Maternal 2019

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?

A reduction in respiratory distress in the newborn Betamethasone is a glucocorticolid that is given to stimulate fetal lung maturity and prevent respiratory distress.

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.)

Acrocyanosis Positive Babinski reflex Two umbilical arteries visible

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?

"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing

A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 ml of dextrose 5% in water (DsW). The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50ml

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?

Protect the client's head and feet from cold A CORRECT Protecting the client's head and feet from cold air should be included in the plan because this is a traditional Hispanic practice during the postpartum period.

A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?

Report of decreased fetal movement The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress.

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?

Have the client change position. Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.

A nurse is caring for a client who is at 30 woeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects?

Respiratory rate 10/min CORRECT The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and Increase oxygenation to the fetus.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?

Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed.

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?

Verify that the parent's identification band matches the newborn's identification The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?

vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?

Weight gain of 22 kg (4.8 Ib) CORRECT A weight gain of 2.2 kg (4.8 Ib) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizura. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizuro?

Administer oxygen via a nonrebreather mask. CORRECT When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus

A nurse assessing four newborns. Whlch of the following findings should the nurse report to the provider?

Anewborm who is 18 hr old and nas an axillary temperature of 37.7C(99.9 F) nurse should report this finding to the provider. An alary temperature greater than 37.5 C (99.5 F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore the

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?

Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. breasts for 15 to 20 min, repeating the application for two to three sessions as needed The nurse should instruct the client to place the cabbage leaves on the More frequent applications could decrease the client's milk supply.

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?

Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of following images indicates the first step of Leopold maneuvers?

Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with her palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?

FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore. this is an expected finding by the nurse.

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Fundal height measurement fundal height measurement of 30 cm should be reported to the provider. Fundal height gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider should be measured in centimeters and is the same as the number of

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe?

Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected maternal circulation, This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative. placental abruption to determine if fetal blood is in

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?

Massage the clients fundus Uterine atony and postoartum hemorrhage indicate that this client is at the greatest risk for hypovolemic ahock Ths can compromise the perfusion to the client's vital organt, which can ead to death. Therefore, the nhurses priority is to massage the clients fundus to minimite blood loss

A nurse is carling for a clent who Is at 15 weeks of gextatlon, Is Rh-negative, and has Jurt hed an amnlocenteala. Which of the fallowing Interventions is the nurse's prlarty following the procedure?

Monitor the FHR. greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.

A nursa is teaching a client who is at 10 woeks of gestation about nutrition during prognancy. Which of the following statements by the client indicates an understanding of the teaching?

O 1 should take 600 micrograms of folic acid each day." client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?

O Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?

O Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. breasts for 15 to 20 min, repeating the application for two to three sessions as needed The nurse should instruct the client to place the cabbage leaves on the More frequent applications could decrease the client's milk supply.

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?

OYou can still become pregnant if you are breastfeeding" The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity?

Calcium gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote.

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?

client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.