterm newborn is given oxygen by way of a hood. What should the plan of care for this neonate include?

Ensuring that the oxygen is continuously warmed and humidified

When the cervix of a woman in labor is dilated 9 cm, she states that she has the urge to push. How should the nurse respond?

Having her pant-blow during contractions

A woman's pregnancy has been uneventful, and she has gained 25 lb. At term her hemoglobin level is 10.6 g/dL and her hematocrit is 31%. What does the nurse identify as the reason for these hemoglobin and hematocrit levels?

Hemodilution

The nurse reviews the blood test results of a client at 24 weeks' gestation. Which finding should be reported to the health care provider?

Hemoglobin: 10.8 g/dL

An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant?

Obtaining heel blood to test the glucose level

A new mother asks a nurse how to care for her baby's umbilical cord stump. What should the nurse teach the mother?

Provide sponge baths until the stump falls off.

At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? Select all that apply.

- Long nails - Wrinkled skin

After an assessment of a male newborn, the nurse suspects postmaturity. Which observations help confirm this conclusion? Select all that apply.

- Profuse scalp hair - Parchmentlike skin - Creases covering the entire soles

A laboring client who is positive for Group B Streptococcus is given an initial dose of ampicillin (Omipen) 2 g at 9 am. According to established guidelines for intrapartum management of this client, the next dose should be:

1 g given at 1 pm

At 1 minute after birth the nurse determines that an infant is crying, has a heart rate of 140 beats/min, has blue hands and feet, resists the suction catheter, and keeps the legs flexed and the arms extended. What Apgar score should the nurse assign?

8

Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body.

9

A newborn was delivered 25 minutes earlier. Once identification bands have been applied and vital signs have been taken, what interventions does the nurse need to complete? Place these actions in the order of their priority

Assisting the new mother with breastfeeding Taking and recording weight and height Placing the infant under a warmer and attaching a sensor probe Performing a head-to-toe physical examination Giving erythromycin eye ointment and a vitamin K shot

A nurse who is caring for a client in labor uses Nitrazine paper to test the pH of the client's leaking vaginal fluid. What color will the Nitrazine paper turn if the leakage is amniotic fluid?

Blue

An infant is admitted to the nursery after a difficult shoulder birth. For what condition should the nurse assess this newborn?

Brachial plexus injury While examining a newborn the nurse brushes a finger upward on the infant's sole. The newborn responds by fanning the toes outward. Which reflex is the nurse eliciting? Babinski

A nurse is estimating a newborn's gestational age. What parameters should the nurse assess? Select all that apply.

Breast size Genital development

A client and her partner are working together during the woman's labor. The client's cervix is now dilated to 7 cm, and the presenting part is low in the midpelvis. What should the nurse instruct the partner to do that will alleviate the client's discomfort during contractions?

Deep-breathe slowly.

A newborn male infant was circumcised 2 hours ago. Thirty minutes later, the nurse notes blood oozing from the penis. Which intervention should the nurse implement?

Donning sterile gloves and applying direct pressure, using sterile gauze

A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The most appropriate recommendation by the nurse is to have the client call the clinic with the results after she has:

Drunk a glass of orange juice and timed 10 fetal movements

A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief

Eat dry crackers before you get out of bed.

The nurse is differentiating between cephalohematoma and caput succedaneum. What finding is unique to caput succedaneum?

Edema that crosses the suture line

Two days after birth a neonate's head circumference is 16 inches (40 cm) and the chest circumference is 13 inches (32.5 cm). What does the nurse infer from these measurements?

Enlarged head,

A client at 32 weeks' gestation is admitted in active labor. Her cervix is effaced and dilated 4 cm. Intramuscular betamethasone (Celestone) 12 mg is prescribed. What should the nurse tell the client about why the medication is being given?

Fetal lung maturity is accelerated.

A 15-year-old emancipated minor gave birth to a boy 36 hours ago and has requested a circumcision. What is the medical priority?

Getting an informed consent signed by the mother of the baby

When a nurse who is carrying a newborn to the mother enters the room, a visitor asks to hold the infant. The visitor is sneezing and coughing. What is the most important measure for the nurse to take?

Having the visitor step outside the room

A small-for-gestational-age (SGA) newborn who has just been admitted to the nursery has a high-pitched cry, appears jittery, and exhibits irregular respirations. What complication does the nurse suspect?

Hypoglycemia

While assessing a 9-lb neonate 2 hours after birth, a nurse notes jitteriness, apneic episodes, tachycardia, and temperature instability. What complication do these findings indicate to the nurse?

Hypoglycemia

The laboratory results of a woman in labor indicate the presence of cocaine and alcohol. Which characteristics should cause the nurse to recognize fetal alcohol syndrome (FAS) in the newborn? Select all that apply.

Hypotonia Hypoplastic maxilla Small, upturned nose

A nurse assessing a newborn suspects Down syndrome. Which characteristics support this conclusion? Select all that apply.

Hypotonia Singe transverse palmar crease Epicanthal eye folds

A nurse is caring for a client who is admitted to the birthing unit with a diagnosis of abruptio placentae. For what complication associated with this problem should the nurse monitor this client?

Hypovolemic shock

A nurse concludes that a positive contraction stress test (CST) result may be indicative of potential fetal compromise. A CST result is considered positive when during contractions the fetal heart rate shows:

Late decelerations--

A pregnant client at 37 weeks' gestation is taught about signs and symptoms that should be reported immediately to the primary care provider. The nurse determines that the client understands the information presented when she states that she will immediately report:

Leakage of fluid from the vagina

A primipara is admitted to the birthing room in active labor. The fetus's head is engaged and the cervix is dilated 9 cm when there is a gush of fluid from the vagina. Place the nursing actions in order of priority.

Monitor the fetal heart rate for signs of compromise. Test the fluid's pH with Nitrazine paper. Perform a vaginal examination to ascertain the progression of labor. Notify the practitioner

An infant of a diabetic mother is admitted to the neonatal intensive care unit. What is the priority nursing intervention for this infant?

Obtaining heel blood to test the glucose level Five minutes after being born, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings? Opioid drug withdrawal

A nurse is assessing the head of a healthy newborn after a cesarean birth. What does the nurse expect to identify?

Open anterior and posterior fontanels

The nurse concludes that a couple with a newborn with Erb's palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion?

Recovery usually occurs in about 3 months.

A nurse is assessing a client in active labor for signs that the transition phase is beginning. What change does the nurse expect?

Rectal pressure during contractions

A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a course on several tests during pregnancy. Place the tests in the order in which they should be performed during pregnancy.

Sickle cell screening α-Fetoprotein (AFP) testing for neural tube defects Serum glucose for gestational diabetes Fetal movement test Group B Streptococcus culture

A nurse is conducting the admission assessment of a client who is positive for Group B Streptococcus (GBS). Which finding is of most concern to the nurse?

Spontaneous rupture of membranes 3 hours ago

A client is receiving an intravenous piggyback infusion of oxytocin (Pitocin) to augment labor. The nurse identifies three contractions lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is followed in response to this observation. List in order of priority the nursing actions that should be taken.

Stop the piggyback infusion. Check the fetal heart rate (FHR). Determine whether the contractions have diminished Notify the health care provider. Administer oxygen by way of facemask. Document the responses of the client and fetus.

The nurse is providing discharge teaching to the parents of a 3-day-old infant. The mother expresses concern about sudden infant death syndrome (SIDS). To reduce the risk of SIDS during sleep, the nurse instructs the parents to position the infant:

Supine

An internal fetal monitor is applied while a client is in labor. What should the nurse explain about positioning while the monitor is in place?

The most comfortable position may be assumed.

A client is receiving an oxytocin (Pitocin) infusion for induction of labor. The uterine graph on the electronic monitor indicates no rest period between contractions, and this is confirmed on palpation. What should the nurse do first?

Turn the oxytocin infusion off.

A client arrives in the birthing room with the fetal caput emerging. What should the nurse say to the client during a contraction?

Use the panting-breathing pattern.

What complication should a nurse be alert for in a client receiving an oxytocin (Pitocin) infusion to induce labor?

Uterine tetany

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection?

Vastus lateralis

A nurse is caring for a primigravida during labor. What does the nurse note that indicates that birth is about to take place?

c. The perineum has begun to bulge with each contraction

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. What type of infection control precautions should the nurse institute?

droplet

During the assessment of a client in labor, the cervix is determined to be dilated 4 cm. What stage of labor does the nurse record?

first

A nurse assessing a newborn identifies several characteristics of Turner syndrome. Which features did the nurse observe? Select all that apply.

Webbed neck Female sex organs Widely spaced nipples

A newborn's birth was prolonged because the shoulders were very wide. With which reflex does the nurse anticipate a problem?

moro

At 10 hours of age a neonate's oral cavity is filled with mucus, and cyanosis develops. What should the nurse do first?

suction the infant

A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable. The client reports that she is going to vomit. What phase of the first stage of labor does the nurse suspect the client has entered?

transition

The nurse is assessing a newborn for developmental dysplasia of the hip (DDH). Where does the nurse look for extra skinfolds?

Back of the thigh

A nurse is assessing a newborn born after 32 weeks' gestation. What clinical finding does the nurse anticipate?

Barely visible areola and nipple

A primigravida is admitted to the birthing unit in active labor. The fetus is in a breech presentation. What physiological response does the nurse expect during this client's labor?

Greenish-tinged amniotic fluid,

client is scheduled for a nonstress test in the 37th week of gestation. A nurse explains the procedure. Which statement demonstrates that the client understands the teaching?

If the heart reacts well, my baby should do OK when I give birth.

A neonate has phenylketonuria (PKU). What information should the nurse include in a discussion with the parents when explaining what caused their infant's problem?

Inborn error of metabolism

Organize the steps in infant cardiopulmonary resuscitation (CPR) in the correct sequence.

Note the infant's color and tap or gently shake the shoulders. Position the infant supine on a firm, flat surface. Open the airway with the head tilt-chin lift method and listen for exhalation. Initiate rescue breathing at a rate of 40 to 60 breaths/min. Check the pulse at the brachial artery. Initiate chest compressions in a 30:2 ratio.

A pregnant client with severe abdominal pain and heavy bleeding is prepared for a cesarean birth. What is the priority nursing intervention?

Obtaining informed consent and assessing the client for drug allergies

An expectant couple asks the nurse about the cause of low back pain during labor. The nurse replies that this pain occurs most often when the fetus is positioned:

Occiput posterior

A nurse is caring for a client in active labor. What positions should the nurse encourage the client to assume to help promote comfort during back labor? Select all that apply.

Sitting Lateral Knee-chest

A nurse is estimating an infant's gestational age. What parameter is most likely to indicate gestational age?

Size of breast tissue and genitalia

A nurse determines that the husband of a client in the early phase of labor understands the teaching from childbirth classes when he helps his wife use the breathing pattern of:

Slow-chest

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? Select all that apply.

Small breast buds Wrinkled thin skin Pinnae that remain flat when folded

A nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply.

Sneezing Hyperactivity High-pitched cry

What should nursing care for the affected arm of an infant born with Erb-Duchenne paralysis (brachial palsy) include?

Teaching the parents to manipulate the arm muscles

A nurse is assessing a newborn with a myelomeningocele. What clinical findings prompt the nurse to suspect hydrocephalus? Select all that apply.

Tense fontanels High-pitched crying A defect in the lumbosacral area

A nonstress test (NST) is scheduled for a client with mild preeclampsia. During the test, the client asks the nurse what it means when the fetal heart rate goes up every time the fetus moves. What should the nurse consider before responding?

These accelerations are a sign of fetal well-being.

A nurse admits a client in active labor to the birthing center. She is 100% effaced, dilated 3 cm, and at +1 station. What stage of labor does the nurse identify?

first

Absence or weakness of which of the following reflexes during the newborn assessment should the nurse report to the health care provider?

gag

A nurse at the prenatal clinic examines a client and determines that her uterus has risen out of the pelvis and is now an abdominal organ. At what week of gestation would the nurse expect this assessment finding to occur?

12th week of pregnancy

The parents of a newborn boy ask the nurse, "Is circumcision really necessary?" How should the nurse reply?

"Circumcision is a personal decision for the parents to make."

What part of the foot is the best site to use for the puncture?

outer heel

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which postmature signs does the nurse identify? Select all that apply.

- Cracked and peeling skin - Long scalp hair and fingernails - Creases covering the neonate's full soles and palms

A nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply.

- Tachypnea - Exaggerated Moro reflex - Prolonged, high-pitched cry - Restlessness and excessive activity

Which breathing technique should the nurse instruct the client to use as the head of the fetus is crowning?

blowing

One minute after birth a nurse assesses a newborn and auscultates a heart rate of 90 beats/min. The newborn has a strong, loud cry; moves all extremities well; and has acrocyanosis but is otherwise pink. What is this neonate's Apgar score?

8

A nurse who is assessing a newborn 1 minute after birth determines that the cry is lusty, the heart rate is 150 beats/min, and the extremities are flexed but that the bottoms of the feet have a marked bluish tinge. What Apgar score does the nurse assign to the neonate?

9

A nurse is planning a prenatal class about the changes that occur during pregnancy and the necessity of routine health care throughout pregnancy. Which cardiovascular compensatory mechanisms should the nurse explain will occur? Select all that apply.

Increased blood volume Increased cardiac output Enlargement of the heart

What is the priority nursing action during a client's second stage of labor?

Assessing the perineum for bulging

A nurse in the birthing unit assesses a primigravida who is at 42 weeks' gestation. Fluid is leaking from her vagina, and she is complaining of back pain. Which conclusion is supported by the data collected?

Cesarean birth is anticipated.

A client at 11 weeks' gestation reports having to urinate more often. The nurse explains that urinary frequency often occurs because bladder capacity during pregnancy is diminished by:

Compression by the enlarging uterus

A nurse is caring for a client in labor whose fetus is in the breech presentation. For what complication should the nurse monitor the client?

Compression of the cord

While reviewing the health history of a newborn with suspected jaundice, the nurse recalls that some risk factors place infants at a higher risk developing jaundice. Which conditions are risk factors for jaundice? Select all that apply.

Infection Prematurity Breastfeeding Maternal diabetes

A nurse in the neonatal intensive care unit is caring for a preterm newborn with respiratory distress syndrome (RDS). What clinical finding does the nurse expect?

Diminished breath sounds

While having contractions every 2 to 3 minutes lasting from 60 to 90 seconds, a client complains of severe rectal pressure. What should the nurse do?

Inspect the client's perineum for bulging.

The nurse is caring for a client in her third trimester who is to undergo amniocentesis. What should the nurse do to prepare the client for this test?

Instruct her to void immediately before the test.

A nurse teaches the mother of a newborn with phenylketonuria (PKU) why it is important to restrict the amount of phenylalanine in her infant's formula. Because all proteins contain this essential amino acid, the nurse suggests appropriate formulas. Which formulas are safe for this infant? Select all that apply.

Phenex Lofenalac

A client in labor at 39 weeks' gestation is told by the health care provider that she will need a cesarean birth. The nurse reviews the client's prenatal history. What preexisting condition is the most likely reason for the cesarean birth?

Active genital herpes

During a prenatal examination a nurse draws blood from an Rh-negative client. The nurse explains that an indirect Coombs test will be performed to predict whether the fetus is at risk for:

Acute hemolytic anemia

A client who is lying in the supine position while in active labor is receiving an intravenous oxytocin (Pitocin) infusion and has external monitors in place. Using the monitoring strips below, identify the appropriate nursing interventions. Select all that apply.

Administer oxygen. Turn the client on the side. Discontinue the oxytocin infusion.

After hyperbilirubinemia develops in a neonate, phototherapy is prescribed. What should the plan of care for an infant undergoing phototherapy include?

Administering additional fluids every 2 hours

A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do?

Apply cold packs and a snugly fitting bra

A nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her about minimizing breast discomfort?

Apply covered ice packs to the breasts.

A client in labor is experiencing discomfort because her fetus is in the occiput posterior position. What nursing action will help relieve this discomfort?

Applying pressure against her sacrum

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations?

Partial abruptio placentae

A nurse teaches a group of postpartum clients that all their newborns will be screened for phenylketonuria (PKU) to:

Assess protein metabolism

A client gives birth to a full-term newborn with an 8/9 Apgar score. Place the initial nursing care actions in order of their priority.

Place skin to skin. Apply identification band to mother and infant Perform physical assessment. Instill antibiotic prophylaxis and administer vitamin K.

A client who has missed two menstrual periods arrives at the prenatal clinic with vaginal bleeding and one-sided lower quadrant pain. What condition does the nurse suspect?

Ectopic pregnancy

The nurse is caring for a client who has just received epidural anesthesia. Which finding would be of most concern?

Hypotension

While inspecting her newborn a mother asks the nurse whether her baby has flat feet. How should the nurse respond?

Infants' feet appear flat because the arch is covered with a fat pad.

What actions are part of nursing care during the fourth stage of labor for the client with a fourth-degree laceration? Select all that apply.

Pain management with oral analgesics Assessment of the site every 15 minutes Application of an ice pack for 20-minute intervals

What is the most common complication for which a nurse must monitor preterm infants?

Respiratory distress

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? Select all that apply.

Smoker Twin gestation

Which position does the nurse teach the client to avoid when she experiences back pain during labor?

Supine position

The health care provider completes the vaginal examination by determining that the presenting part of the fetus is at -1 station. What does this information mean?

The head is 1 cm above the ischial spines.

The arch of the newborn's foot is covered with a fat pad, giving the foot the appearance of being flat.

The nurse is caring for a newborn with caput succedaneum. The nurse is able to differentiate caput succedaneum from cephalhematoma because caput succedaneum features scalp edema that: Crosses the suture line

A 42-year-old client at 39 weeks' gestation has a reactive non-stress test (NST). What should the nurse explain to the client about the positive result?

This is the desired response at this stage of gestation.

The mother of a neonate with Down syndrome visits the clinic 1 week after delivery. She explains to the nurse that she is having problems feeding her baby. What is the probable cause of these feeding difficulties?

Tongue thrust

Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known drug abuser? Select all that apply

Tremors hyperactivity

A preterm infant is started on digoxin (Lanoxin) and furosemide (Lasix) for persistent patent ductus arteriosus. Which nursing assessment provides the best indication of the effectiveness of the furosemide?

Urine output exceeds fluid intake

On a 6-week postpartum visit a new mother tells a nurse she wants to feed her baby whole milk after 2 months because she will be returning to work and can no longer breastfeed. The nurse plans to teach her that she should switch to formula feeding because whole milk does not meet the infant's nutritional requirements for:

Vitamin C and iron

A client in active labor has an external fetal monitor in place. Using the monitor strip, identify the correct assessment.

FHR baseline at150 beats/min

The cervix of a client in labor is fully dilated and 100% effaced. The fetal head is at +3 station, the fetal heart rate ranges from 140 to 150 beats/min, and the contractions, lasting 60 seconds, are 2 minutes apart. What does the nurse expect to see when inspecting the perineum?

Enlarging area of caput with each contraction

A non-stress test is scheduled for a client with preeclampsia. During the non-stress test the nurse concludes that if non periodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates:

Fetal well-being

A multiparous client presents to the labor and delivery area in active labor. The initial vaginal examination reveals that the cervix is dilated 4 cm and 100% effaced. Two hours later the client experiences rectal pressure, followed by delivery 5 minutes later. How is this delivery best documented?

Precipitous vaginal delivery