Maternal ATI B

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

"I will have blood tests because my potassium might decrease."An adverse effect of terbutaline is hypokalemia.

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

"I will need this medication if I have an amniocentesis." Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make?

"This procedure should have no effect on your sexual performance or adequacy." The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function.

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?

"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.

WBC

5,000-15,000 within normal range

Serum Albumin Level

A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition.

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

Blood glucose 30 mg/dL Newborns less than 24 hr old should have a blood glucose of 40 to 45 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider.

Hct

Hct of 39% is within the expected reference range and does not indicate a postpartum complication.

A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider?

Hemoglobin 10 g/dL A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

Massage the client's fundus. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)

Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives.

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?

Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider?

Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

RBC

This red blood cell count is within the expected reference range of 5 to 6.25 million/mm3 for a client who is pregnant and does not require reporting. This count increases by 20% to 30% during pregnancy.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Transition The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.