Final Exam OB

A nurse is teaching a woman about measures to prevent preterm labor in future pregnancies because the woman just experienced preterm labor with her most recent pregnancy. The nurse determines that the teaching was successful based on which statement by the woman?

"I'll make sure to limit the amount of long distance traveling I do."

When the nurse is alone with a client, the client says, "It was all my fault. The house was so messy when my partner got home, and I know my partner hates that." Which response would be most appropriate?

"It is not your fault. No one deserves to be hurt."

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?

"It's difficult to say, but it will probably return in about 2 to 3 weeks."

The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse's teaching was successful?

"Pregnancy affects insulin production, so I'll need to make adjustments in my diet."

A physically abused pregnant woman reports to the nurse that her spouse has stopped hitting her and promises never to hurt her again. Which response by the nurse would be most appropriate?

"Remember, the cycle of violence often repeats itself."

A nurse is explaining the use of effleurage as a pain relief measure during labor. Which statement would the nurse most likely use when explaining this measure?

"The technique involves light stroking of the abdomen with breathing."

During a prenatal visit, a pregnant woman says, "I know the amniotic fluid is important, but can you tell me more about it?" When describing amniotic fluid to a pregnant woman, which description would the nurse most likely include?

"This fluid acts as a cushion to help to protect your baby from injury."

After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?

"Unfortunately, I'm going to have to stay quite still in bed while it is in place."

A nurse is describing the different types of regional analgesia and anesthesia for labor to a group of pregnant women. Which statement by the group indicates that the teaching was successful?

"We can get up and walk around after receiving combined spinal-epidural analgesia."

After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching?

"When I put on a new pad, I'll start at the back and go forward."

A premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? Select all that apply. A. increased serum bilirubin levels B. clay-colored stools C. tea-colored urine D. cyanosis E. Mongolian spots

Answer: A, B, C

After teaching a pregnant woman with iron deficiency anemia about nutrition, the nurse determines that the teaching was successful when the woman identifies which foods as being good sources of iron in her diet? Select all that apply. A. dried fruits B. peanut butter C. meats D. milk E. white bread

Answer: A, B, C

A client who is six weeks' pregnant asks the prenatal nurse, "What development has taken place with my baby by now?" Which information should the nurse include in the response? Select all that apply A. "By week 3 there would be the beginning development of the brain, spinal cord, and heart." B. "By week 4 the arms and legs begin to grow and develop." C. "By week 5 the heart now beats and the eyes and ears can be seen." D. "By week 6 the lungs begin forming and the baby circulation is established." E. "By week 6 the baby makes active movements with sucking motions made with the mouth."

Answer: A, B, C, D

After teaching a group of young adults about sexual violence, the nurse determines that the teaching was successful when the group identifies which acts as a type of sexual violence? Select all that apply. A. female genital mutilation B. bondage C. infanticide D. human trafficking E. prostitution

Answer: A, B, C, D

A nurse is working with a victim of intimate partner violence, helping the client develop a safety plan. Which items would the nurse suggest that the client take when leaving? Select all that apply A. driver's license B. Social Security number C. cash D. phone cards E. health insurance cards

Answer: A, B, C, E

A pregnant client at 30 weeks' gestation calls the clinic because she thinks that she may be in labor. To determine if the client is experiencing labor, which question(s) would be appropriate for the nurse to ask? Select all that apply. A. "Are you feeling any pressure or heaviness in your pelvis?" B. "Are you having contractions that come and go, off and on?" C. "Have you noticed any fluid leaking from your vagina?" D. "Are you having problems with heartburn?" E. "Have you been having any nausea or vomiting?"

Answer: A, B, C, E

While obtaining a history from a woman at a regularly scheduled physical, the nurse notices various bruises on the client's upper extremity. The client dismisses the bruising and changes the abirb.com/test subject. Which additional information about the woman as a victim would the nurse discuss with the healthcare provider when relaying the physical assessment data? Select all that apply. A. A dysfunctional family system B. A low academic achievement C. A victim of childhood violence D. Limited alcohol consumption E. Economic stress

Answer: A, B, C, E

A nurse is providing nutritional counseling to a pregnant woman and gives her suggestions about consuming foods that are high in folic acid. As part of the plan of care, the client is to keep a food diary that the client and nurse will review at the next visit. When reviewing the client's diary, which meals would indicate to the nurse that the client is increasing her intake of folic acid? Select all that apply. A. chicken breast with baked potato and broccoli B. cheeseburger with spinach and baked beans C. pork chop with mashed potatoes and green beans D. strawberry walnut salad with romaine lettuce E. fried chicken sandwich with mayonnaise and avocado

Answer: A, B, D

A prenatal nurse is conducting a class on healthy pregnancy and explains the role of placental hormones. Which statements would the nurse make? Select all that apply. A. Human chorionic gonadotropin is the basis for pregnancy tests. B. Human placental lactogen participates in the development of maternal breasts for lactation. C. Thyroxin modulates fetal and maternal metabolism. D. Progesterone stimulates maternal metabolism and breast development. E. Relaxin causes enlargement of a woman's breasts, uterus, and external genitalia. F. Estrogen causes enlargement of a woman's breasts.

Answer: A, B, D, F

A nurse is providing a refresher class for a group of postpartum nurses. The nurse reviews the risk factors associated with postpartum hemorrhage. The group demonstrates understanding of the information when they identify which risk factors associated with uterine tone? Select all that apply. A. rapid labor B. retained blood clots C. hydramnios D. operative birth E. fetal malpostion

Answer: A, C

A nurse is teaching a group of college students about rape and sexual assault. The nurse determines that additional teaching is necessary based on which statements by the group? Select all that apply A. Most victims of rape tell someone about it. B. Few individuals falsely cry "rape." C. Women have rape fantasies desiring to be raped. D. A rape victim feels vulnerable and betrayed afterwards. E. Medication and counseling can help a rape victim cope

Answer: A, C

.The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which measures would the nurse most likely include in this teaching plan? Select all that apply. A. taking the prescribed antibiotic until it is finished B. checking temperature once a week C. washing hands before and after perineal care D. handling perineal pads by the edges E. directing peribottle to flow from back to front

Answer: A, C, D

Which characteristics about amniotic fluid would alert the prenatal nurse to further investigate? Select all that apply. A. Oligohydramnios is noted on assessment. B. The amount of amniotic fluid fluctuates at each checkup. C. Polyhydramnios is noted on assessment. D. The client has approximately 2 L of amniotic fluid at term. E. The client has approximately 1 L of amniotic fluid at term

Answer: A, C, D

A nurse is preparing a class on newborn adaptations for a group of soon-to-be parents. When describing the change from fetal to newborn circulation, which information would the nurse include? Select all that apply A. Decrease in right atrial pressure leads to closure of the foramen ovale. B. Increase in oxygen levels leads to a decrease in systemic vascular resistance. C. Onset of respirations leads to a decrease in pulmonary vascular resistance. D. Increase in pressure in the left atrium results from increases in pulmonary blood flow. E. Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

Answer: A, C, D, E

The nurse notifies the obstetrical team immediately because the nurse suspects that the pregnant woman may be exhibiting signs and symptoms of amniotic fluid embolism. When reporting this suspicion, which finding(s) would the nurse include in the report? Select all that apply. A. significant difficulty breathing B. hypertension C. tachycardia D. pulmonary edema E. bleeding with bruising

Answer: A, C, D, E

A 32-year-old black woman in her second trimester has come to the clinic for an evaluation. While interviewing the client, she reports a history of fibroids and urinary tract infection. The client states, "I know smoking is bad and I have tried to stop, but it is impossible. I have cut down quite a bit though, and I do not drink alcohol." Complete blood count results reveal a low red blood cell count, low hemoglobin, and low hematocrit. When planning this client's care, abirb.com/test which factor(s) would the nurse identify as increasing the client's risk for preterm labor? Select all that apply. A. African heritage B. Maternal age C. History of fibroids D. Cigarette smoking E. History of urinary tract infections F. Complete blood count result

Answer: A, C, D, E, F

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply. A. respiratory distress B. decreased oxygen needs C. hypoglycemia D. metabolic alkalosis E. jaundice

Answer: A, C, E

A nurse is teaching a woman with mild preeclampsia about important areas that she needs to monitor at home. The nurse determines that the teaching was successful based on which statements by the woman? Select all that apply. A. "I should check my blood pressure twice a day." B. "I will weigh myself once a week." C. "I should complete a fetal kick count each day." D. "I will check my urine for protein four times a day." E. "I'll call my health care provider if I have burning when I urinate."

Answer: A, C, E

A woman visits the prenatal clinic and is noted to have oligohydramnios. The client asks, "Why is this fluid important anyway?" Which statements would be included in the nurse's response? Select all that apply A. "Amniotic fluid helps maintain your baby's body temperature." B. "The fetus ingests amniotic fluid for its nourishment." C. "Too little amniotic fluid is linked with placental problems." D. "Amniotic fluid keeps your baby free from any teratogens." E. "It acts like a cushion protecting your baby from trauma that may occur."

Answer: A, C, E

A nurse suspects that a pregnant client may be experiencing a placental abruption based on assessment of which finding? Select all that apply. A. dark red vaginal bleeding B. insidious onset C. absence of pain D. rigid uterus E. absent fetal heart tones

Answer: A, D, E

After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply. A. prolonged labor B. placenta previa C. null parity D. hydramnios E. labor augmentation

Answer: B, D, E

A nurse is assessing a newborn's reflexes. The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot to elicit which reflex?

Babinski

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:

Blue

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next?

Document this as pseudo menstruation.

A pregnant woman undergoes a triple screen at 16 to 18 weeks' gestation. What would the nurse suspect if the woman's estriol and alpha-fetoprotein levels are decreased with high hCG levels?

Down Syndrome

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

Dry the newborn thoroughly

A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrates understanding when they make which statement about this condition?

Getting some outside help for housework can lessen feelings of being overwhelmed

When teaching a pregnant client about the physiologic changes of pregnancy, the nurse reviews the effect of pregnancy on glucose metabolism. Which underlying reason for the effect would the nurse include?

Glucose moves through the placenta to assist the fetus

A client comes to the clinic for an evaluation. The client is at 22 weeks' gestation. After reviewing a client's history, which factor would the nurse identify as placing her at risk for preeclampsia?

Her mother had preeclampsia during pregnancy.

A pregnant woman with diabetes at 10 weeks' gestation has a glycosylated hemoglobin (HbA1c) level of 13%. At this time the nurse should be most concerned about which possible fetal outcome?

congenital anomalies

A nurse is caring for several women in labor. The nurse determines that which woman is the latent phase of labor?

contractions every 5 minutes, cervical dilation 3 cm

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism

evaporation

When planning the care of a woman in the latent phase of labor, the nurse would anticipate assessing the fetal heart rate at which interval?

every 30 to 60 minutes

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

hemorrhage

A nurse is assessing a pregnant woman with gestational hypertension. Which finding would lead the nurse to suspect that the client has developed severe preeclampsia?

hyperreflexia

A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program?

inspecting the placenta after delivery for intactness

A nurse is assessing a rape survivor for posttraumatic stress disorder. The nurse asks the survivor, "Do you feel as though you are reliving the trauma?" The nurse is assessing for which effect of the trauma?

intrusive thoughts

A nurse is reading a journal article about the various medications used for pain relief during labor. Which drug would the nurse note as producing amnesia but no analgesia?

midazolam

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

naloxone

The nurse is assessing the latest laboratory results of a pregnant client who is at 17 weeks gestation. The nurse should prepare to teach the client about which possible defects after noting the maternal serum alpha-fetoprotein level is elevated above normal?

open spinal defects

A nurse is visiting a postpartum woman who gave birth to a healthy newborn 5 days ago. Which finding would the nurse expect?

pinkish brown discharge

Assessment of a pregnant woman reveals oligohydramnios. The nurse would be alert for the development of which condition?

placental insufficiency

A woman pregnant with twins comes to the clinic for an evaluation. While assessing the client, the nurse would be especially alert for signs and symptoms for which potential problem?

preeclampsia

A nurse is working with a victim of intimate partner violence. Which intervention would be most important for this client?

providing for the client's safety

A nurse is reviewing a client's history and physical examination findings. Which information would the nurse identify as contributing to the client's risk for an ectopic pregnancy?

recurrent pelvic infections

During a follow-up visit to the clinic, a victim of sexual assault reports changing jobs and moving to another town. The client tells the nurse, "I pretty much stay to myself at work and at home." The nurse interprets these findings to indicate that the client is in which phase of rape recovery?

reorganization

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

respiratory and cardiovascular

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?

respiratory depression

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess?

respiratory rate 45 breaths/minute, irregular

While observing the interaction between a newborn and the mother, the nurse notes the newborn nestling into the arms of the mother. The nurse identifies this as which behavior?

social behaviors

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate?

"I have a toddler and preschooler at home who need my attention."

After teaching a woman who has had an evacuation for gestational trophoblastic disease (hydatidiform mole or molar pregnancy) about her condition, which statement indicates that the nurse's teaching was successful?

"I will be sure to avoid getting pregnant for at least 1 year."

A nurse is teaching a pregnant woman at risk for preterm labor about what to do if she experiences signs and symptoms. The nurse determines that the teaching was successful when the woman makes which statement?

"I'll drink several glasses of water."

A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression?

"I'm feeling so guilty and worthless lately."

A pregnant woman is discussing nonpharmacologic pain control measures with the nurse in anticipation of labor. After discussing the various breathing patterns that can be used, the woman decides to use slow-paced breathing. Which instruction would the nurse provide to the woman about this technique.

"Inhale through your nose and exhale through pursed lips."

A nurse is presenting a discussion on sexual violence at a local community college. When describing the incidence of sexual violence, the nurse would identify that a woman has which chance of experiencing a sexual assault in her lifetime?

1/5

A nurse measures a pregnant woman's fundal height and finds it to be 28 cm. The nurse interprets this to indicate that the client is at how many weeks' gestation?

28 weeks' gestation

A client who is 4 months pregnant is at the prenatal clinic for her initial visit. Her history reveals she has 7-year-old twins who were born at 34 weeks' gestation, a 2-year-old son born at 39 weeks' gestation, and a spontaneous abortion (miscarriage) 1 year ago at 6 weeks' gestation. Using the GTPAL method, the nurse would document her obstetric history as?

4 1 1 1 3

A woman's amniotic fluid is noted to be cloudy. The nurse interprets this finding as

A possible infection

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?

Rewarm the newborn gradually

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

are unable to shiver effectively to increase heat production.

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result?

6.1 mEq/L

A pregnant woman with gestational diabetes comes to the clinic for a fasting blood glucose level. When reviewing the results, the nurse determines that the woman is achieving good glucose control based on which result?

88 mg/dL

Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which finding would the nurse expect to assess? Select all that apply. A. diaphoresis B. tachycardia C. oliguria D. cool extremities E. confusion

Answer: A, D

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply. A. history of diabetes B. labor of 12 hours C. rupture of membranes for 16 hours D. hemoglobin level 10 mg/dL E. placenta requiring manual extraction

Answer: A, D, E

A nurse is providing care to a woman in labor. The nurse determines that the client is in the active phase based on which assessment findings? Select all that apply. A. cervical dilation of 6 cm B. contractions every 2 to 3 minutes C. cervical effacement of 30% D. contractions every 90 seconds E. strong desire to push

Answer: A, B

A nurse is taking a history on a woman who is at 20 weeks' gestation. The woman reports that she feels some heaviness in her thighs since yesterday. The nurse suspects that the woman may be experiencing preterm labor based on which additional assessment findings? Select all that apply. A. dull low backache B. viscous vaginal discharge C. dysuria D. constipation E. occasional cramping

Answer: A, B, C

A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply. A. cephalhematoma B. molding C. closed fontanels D. caput succedaneum E. posterior fontanel diameter 1.5 cm

Answer: A,B,D

A nurse is assessing a newborn who is about 4½ hours old. The nurse would expect this newborn to exhibit which behavior? A. sleeping B. interest in environmental stimuli C. passage of meconium D. difficulty arousing the newborn E. spontaneous Moro reflexes

Answer: B, C

A group of nurses is preparing a violence prevention program. The group is researching information about risk factors for intimate partner violence related to the individual. Based on their research, which risk factors would the nurses expect to address? Select all that apply. A. dysfunctional family system B. low academic achievement C. victim of childhood violence D. heavy alcohol consumption E. economic stress

Answer: B, C, D

The nurse is assessing a newborn's eyes. Which findings would the nurse identify as normal? Select all that apply. A. slow blink response B. able to track object to midline C. transient deviation of the eyes D. involuntary repetitive eye movement E. absent red reflex

Answer: B, C, D

A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who is not expected to live. Which interventions are appropriate at this time? Select all that apply. A. Advise the parents that the hospital can make the arrangements. B. Offer to pray with the family if appropriate. C. Leave the parents to talk through their next steps. abirb.com/test D. Initiate spiritual comfort by calling the hospital clergy, if appropriate. E. Respect variations in the family's spiritual needs and readiness.

Answer: B, D, E

A group of nurses are preparing a program about rape and sexual assault for a community health center. Which information would the nurses include as being most accurate? Select all that apply. A. Most victims of rape tell someone about it. B. Few people falsely cry "rape." C. Women have rape fantasies desiring to be raped. D. A rape victim feels vulnerable and betrayed afterwards. E. Medication and counseling can help a rape victim cope.

Answer: B, D, E

A nurse is developing a teaching plan about nutrition for a group of pregnant women. Which recommendations would the nurse include in the discussion? Select all that apply A. Keep weight gain to 15 lb (6.8 kg). B. Eat three meals with snacking. C. Limit the use of salt in cooking. D. Avoid using diuretics. E. Participate in physical activity.

Answer: B, D, E

A pregnant woman at 31-weeks' gestation calls the clinic and tells the nurse that she is having contractions sporadically. Which instructions would be most appropriate for the nurse to give the woman? Select all that apply. A. "Walk around the house for the next half hour." B. "Drink two or three glasses of water." C. "Lie down on your back." D. "Try emptying your bladder." E. "Stop what you are doing and rest."

Answer: B, D, E

A nurse suspects that a client is experiencing intimate partner violence and uses a screening protocol to gather additional information from the client. When asking the client direct questions, which behavior by the nurse would be appropriate to elicit accurate information? Select all that apply. A. Look away from the client when asking any questions. B. Avoid the use of technical language. C. Minimize what the client says. D. Use leading questions. E. Wait patiently for the client to answer.

Answer: B, E

Which approach would be most appropriate when counseling a client who is a suspected victim of intimate partner violence?

Ask, "Have you ever been physically hurt by your partner?"

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse interprets this as indicating:

motor maturity

When describing the stages of labor to a pregnant woman, which of the following would the nurse identify as the major change occurring during the first stage?

Cervical dilation

A pregnant client with preeclampsia is being treated with intravenous magnesium sulfate. The nurse assesses the client's deep tendon reflexes and grades them as 4+. The nurse notifies the abirb.com/test health care provider about this finding, describing them using which term to ensure accurate communication?

Clonus

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

nasal flaring

The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?

Decrease the serum bilirubin level.

A woman receives magnesium sulfate as treatment for preterm labor. The nurse assess and maintains the infusion at the prescribed rate based on which finding?

Decreased fetal heart rate variability

When preparing a woman for an amniocentesis, the nurse would instruct her to perform which action?

Empty the bladder

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, abirb.com/test intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate?

Encourage the parents to touch their preterm newborn.

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?

Foul odor

Assessment of a newborn reveals a heart rate of 180 beats per minute. To determine whether this finding is a common variation rather than a sign of distress, what else does the nurse need to know?

How many hours old is this newborn?

Which information would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice?

Pathologic jaundice appears within 24 hours after birth.

Which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn?

Provide opportunities for them to hold the newborn

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth?

Show the newborn to the parents as soon as possible while explaining the defect.

In addition to providing privacy, which action would be most appropriate initially in situations involving suspected intimate partner violence?

Tell the client, "Injuries like these don't usually happen by accident."

A nurse is listening to a client who is a victim of intimate partner violence. The client is describing how events would unfold with the partner. The nurse interprets the client's statements and identifies which action as characteristic of the second phase of the cycle of violence?

The physical battery is abrupt and unpredictable.

A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F (35 degrees C). What could explain the assessment finding?

The supply of brown adipose tissue is not developed.

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

The temperature of the water should be at least 105

When a nurse suspects that a client may be a victim of intimate partner violence, the first action should be to:

ask the client about the injuries and if they are related to intimate partner violence.

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR?

between the umbilicus and the symphysis pubis

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

calcium gluconate

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

cervical dilation (dilatation)

A woman in labor is to receive continuous internal electronic fetal monitoring. The nurse prepares the client for this monitoring based on the understanding that which criterion must be present?

cervical dilation of 2 cm or more

A nurse is describing the cycle of violence to a community group. When explaining the first phase, the nurse would include which description?

characterized by tension-building and minor battery

The nurse is presenting a class at a local community health center on violence during pregnancy. Which possible complication would the nurse include?

chorioamnionitis

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

conduction

A nurse is providing care to a newborn who is receiving phototherapy. Which action would the nurse most likely include in the plan of care?

covering the newborn's eyes while under the bililights

A nurse is conducting a program for pregnant women with gestational diabetes about reducing complications. The nurse determines that the teaching was successful when the group identifies which factor as being most important in helping to reduce complications associated with pregnancy and diabetes?

degree of blood glucose control achieved during the pregnancy

A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to suspect that a woman is experiencing postpartum psychosis?

delirium

A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn?

diabetes

A nurse is caring for a recent rape victim. The nurse would expect this client to experience which phase first?

disorganization

A nurse is working with a group of clients who are victims of intimate partner violence. The nurse focuses interventions on which area as the primary goal?

empowering them to regain control of their life

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?

frequent scant voidings

When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?

fundal height measurement

Which assessment finding will alert the nurse to be on the lookout for possible placental abruption during labor?

gestational hypertension

The nurse is discussing the insulin needs of a primiparous client with diabetes who has been using insulin for the past few years. The nurse informs the client that her insulin needs will increase during pregnancy based on the nurse's understanding that the placenta produces what?

hPL, which deceases the effectiveness of insulin

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom?

hardening of an area in the affected breast

A nurse is teaching a group of new parents about their newborns' sensory capabilities. The nurse would identify which sense as being well-developed at birth?

hearing

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn?

infection

A group of nurses are reviewing information about the changes in the newborn's lungs that must occur to maintain respiratory function. The nurses demonstrate understanding of this information when they identify which event as occurring first?

initiation of respiratory movement

After teaching an in-service program to a group of nurses working in newborn nursery about a neutral thermal environment, the nurse determines that the teaching was successful when the group identifies which process as the newborn's primary method of heat production?

nonshivering thermogenesis

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

normal progression of behavior.

A nurse is assessing a newborn and observes the newborn moving his head and eyes toward a loud sound. The nurse interprets this as which behavior?

orientation

When describing an episode of intimate partner violence, the victim reports attempting to calm the partner down to keep things from escalating. The nurse interprets this behavior as reflecting which phase of the cycle of violence?

tension-building

A nurse is conducting an in-service program for a group of staff nurses. After teaching the group about ovarian cysts, the nurse determines that the teaching was successful when the group identifies which type of cyst as being associated with hydatidiform mole?

theca-lutein cyst

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which factor would the nurse identify as being a significant contributor to this condition?

use of anesthetics

A nurse is reviewing a journal article on the causes of postpartum hemorrhage. Which condition would the nurse most likely find as the most common cause?

uterine atony

Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?

uterine atony, placenta previa, operative procedures

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?

uterus becomes globular

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration?

variable decelerations

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

vision

As part of an in-service program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn?

within the first 6 weeks

A nurse is preparing a presentation about ways to minimize heat loss in the newborn. Which measure would the nurse include to prevent heat loss through convection?

working inside an isolette as much as possible.

The nurse observes the stool of a newborn who has begun to breastfeed. Which finding would the nurse expect?

yellowish-brown, seedy stool

The nurse observes the stool of a newborn who is being bottle-fed. The newborn is 2 days old. What would the nurse expect to find?

yellowish-green, pasty stool